Oneida Comprehensive H ealth Division

Oneida Community H ealth Center Behavioral H ealth Services Anna John Nursing H ome Employee H ealth NursingPO Box

365Oneida, W I 54155

The mailing address to all locations is: P.O. Box 365, Oneida, W I 54155

MEMORANDUM OF AGREEMENT BETWEEN THE

ONEIDA COMMUNITY HEALTH CENTER DIABETES TEAM

AND THEONEIDA COMMUNITY HEALTH CENTER HEALTH

PROMOTION/DISEASE PREVENTION DEPARTMENTAND THE

ONEIDA FAMILY FITNESS CENTER

Oneida Community Health Center

525 Airport Dr., Oneida, WI 54155 Phone: (920)-869-2711 or 1-866-869-2711

Fax: (920) 869-1780

Behavioral Health Services 2640 West Point Rd., Green Bay, WI 54304

Phone: (920)490-3790 or 1-888-490-2457

Fax: (920) 490-3883

Anna John Nursing Home W846 Cty Rd EE, DePere, WI 54115 Phone: (920) 869-2797 Fax: (920) 869-3238

Employee Health Nursing 701 Packerland Dr., Green Bay, WI 54303

Phone: (920)405-4492 Fax: (920) 405-4494

1. Preamble1.1. This Memorandum of Agreement (MOA) is entered into by the Oneida

Community Health Center (OCHC) Diabetes Team (DT), Health Promotion/Disease Prevention (HPDP), and the Oneida Family Fitness Center (OFF).

2. Purpose2.1. The purpose of this MOA is provide the framework within which the OCHC DT,

OCHC HPDP, and OFF will work collaboratively to provide structured exercise programs for patients referred by an OCHC physician or other OCHD medical professional needing assistance with prevention and/or control of medically diagnosed conditions. These collaborative programs are currently referred to as: TRIAD Program (Taking Responsibility In Addressing Diabetes), Twatakalitats Program, and DPP or Diabetes Prevention Program). They are joint efforts between the OCHC DT, OCHC HPDP, and OFF. These programs are funded by the Special Diabetes Program for Indians (SDPI) Grant, Health Promotion/Disease Prevention Cooperative Agreement (HPDP), and Diabetes Prevention Program (DPP) and are subject to follow all grant policies as well as applicable tribal, organizational, and department policies.

Memorandum of agreement with health partnersOneida Tribe of Indians of Wisconsin

3. Definitions1. TRIAD: Taking Responsibility In Addressing Diabetes2. HPDP: Health Promotion/Disease Prevention Grant for Twatakalitats

Program3. DPP: Diabetes Prevention Program4. C2F: Commit to Fit Program5. OCHD: Oneida Comprehensive Health Division6. DT: Diabetes Team7. Graduates: Patients/Clients who successfully complete the 12 or 16

week programs including pre and post assessments.4. Scope and Nature of Services

4.1. Designated OCHC DT, HPDP, and OFF personnel will work together to provide services to:4.1.1.4.1.2.

Follow up on health screenings and readiness assessments. Implement wellness coaching to enhance physical activity goal achievement, retention, provide medical record documentation, and provide advocacy for each patient.Provide weekly, biweekly or monthly education related to a healthy lifestyle.Design and implement individualized fitness plans to include cardiovascular and strength training.Maintain records as required by OCHC, OFF, and applicable grants/cooperative agreements.Develop programs in response to the IHS Standards of Diabetes Care, American Diabetes Association, and American College ofSports Medicine as applicable.

4.1.3.

4.1.4.

4.1.5.

4.1.6.

5. Implementation Process and Responsibilities5.1. The OCHC through the DT agrees to assure the following:

5.1.1. Patients needing or requesting assistance with lifestyle modifications to prevent or control medical conditions will be referred by their health care provider or OCHD staff to a wellness program.The health care provider or OCHD staff will complete and submit theMedical Clearance/Referral Form and HIPPA Authorization form to a designated basket in the DT office.The DT enters the patient into TRIAD database and an HPDP Referral (electronic) database, verifying all forms have been completed.The DT and health care provider completes the medical screening to verify the patient is safe to exercise with an acceptable A1C level.

5.1.2.

5.1.3.

5.1.4.

5.1.4.1. If the patient is not safe to exercise, the DT will follow up every 3 months with the patient.The DT will assist the patient by scheduling appointments as needed with the appropriate healthcare provider.Once the patient is deemed safe to exercise by their health care provider, the DT refers the patient to HPDP.

5.1.4.2.

5.1.4.3.

5.1.5. The DT will provide HPDP with the Medical Clearance/Referral Form. The HIPPA authorization form will be filed in the patient’s medical record.The DT will update HPDP and OFF staff as necessary with any patient information and/or changes that may occur.Submit quarterly report, which includes: Pre and Post Hemoglobin A1C tests.Provide copy of report summary to all parties involved in this agreement.

5.1.6.

5.1.7.

5.1.8.

5.2. The OCHC through HPDP agrees to assure the following:5.2.1. HPDP will receive all physician referrals via email with a scanned

copy of the Medical Clearance/Referral Form. HIPPA authorization form will be kept in the patient’s medical record.HPDP will assign a coach based on availability and to meet the need of the patient.HPDP staff will contact the patient and complete the readinessassessment.

5.2.2.

5.2.3.

5.2.3.1. Pre-contemplation stage: The HPDP staff will follow up monthly with patient to educate, support, and motivate patient until he/she moves from “Pre-contemplation” to “Contemplation” or “Preparation” stage.Contemplation stage: The HPDP staff will work with patienton a biweekly basis using Motivational Interviewing and Appreciative Inquiry until patient moves from “Contemplation” to “Preparation” stage.Preparation stage: The HPDP staff will refer the patient tothe appropriate program: TRIAD, C2F or DPP. Action/Maintenance Stage: At this stage the patient is already meeting the outcomes of the programs. HPDP Staff will document this stage in the HPDP Referral Database.The patient will not enter TRIAD, C2F, or DPP but may be offered a Personal Training session and/or monthly follow up visits for goal setting.

5.2.3.2.

5.2.3.3.

5.2.3.4.

5.2.4. HPDP will:5.2.4.1.5.2.4.2.5.2.4.3.

Introduce patient to appropriate program. Set up Wellness Vision appointment.Send or provide Wellness Assessment to patient.

5.2.5. Upon completion of the Wellness vision, HPDP staff will:1. Set up weekly, biweekly or monthly follow up coaching

appointments for goal setting and tracking fitness progress. For TRIAD, see attached “HPDP Weekly Programming.”

2. Provide referral to appropriate program which includes a copy of Medical Clearance/Referral Form, Wellness Vision and Wellness Assessment results.

5.2.6. Upon completion of any program:5.2.6.1.5.2.6.2.5.2.6.3.

Complete post Wellness Assessment.Assist patient in scheduling post Fitness Assessment. Assess initial program goals and set new goals for 3, 6 or 9 months.Offer and/or schedule monthly follow up coaching visits, at patient’s discretion.For TRIAD, provide patient a confidential space to completeTRIAD evaluation form and seal in an envelope. HPDP staff will forward to Diabetes Program Supervisor.For TRIAD, provide athletic shoe voucher and walk patient to OFF to order appropriate shoe size.

5.2.6.4.

5.2.6.5.

5.2.6.6.

Monthly coaching visits will continue for 6-9 months at which time another Wellness Assessment will be completed.Using Prochaska’s Stages of Change Model, determine whether patient should continue monthly, quarterly, or semi-annual follow upcoaching visits.Submit monthly report for TRIAD to Diabetes Program Supervisor, which includes:

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.

# of active participants# of coaching sessions# of self reported physical activity minutes# check-ins to OFF Weight loss

5.2.9. Submit quarterly report to Diabetes Program Supervisor, which includes:5.2.9.1.Total # of participants 5.2.9.2.Total # of coaching sessions5.2.9.3.Average self reported physical activity minutes 5.2.9.4.Total # of check-ins to OFF5.2.9.5.Total weight lossActively participate in SDPI/DPP Grant Team meetings.Provide copy of report summary for DPP to all parties involved in this agreement.

5.2.10.5.2.11.

5.3. The OFF agrees to assure the following:5.3.1. OFF will receive referrals from HP/DP via Medical

Clearance/Referral Form.The patient will present the Medical Clearance/Referral Form to OFF Front Desk who will assist patient with membership application androute patient to Fitness Service Desk to begin appropriate program.5.3.2.1. TRIAD:

5.3.2.

1. Personal training will occur weekly for 12 weeks, in ½ hour sessions. See attached “Weekly Trainer Responsibilities.”

2. Personal training will include brief patient education, and cardiovascular and strength training.

3. Additional personal training will be offered to“graduates” as deemed necessary and agreed upon by DT, HP, and OFF.

4. Designated Fitness Specialists will complete pre and post fitness assessments to include thefollowing: BMI, Height, Weight, Waist:Hip, Blood Pressure, Resting Heart Rate, appropriate AerobicFitness test, Strength test, and appropriate Flexibility test.

5. At completion of personal training, Fitness Specialist will inform client about final incentive ofathletic shoe to be distributed by HPDP coach. Give client form with HPDP specialist nameand phone number for patient to contact them and set up final appointment.

6. Submit post Fitness Assessment results to HPDP Coach upon completion of the program.

7. Submit monthly report to Diabetes Program Supervisor, which includes the following forpatients WITHOUT COACHING: 5.3.2.1.6.1 # of active participants5.3.2.1.6.2 # self reported physical activity minutes 5.3.2.1.6.3 # check ins to OFF5.3.2.1.6.4 Weight loss

8. Submit quarterly reports to Diabetes Program Supervisor, which includes:

1. Total # of participants2. Average change in BMI

3. Average change in Waist to Hip Ratio 5.3.2.1.8.4. Average change in Aerobic Fitness 5.3.2.1.8.5. Average change in Strength 5.3.2.1.8.6. Average change in Flexibility5.3.2.2. C2F:

1. Individual sessions following C2F Program protocol for 12 weeks.

2. Submit post fitness assessment results to HPDPCoach upon completion of the program.

5.3.2.3. DPP:

5.3.2.3.1. Fitness Specialist will complete pre and post fitness assessments for DPP Participants that are OFF Members, to include: BMI, Height, Weight, Waist:Hip, Blood Pressure, Resting Heart Rate, appropriate Aerobic Fitness test, Strength test and appropriate Flexibility test.Submit post Fitness Assessment results to HPSpecialist/DPP Coordinator upon completion of the program.Provide availability of space for After-Core activities involving physical activity.Provide availability of OFF Education Room to teach DPP Curriculum.Submit quarterly reports to HP Specialist/DPP Coordinator, which includes:1.Average change in BMI2.Average change in Waist to Hip Ratio 5.3.2.3.5.3. Average change in Aerobic Fitness 5.3.2.3.5.4. Average change in Strength 5.3.2.3.5.5. Average change in Flexibility

5.3.2.3.2.

5.3.2.3.3.

5.3.2.3.4.

5.3.2.3.5.

5.4. Incentives:1. TRIAD:

1. The DT will purchase and provide HPDP and/or OFF with patient incentives:

2. Incentives will be awarded to patients who meet minimumrequirements as defined by the TRIAD committee.

3. Incentives will be purchased from the SDPI grant.4. SDPI Grant policy allows for incentives that do not exceed $30.5. Incentives will be stored and inventoried at OCHC and

handed out by HP/DP and/or OFF.6. Types of incentives are determined by OCHC DT, HP/DP, and

OFF.7. See attached “TRIAD Incentive Structure.”

5.1.1. TRIAD and DPP fitness participation (Note: HPDP fitness participation incentive will begin 9/1/11):5.1.1.1. Patients verifying facility usage of at least 2 times

per weekeach quarter will receive an Oneida Retail Card in the amount

of $25.00.5.3.2.3.1. HPDP Coach will provide patient incentive upon verification.

6. Fiscal agreements1. For TRIAD:

1. Fitness Specialists will maintain a combined 40 hours for individualized personal training and TRIAD administrative duties.

2. At the close of each month, Oneida Family Fitness representative willemail total hours for personal training and TRIAD administrative duties to Diabetes Program Supervisor.

3. Diabetes Program Supervisor will forward to Accounting representative to complete journal entry transfer for the reported hours.

4. At the close of each month, Accounting will reimburse OFF a maximum of 40 hours per week to include the exact personnel, fringe, and indirectcosts through Special Diabetes Program for Indians Grant.

5. An IT PO will be made in the amount of $1750 for 50 1-hour personal training sessions at $35.00/session to be used for TRIAD graduates.

2. For DPP:1. Fitness Specialists will maintain a combined 20 hours for Just Move It –

Oneida event planning/facilitating, quarterly group exercise instruction (as needed), pre/post fitness assessments, collection/report data as required by DPP Grant, and any other grant responsibilities related to physical activity as designated by DPP Program Director (HPDP Supervisor).

2. HPDP Supervisor, through DPP Cooperative Agreement, will work withAccounting to reimburse a maximum of 20 hours per week to include, personnel, fringe and indirect costs.

3. At the close of each month, HPDP Supervisor will request total hours of participating in DPP for the month via email.

4. HPDP Supervisor will send email request to Accounting to complete journal entry transfer for the reported hours.

3. Membership costs will not incur to HPDP or DT. OFF agrees to the following membership prices that will be paid by any patient referred into the designatedprograms, if and only if, the patient does not qualify for scholarship eligibility. This price includes waiving the initiation fee.

6.3.1.6.3.2.6.3.3.6.3.4.

Youth membership (under 18 years of age) - $25.00/year Adult membership (18 years of age and over) - $75.00/year Elder membership (over 55 years of age) - $25.00/year Family membership (includes 2 adults) - $150.00/year

7. Disclaimers, Terms, and Termination of Agreement1. Continuation of the TRIAD and DPP program is contingent upon

SDPI/DPP Grant funding.2. The effective date of the MOA is October 7, 2011 and remains in

effect annually until amended or terminated by either party.3. The parties agree that this MOA may be terminated at any time upon thirty

(30) calendar days notice by either party. This notice must be in writing, andaddressed and delivered to the other party’s signatory or signatories to this MOA.

7.4. Each party agrees that this MOA does not absolve them of responsibilities and obligations that have been or may be established in Constitutions, By-Laws, and Policies of each organization.

8. Amendments8.1 Amendments to this MOA shall be by mutual consent and shall become

a part of this MOA by addendum. All amendments shall be signed by the signatories of this MOA.

On Behalf of the Oneida Tribe of Indians of Wisconsin:

By signing below I agree to all terms of this contract.

Ryan WaterstreetOneida Family Fitness Director

Date

Scott MurrayFitness, Adventure & Recreation Area Manager

Date

Ravinder Vir, M.D.Comprehensive Health Division Medical Director Oneida Community Health Center

Date

Debra J Danforth, RN, BSNComprehensive Health Division Operations Director Oneida Community Health Center

Date