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Collaborative Exercise Programs for Medically Diagnosed Conditions

Memorandum of Agreement between the Oneida Community Health Center Diabetes Team, Health Promotion/Disease Prevention Department, and Oneida Family Fitness Center to provide structured exercise programs for patients referred by healthcare professionals.

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Collaborative Exercise Programs for Medically Diagnosed Conditions

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  1. Memorandum of agreement with health partners • Oneida Tribe of Indians of Wisconsin MEMORANDUMOFAGREEMENT BETWEENTHEONEIDACOMMUNITYHEALTHCENTERDIABETESTEAMANDTHEONEIDACOMMUNITYHEALTHCENTERHEALTHPROMOTION/DISEASEPREVENTIONDEPARTMENTANDTHEONEIDAFAMILYFITNESSCENTER OneidaComprehensiveHealthDivision OneidaCommunityHealthCenterBehavioralHealthServicesAnnaJohnNursingHomeEmployeeHealthNursing POBox365 Oneida, WI54155 • Preamble 1.1.ThisMemorandumofAgreement (MOA)isenteredintobytheOneida CommunityHealthCenter(OCHC)DiabetesTeam(DT),Health Promotion/DiseasePrevention(HPDP),andtheOneidaFamily FitnessCenter (OFF). • 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. Definitions • TRIAD: TakingResponsibilityInAddressingDiabetes • HPDP:HealthPromotion/DiseasePreventionGrantforTwatakalitatsProgram • DPP:DiabetesPreventionProgram • C2F:CommittoFitProgram • OCHD:OneidaComprehensiveHealthDivision • DT:DiabetesTeam • Graduates:Patients/Clientswhosuccessfullycompletethe12or16week programsincludingpreandpostassessments. • ScopeandNatureofServices 4.1.DesignatedOCHCDT,HPDP,andOFFpersonnelwillworktogethertoprovide servicesto: 4.1.1. Followuponhealthscreeningsandreadinessassessments. 4.1.2. Implementwellnesscoachingtoenhancephysicalactivitygoal achievement,retention,providemedicalrecorddocumentation,and provideadvocacyforeachpatient. 4.1.3 Provideweekly,biweeklyormonthlyeducationrelatedtoahealthylifestyle. 4.1.4. Designandimplementindividualizedfitnessplanstoinclude cardiovascularandstrengthtraining. 4.1.5. Maintainrecordsas requiredbyOCHC,OFF,andapplicable grants/cooperativeagreements. 4.1.6. DevelopprogramsinresponsetotheIHSStandardsofDiabetes Care,AmericanDiabetesAssociation,andAmericanCollegeof SportsMedicineasapplicable. • Implementation ProcessandResponsibilities 5.1.TheOCHC throughtheDTagrees toassurethefollowing: 5.1.1. Patientsneedingorrequestingassistancewithlifestylemodifications topreventorcontrolmedicalconditionswillbereferredbytheirhealth careproviderorOCHDstafftoawellnessprogram. 5.1.2. ThehealthcareproviderorOCHDstaffwillcompleteandsubmittheMedicalClearance/Referral FormandHIPPAAuthorizationformtoa designatedbasketintheDToffice. 5.1.3. TheDT entersthepatientintoTRIADdatabaseandanHPDPReferral (electronic)database,verifyingallformshavebeencompleted. 5.1.4. TheDT andhealthcareprovidercompletesthemedicalscreeningto verifythepatientissafetoexercisewithanacceptableA1Clevel. 5.1.4.1. If thepatientisnotsafetoexercise,theDTwillfollowupevery3monthswiththepatient. 5.1.4.2. TheDTwillassistthepatientbyschedulingappointmentsas neededwiththeappropriatehealthcareprovider. 5.1.4.3. Oncethepatientisdeemedsafetoexercisebytheirhealth careprovider,theDT refersthepatienttoHPDP.

  3. 5.1.5. TheDTwillprovideHPDPwiththeMedicalClearance/ReferralForm. TheHIPPA authorizationformwillbefiledinthepatient’smedical record. 5.1.6. TheDTwillupdateHPDP andOFFstaffasnecessarywithany patientinformationand/orchangesthatmayoccur. 5.1.7. Submitquarterlyreport,whichincludes:PreandPostHemoglobinA1Ctests. 5.1.8. Providecopyofreportsummarytoallpartiesinvolvedinthis agreement. 5.2.TheOCHC throughHPDP agrees toassurethefollowing: 5.2.1. HPDPwillreceiveallphysicianreferralsviaemailwithascanned copyoftheMedicalClearance/Referral Form.HIPPA authorization formwillbekeptinthepatient’smedicalrecord. 5.2.2. HPDPwillassignacoachbasedonavailabilityandtomeettheneed ofthepatient. 5.2.3. HPDPstaffwillcontactthepatientandcompletethereadinessassessment. 5.2.3.1. Pre-contemplationstage:TheHPDP staffwillfollowupmonthlywithpatienttoeducate,support,andmotivate patientuntilhe/shemovesfrom“Pre-contemplation”to “Contemplation”or“Preparation”stage. 5.2.3.2. Contemplationstage: TheHPDP staffwillworkwithpatient onabiweeklybasisusingMotivationalInterviewingandAppreciativeInquiryuntilpatientmovesfrom“Contemplation”to“Preparation”stage. 5.2.3.3. Preparationstage: TheHPDP staffwillreferthepatientto theappropriateprogram: TRIAD,C2ForDPP. Action/MaintenanceStage:Atthisstagethepatientis alreadymeetingtheoutcomesoftheprograms.HPDPStaff willdocumentthisstageintheHPDPReferralDatabase.ThepatientwillnotenterTRIAD,C2F,orDPP butmaybe offeredaPersonalTrainingsessionand/ormonthlyfollowup visitsforgoalsetting. 5.2.4. HPDPwill: 5.2.4.1 Introducepatienttoappropriateprogram. 5.2.4.2. SetupWellnessVisionappointment. 5.2.4.3. 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. CompletepostWellnessAssessment. 5.2.6.2. AssistpatientinschedulingpostFitnessAssessment. 5.2.6.3. Assessinitialprogramgoalsandsetnewgoalsfor3,6or9months. 5.2.6.4. Offerand/orschedulemonthlyfollowupcoachingvisits,at patient’sdiscretion. 5.2.6.5. ForTRIAD,providepatientaconfidentialspacetocomplete TRIADevaluationformandsealinanenvelope.HPDP staff willforwardtoDiabetesProgramSupervisor. 5.2.6.6. ForTRIAD,provideathleticshoevoucherandwalkpatientto OFFtoorderappropriateshoesize. Monthlycoachingvisitswillcontinuefor6-9monthsatwhichtime anotherWellnessAssessmentwillbecompleted. 5.2.7. UsingProchaska’sStagesofChangeModel,determinewhether patientshouldcontinuemonthly,quarterly,orsemi-annualfollowup coachingvisits. 5.2.8. SubmitmonthlyreportforTRIADtoDiabetesProgramSupervisor, whichincludes: 5.2.8.1. #ofactiveparticipants 5.2.8.2. #ofcoachingsessions 5.2.8.3. #ofselfreportedphysicalactivityminutes 5.2.8.4. #check-instoOFF 5.2.8.5. Weightloss 5.2.9. SubmitquarterlyreporttoDiabetesProgramSupervisor,whichincludes: 5.2.9.1. Total#ofparticipants • 5.2.9.2. Total # of coaching sessions 5.2.9.3. Averageselfreportedphysicalactivityminutes 5.2.9.4. Total#ofcheck-instoOFF 5.2.9.5. Totalweightloss 5.2.10. ActivelyparticipateinSDPI/DPPGrant Teammeetings. 5.2.11. ProvidecopyofreportsummaryforDPP toallpartiesinvolvedinthis agreement. 5.3.TheOFFagreestoassurethefollowing: 5.3.1. OFFwillreceivereferralsfromHP/DPviaMedicalClearance/Referral Form. 5.3.2. ThepatientwillpresenttheMedicalClearance/ReferralFormtoOFFFrontDeskwhowillassistpatientwithmembershipapplicationand routepatienttoFitnessServiceDesktobeginappropriateprogram. 5.3.2.1.TRIAD:

  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 athleticshoetobedistributedbyHPDP 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. 5.3.2.3.2. SubmitpostFitnessAssessmentresultstoHP Specialist/DPPCoordinatoruponcompletionof theprogram. 5.3.2.3.3. ProvideavailabilityofspaceforAfter-Core activitiesinvolvingphysicalactivity. 5.3.2.3.4. ProvideavailabilityofOFFEducationRoomto teachDPPCurriculum. 5.3.2.3.5. 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 5.4. 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. 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. Youthmembership(under18yearsofage)-$25.00/year 6.3.2. Adultmembership(18yearsofageandover)-$75.00/year 6.3.3. Eldermembership(over55yearsofage)-$25.00/year 6.3.4. Familymembership(includes2adults)-$150.00/year • 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. • Amendments 8.1 AmendmentstothisMOAshallbebymutualconsentandshallbecomea partofthisMOA byaddendum.Allamendmentsshallbesignedbythe signatoriesofthisMOA. OnBehalfoftheOneidaTribeofIndiansofWisconsin: BysigningbelowIagreetoalltermsofthiscontract. • __________________________ ___________ OneidaFamilyFitnessDirector Date • __________________________ ___________ • Fitness,Adventure&RecreationAreaManagerDate • __________________________ ___________ ComprehensiveHealthDivisionMedicalDirector Date OneidaCommunityHealthCenter • __________________________ ___________ ComprehensiveHealthDivisionOperationsDirector Date OneidaCommunityHealthCenter

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