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Meson Port Townsend, WA 98368
, www.JeffersonCountyPublicHealth.org
Consent agenda
Public HeatSeptember 10, 2019
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Vicki Kirkpatrick, Director, JCPH
Apple Martine, Community Health Director, JCPH
DATE:
SUBJECT: Agenda - Addendum A to Memorandum of Understanding with
UPSTREAM; December 20, 2018 - December 20, 2023
STATEMENT OF ISSUE:
Jefferson County Public Health requests approval of Addendum A Partnership Schedule to the Memorandum
of Understanding (MOU) with UPSTREAM for technical assistance and quality improvement (TA/QI) services;
December 20, 2018 - December 20, 2023
ANALYSIS/STRATEGIC GOALS/PRO'S and CON'S:
JCPH has been selected as one of four family planning programs forming the latest cohort of Washington
participating clinics to receive TA/QI services from UPSTREAM. It is an opportunity that will provide for
improvements around goals of cost savings, client service enhancement, and inventory management to
ensure timely access to contraceptive methods. Addendum A Partnership Schedule more explicitly states
milestones and incentive payments that JCPH is now eligible for under the original MOU with Upstream.
FISCAL IMPACT/COST BENEFIT ANALYSIS:
The services provided to the Family Planning program is provided at no cost to JCPH, will provide for quality
improvement and, assuming JCPH Family Planning program meets milestones, will provide incentive funds
that can be used to stabilize inventory and improve access.
RECOMMENDATIONS: JCPH management requests approval of Addendum A Partnership Schedule to
the Memorandum of Understanding with UPSTREAM for quality improvement and technical assistance
services; December 20, 2018 - December 20, 2023
REVIEWED B
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' Pffip Morle Co ty Administrator Date
Community Health Environmental Public Health
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360-385-9400 (f) 360-379-4487
360-385-9401 (f) Always working for a safer and healthier community
upstream
(1),
ADDENDUM A
PARTNERSHIP SCHEDULE
TO
MEMORANDUM OF UNDERSTANDING
THIS PARTNERSHIP SCHEDULE ("Partnership Schedule") is entered into between Upstream USA, Inc.
("Upstream") and Jefferson County Public Health ("Organization") and is made a part of and is subject to the
terms of the Memorandum of Understanding entered into between Upstream and Organization dated
12/20/2018 ("MOU").
Background
Upstream supports the lives of all women by providing evidence-based reproductive health training and
technical assistance to, and by making interventions related to contraceptive care with, health agencies across
the nation. Upstream has developed training and technical assistance based on the Quality Family Planning
recommendations collaboratively developed by the Centers for Disease Control and Prevention and the Office
of Population Affairs of the U.S. Department of Health and Human Services. The goals of such training and
technical assistance are to improve the likelihood that individuals will achieve their desired number and spacing
of children, to increase the chances that a baby will be born healthy, and improve their health even if they
choose to not have children. Organization desires for Upstream to provide such training and technical
assistance to, and make such interventions with, Organization pursuant to the terms herein.
1. Partnership Content:
Upstream and Organization agree to engage in a contraceptive care quality improvement partnership,
which will include the following content and activities, as further described herein:
• Training
• Precepting
• Technical assistance
• Implementation coaching
• Surveys and key informant interviews
• Subscription to analytic platform/dashboard
• Data exchange, de-identification, aggregation, and analysis
• Quality improvement activities
• Quality improvement measures and dashboard reports
• Process and quality improvement milestones
• Partnership funds
2. General Obligations of Organization:
a) Organization Sponsors and Champions.
i) Leadership "Executive Sponsor". Organization shall identify a member of the
executive leadership team to sponsor the partnership between Upstream and Organization, specifically
to communicate that the work aligns with Organizational priorities so that administrative and clinical
leadership can allocate the required staff time and resources, and support and enable key leaders and
staff to lead Upstream's initiative at Organization and within the health centers.
ii) Agency Champion(s). Organization shall identify a staff person(s) who is the
appropriate choice to be an Agency Champion(s) because of their role, expertise, and enthusiasm for
the initiative. The Agency Champion is the liaison for supporting all Upstream activities in collaboration
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with Organization. This may require both an administrative champion and a clinical champion as the
responsibilities include, but are not limited to, the following:
A. Preparing staff dashboards for training, selecting training dates, and ensuring
completion of staff surveys;
B. Participating in and ensuring completion of pre-training, post-training, and ongoing
phone meetings and in-person visits conducted by Upstream's Quality
Improvement Team;
C. Facilitating necessary introductions to connect the Quality Improvement Team,
specifically the Quality Improvement Advisor, with site-level points of contact for
further site-specific scheduling needs;
D. Providing timely responses to requests for coordination, information, and feedback
before, during, and after training;
E. Meeting regularly with Upstream-assigned Quality Improvement Advisor to identify
and address barriers related to the provision of same-day contraceptive care;
F. Ensuring the completion of training for clinicians, including developing and
executing a precepting plan for new learners, and training for support staff; and
G. Helping to facilitate other data and information-gathering activities, such as patient
surveys and key informant interviews.
b) Subscription to Analytic Platform / Dashboard. Organization has entered into a
subscription agreement directly with Azara Healthcare LLC ("Azara"), a subcontractor of Upstream
("Subcontractor"), in order to gain access to the data reporting and analytics proprietary system known as
"DRVS". The DRVS analytic platform and dashboard is required for participation in the partnership delineated
in this Partnership Schedule. The DRVS analytic platform and dashboard enables Organization to track
progress on Upstream's family planning quality improvement measures (as described herein). The DRVS
analytic platform will also enable Upstream to monitor progress on these measures, though Upstream's view of
the platform will be limited to summary measures and will not include any person-level data.
c) Data Exchange. Organization shall provide any required clinical and practice management
data directly to Subcontractor, including, but not limited to, electronic health record ("EHR") and other data, for
a designated period before, during, and after the term of Upstream's engagement with Organization. Among
other purposes, the data will inform quality improvement and track progress toward goals of initiatives related
to the MOU and/or this Partnership Schedule. The data may also include, without limitation, interim data on
implementation, outcomes, and other EHR data.
i) To the extent that any Protected Health Information ("PHI"), as that term is defined
under the Health Insurance Portability and Accountability Act of 1996, as amended, and its
implementing regulations (collectively, "HIPAA"), is provided by or on behalf of Organization pursuant
to the MOU or this Partnership Schedule, Organization shall provide such PHI directly and exclusively
to Subcontractor under the terms of the BAA (as defined below), which has been established by and
between Organization and Subcontractor.
ii) Organization has executed a HIPAA-compliant Business Associate Agreement directly
with Subcontractor ("BAA") to enable such sharing of PHI and to establish the terms governing such
provision. Organization further agrees that it authorizes Subcontractor to generate and provide
aggregate and/or de-identified data or measures, or any combination thereof, to Upstream on behalf of
Organization. Such information will at all times be fully de-identified consistent with HIPAA's de-
identification safe harbor.
iii) Organization shall not, under any circumstances, provide any PHI to Upstream.
Rather, Upstream will only receive aggregate and/or de-identified data and measures directly from
Subcontractor, as authorized by Organization.
d) Data Ownership. Organization agrees that Upstream shall own all aggregate and/or de-
identified data and/or measures that result from the MOU or this Partnership Schedule, including but not limited
to those obtained through DRVS, through patient and staff surveys, and through key informant interviews.
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e) Surveys. Organization shall ensure that all Organization staff participating in training complete
any pre-and post-training surveys aimed at capturing changes in knowledge,confidence,and behaviors related
to the provision of contraception at different points in time. As needed, Organization shall support Upstream's
efforts to survey patients about their experiences and decision-making related to contraceptive care, which
could include surveys of patients at multiple points in time, both prior to program implementation and following
program implementation. From time to time, Upstream, or researchers with whom Upstream contracts, may
wish to do key informant interviews of leadership, administrative staff, or clinicians. Organization shall support
Upstream in these efforts.
f) Participation in Training and Technical Assistance.
i) Training. Organization shall ensure that all staff and clinicians who have patient
contact attend Upstream's training. All cohorts or working groups should attend the same training. This
includes all licensed clinicians, including, but not limited to, doctors, nurse practitioners, physician
assistants,and certified nurse midwives, including those with proficiency in IUD and implant placement;
and front-line and support staff, including, but not limited to, medical assistants, registered nurses,
health educators, front desk staff, and phone/call center staff.
ii) Contraception Counseling. Organization shall ensure that at least eighty (80)
percent of Organization's staff,who attend Upstream's training and who will be providing contraception
counseling, shall be signed off for proficiency in providing said counseling by Upstream.
iii) Precepting. Organization and Upstream will develop a precepting plan in order to
ensure that appropriate clinicians are proficient in IUD and implant placement. This plan will include
strategies for:
A. Ensuring those clinicians deemed necessary to enable same-day access to
contraception for patients, who are new to IUD and/or implant placement, can
complete enough supervised placements with live patients to be signed off as
competent and confident, which may include setting up precepting clinics, utilizing
internal preceptors for training, or having access to Upstream-provided preceptors
and mentors;
B. Identifying and training internal preceptors, and should any site not have an
adequate number of preceptors to work with new learners, scheduling hands-on
precepting clinics hosted by Organization, prior to the Upstream training, such
clinics being focused on those clinicians who will in turn conduct precepting post-
training; and
C. Ensuring that, within three (3) months of training, there will be a sufficient number
of precepted clinicians to enable same-day access for patients.
iv) Technical Assistance. Organization shall commit Organization Champion(s)' time
and leadership attention necessary to prepare for and participate in technical assistance provided by
Upstream's Quality Improvement Advisor. This technical assistance, which will be provided in the
months leading up to and following the training, will be focused on identifying and reducing barriers
related to same-day access to the full range of contraceptive services. Organization Champion(s)and
other leadership and staff as assigned will ensure that appropriate protocols, consents,workflows, EHR
templates, supplies, patient education materials, stock of devices, appropriate billing and coding
practices,and precepting plans are in place,to support the Upstream-recommended contraceptive care
delivery model.
v) Implementation Coaching. Prior to the training, Organization Champion(s) will
identify the point of contact at each health center within Organization, who will coordinate post-training
on-site coaching visits with Upstream's Implementation Coaches, who will support and monitor staff
adoption of the contraceptive counseling model.
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vi) Voluntarism. Organization shall ensure that women of reproductive age ("WRA")
initiating contraception are provided access to the full range of contraceptive methods and high-quality
patient-centered contraceptive counseling that is free from coercion.
g) Title X. If Organization receives Title X funding, Organization will share de-identified Title X
data to Upstream for Upstream to explore changes in Organization's contraceptive-method profile of the relative
use of different contraceptive methods.
h) Permissions. Organization grants Upstream all necessary permissions to share results at
Organization and initiative levels on all data collection and analysis aggregated at Organization level. Such
results will include Organization by name but will not include any PHI. Upstream will warehouse de-identified,
aggregated and disaggregated data once Upstream's intervention with Organization is complete. Organization
also grants Upstream all necessary permissions to confidentially share de-identified and/or aggregated data
with third-party research firms for the purposes of conducting data analyses and evaluation.
3. General Obligations of Upstream:
a) Incentive Total. Upstream will provide funding up to $10,000.00 ("Partnership Funds") to
Organization, paid in installments in accordance with Section 5 of this Partnership Schedule delineated below.
b) Training. Deliver high-quality training for the entire health care team aimed at supporting the
adoption and delivery of high-quality, same-day contraceptive counseling and care. During the training,
Upstream will provide meals for staff and individual time for each new clinician learner on the VirtaMed pelvic
simulator. Upstream will provide additional training as needed, including training for clinician mentors on
facilitating precepting, refresher trainings at staff meetings, customized on-site support for phone and front desk
staff, and training on appropriate billing and coding practices. Upstream will also coordinate with Merck to offer
the Merck Clinical Training Program immediately following the Upstream training.
c) Precepting. Upstream will work with Organization Champion(s) and other key staff and
leadership to ensure precepting is completed for those clinicians deemed necessary to enable same-day
access to contraception for patients, who are new to IUD and/or implant placement, at Organization. This
includes developing a precepting plan, identifying and coordinating the use of external preceptors as needed,
planning precepting clinics, and providing tools such as the VirtaMed pelvic simulator, demo devices, and
competency assessments.
d) Technical Assistance. Upstream will assign Organization a Quality Improvement Team,
including a Quality Improvement Advisor, Quality Improvement Coordinator, and Implementation Coach. This
team will guide the agency in implementing systems and administrative level changes necessary to ensure
same-day access to the full range of contraceptive options. This includes providing support related to billing
and coding, protocols and consents, workflow, EHR documentation, precepting of clinicians to place IUDs and
implants, ordering and stocking contraceptive options, and customized support as needed. As measures
related to the initiative become available to Upstream via Subcontractor and other sources, the Quality
Improvement Team will work with Organization and health center leadership to achieve continuous
improvement.
e) Implementation Coaching. Upstream will assign each site an Implementation Coach to
provide post-training on-site support for staff in order to ensure support staff are providing high-quality
contraceptive counseling to all patients. Implementation Coaches will also work with phone and front desk staff,
train appropriate staff on tray and room set-up for IUD and implant placements and removals, ensure staff and
clinicians implement an effective and efficient workflow, and ensure the clinic makes use of effective patient
education materials.
4. Quality Improvement Measures and Dashboard Reports:
a) Quality Improvement Measures. Upstream's program of quality improvement monitoring
includes a set of Upstream family planning quality improvement measures used to track changes taking place
at Organization. As noted above, these family planning improvement measures will be viewable to Upstream
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through the DRVS platform in the aggregate, will not entail the sharing of any PHI with Upstream, and are as
follows:
i) Percent (%) of Females Aged 15-44 with an answer to the pregnancy intention
screening question ("PISQ") in the EHR
A. Distribution of responses to the PISQ
ii) Percent (%) of Females Aged 15-44 with documentation of contraceptive counseling
in the EHR
iii) Percent (%) of Females Aged 15-44 who are using each of the following X
contraceptive birth control methods at the end of their contraceptive visit, with distribution of responses
among the following methods:
A. Implant
B. IUD/IUS
C. IUD-copper(as EC)
D. Female sterilization
E. Vasectomy
F. Shot/Depo
G. Combined oral contraceptive
H. Progestin-only contraceptive
I. Patch
J. Ring
K. Diaphragm or cervical cap
L. Male condom
M. Female Condom
N. Withdrawal and other methods
0. Spermicide
P. Contraceptive sponge
Q. Fertility awareness-based method (FAM)
R. Emergency contraception (pill)
S. Declines to state/unknown
T. No method— no contraceptive precautions
U. No method—other reason (same sex partner, menopausal, or infertile)
V. Abstinence
W. Pregnant
X. Seeking Pregnancy
iv) Percent (%) of Females Aged 15-44 who are provided a most effective (i.e.,
sterilization, contraceptive implants, IUD/IUS) or moderately effective (i.e., injectable, oral pills, patch,
ring, or diaphragm) method of contraception
v) Percent(%) of Females Aged 15-44 who are provided a LARC method
vi) Percent(%) of Females Aged 15-44 receiving emergency contraception
A. Percent (%) of Females Aged 15-44 receiving emergency contraception who
received copper IUD as emergency contraception
vii) Total implant insertion counts for Females Aged 15-44
viii) Total implant removal counts for Females Aged 15-44
ix) Total IUD insertion counts for Females Aged 15-44
x) Total IUD removal counts for Females Aged 15-44
xi) Percent (%) of Females Aged 15-44 receiving a LARC during the initial contraceptive
visit
xii) Percent(%) of Females Aged 15-44 receiving a LARC during multiple visits.
The alternative measures below will be made available via Subcontractor for analytic purposes but are not tied
directly to quality improvement:
xiii) Percent(%)of Females Aged 15-44 initiating contraception
xiv) Percent(%)of Females Aged 15-44 initiating a LARC method of contraception
xv) Percent(%) of Females Aged 15-44 initiating a non-LARC method of contraception
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Upstream's quality improvement measures may be modified from timeme at Upstream's sole discretion
upon written notice to Organization.
b) Dashboard Reports. As noted above, Organization shall provide Subcontractor with access
to any clinical and practice management data required to calculate the aforementioned measures. Such data
will be collected through the DRVS. Before data are imported into the DRVS, Subcontractor will establish
protocols for data protection and assess data quality. Once the data required to calculate the aforementioned
measures are imported into the DRVS via Organization's EHR, the aforementioned quality improvement
measures will be displayed in a dashboard, displaying Organization at baseline(status prior to Partnership Start
Date, defined below in Section 6(a))and monthly thereafter. The dashboard available to Organization will also
include a set of quality improvement measures beyond Upstream's quality improvement measures, including,
but not limited to, basic primary care measures, cancer screening measures, encounter volume, and no-show
and cancellation tracking measures. Organization hereby grants Upstream access to and use of Organization's
measures and dashboard reports for the purposes set forth herein.
c) Tracking of Measures. Upstream and Organization will use this information to inform quality
improvement activities and investments at Organization and to track progress on the measures. Upstream and
Organization will share access to the Upstream dashboard so that they can interpret the measures together
and jointly set goals and decide on next steps. These data will also serve as one of the data sources for external
evaluation aimed at documenting the results of the Upstream initiative in the State of Washington, and will be
shared with an external evaluator.
5. Process and Quality Improvement Milestones:
According to the following schedule, and provided Organization has fulfilled its commitments as determined by
Upstream in good faith, Upstream will pay Organization upon achievement of each Process Milestone and
Quality Improvement Milestone listed below:
a) Process Milestones.
i) Training Milestone. All support and clinical staff listed in the Organization staff
dashboard shall participate in Upstream's in-person training event. Upon achievement of this milestone
by one hundred (100) percent of Organization's sites, Upstream will pay Organization $2,000.00.
ii) Contraceptive Access Milestone.
A. Access Policies and Guidelines. Organization has instituted access policies that
are regularly reviewed and updated, which formalize the ideal workflow, roles,
responsibilities, and staff training plans to enable best-in-class, same-day access
to the full range of contraceptive methods. Organization has also instituted
medical guidelines allowing for the provision of the full range of methods, including
IUDs and implants. Upon achievement of this milestone section, Upstream will
pay Organization $1,500.00.
B. Base Range Stock. Prior to training occurring, each health center location has:
1) Stocked a base range of LARC options on the shelf, including at least
one hormonal IUD (Mirena, Skyla, Kyleena, or Liletta), the non-
hormonal IUD (Paragard), and the implant(Nexplanon)AND
2) Stocked other prescription methods on the shelf (pill, patch, ring, or
depo shot) OR has the ability to call in same-day to pharmacy.
Upon achievement of this milestone section, Upstream will pay Organization
$2,000.00.
(continued on following page)
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b) Quality Improvement Milestones.
i) PISQ Response Milestone.* Within three (3) months of completed training, at least
eighty(80) percent of WRA who have had at least one encounter in a given month have a documented
response to a PISQ1 in the EHR in the last twelve (12) months.2 Upon achievement of this milestone
in two (2) consecutive months, Upstream will pay Organization $1,500.00.
ii) Contraceptive Counseling Milestone: Within three (3) months of completed
training, among WRA who respond "no" to PISQ during an encounter in a given month, at least eighty
(80) percent receive contraceptive counseling during that visit.3 Upon achievement of this milestone in
two(2) consecutive months, Upstream will pay Organization $1,500.00.
iii) End Method Documentation Milestone: Within three (3) months of completed
training, at least eighty (80) percent of WRA who have had at least one encounter in a given month
have their End Method documented in the EHR.4 Upon achievement of this milestone in two (2)
consecutive months, Upstream will pay Organization $1,500.00.
6. Term and Termination of Partnership Schedule:
a) The term of this Partnership Schedule shall be from 08/19/2019 ("Partnership Start Date")
through 12/20/2023 ("Partnership End Date") (collectively, the "Partnership Term"), unless the MOU is
terminated earlier, in which case this Partnership Schedule shall terminate the date the MOU terminates.
b) Either party may terminate this Partnership Schedule for any reason with or without cause at
any time by giving thirty (30) days' prior written notice to the other party. Upon receipt of such notice, each
party will inform the other party of the extent to which obligations were completed and each party will take steps
to wind down their obligations in an orderly fashion during the notice period.
c) If this Partnership Schedule is terminated prior to the Partnership End Date, Upstream shall
have no obligation to pay any Partnership Funds which would otherwise be paid after the effective date of
termination of this Partnership Schedule.
7. Miscellaneous Provisions:
a) Each of the persons signing below on behalf of a party represents and warrants that he or she
has full requisite power and authority to execute and deliver this Partnership Schedule on behalf of the party
for whom he or she is signing and to bind such party to the terms and conditions of this Partnership Schedule.
b) This Partnership Schedule may be executed in counterparts, each of which shall be deemed
an original and may be executed and delivered by a digitized transmission of a counterpart signature page.
(signatures to follow on next page)
Following the integration of the indicated field in the EHR, as well as validation of the field in the data analytics platform.
1 A Pregnancy Intention Screening Question ("PISQ")should be integrated into the EHR as a field in the medical assistant
workflow. This integration should happen prior to training. The response fields are"yes,""no,""unsure,""ok either way,"
and"N/A,"and should be documented using a checkbox or drop-down menu.
2 The look-back period may be less than twelve(12)months if Organization integrated PISQ into EHR less than twelve
(12)months ago.
3 Contraceptive counseling documentation should be integrated into the EHR as a field in the medical assistant workflow.
The integration should happen prior to training. Response fields can be"yes"or"no,"or a checkbox indicating that
counseling occurred.
4 End method documentation should be integrated into the EHR as a field in the clinician's workflow. The integration
should happen prior to training. End Method is defined as the contraceptive method a patient is using upon exiting their
visit and response fields include all hormonal and non-hormonal contraceptive methods, barrier methods including
condoms, sterilization,fertility awareness methods, pregnancy or seeking pregnancy,abstinence, menopause, no
method, and unknown method.
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IN WITNESS WHEREOF,the parties have executed this Partnership Sc as of the date first above written.
UPSTREAM USA, INC.: JEFFERSON COUNTY PUBLIC HEALTH:
(Signature) (Signature)
Name: Ann Quandt Name: Kate Dean
Title: CFAO Title: Chair, Jefferson County Board of
Commissioners
Date: Date:
Approved as to form only:
Date:
Philip C. Hunsucker,Chief Civil Deputy Prosecuting Attorney
Jefferson County Prosecuting Attorney's Office
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