RFCC Clinical Intake Form (Non-Provider RFCC)

The National Evaluation of the Rural/Frontier Women's Health Coordinator Center

0990-Appendix I - RFCC

RFCC Clinical Intake Form (Non-Provider RFCC)

OMB: 0990-0316

Document [xlsx]
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Overview

General instructions
Clinical Care
Prof Ed & Training
Research
Education & Outreach
Leadership


Sheet 1: General instructions

GENERAL INFORMATION

* The following tables should summarize activities conducted or offered only to RFCC women.

* Include information about RFCC, partner, and non-partner activities. A partner organization is considered an organization with whom you have an established agreement to provide services for a defined period of time. A non-partner typically provides services on a fee-for-service basis and agrees to provide one time only services.

* If needed, include any clarification at the bottom of each table in the "comment" row.

* Please be sure to complete all six tables included in this workbook. A tab for each of the tables is located at the bottom of the workbook. Click on each tab to view the pertinent table. (hint: when printing, select "entire workbook" to print all tables)

Sheet 2: Clinical Care

RFCC NAME: ____________________________ REPORT DATE: _______________ QUARTER: ___________________























HEALTH CARE SERVICES
In the following table, women's health services are categorized into four (4) broad groupings: primary acute care, preventive care, specialty care and enabling services. For each women's health service listed, indicate the total number of encounters, as well as the number of referrals made for RFCC patients and family members (if applicable) to receive a listed service. For example, indicate the total number of physician primary acute care RFCC patient encounters during the Q1 reporting period in cell C10, and the total number of primary acute care patient referrals made by the RFCC or its affiliated health care entity to a physician provider during Q1 in cell M10. If a service is not listed, please include it in the "Other" row.










Report "Referrals" as the number of referrals issued. These columns should not summarize the number of patients who used their referrals (or estimate patient compliance).










Note: P = RFCC Patient, FM = RFCC Patient Family Member, Q1 = First Quarter, Q2 = Second Quarter, Q3 = Third Quarter, Q4 = Fourth Quarter, and YTD = Year to Date.










WOMEN'S HEALTH SERVICE OFFERED PROVIDER PRACTICE SITE (RFCC or RFCC - AFFILIATED HEALTH CARE PROVIDER) NUMBER OF RFCC PATIENT AND FAMILY MEMBER ENCOUNTERS IN 2006 NUMBER OF RFCC PATIENT AND FAMILY MEMBER REFERRALS MADE IN 2006










Q1 Q2 Q3 Q4 YTD Q1 Q2 Q3 Q4 YTD










Primary Acute Care (includes any sick visit primary care services provided by physician and non-physician providers)












Physician Provider (specify specialty) ___________________________





















Non-Physician Provider (specify type(s), i.e., Nurse Midwife, Nurse Practitioner) ___________________________





















Preventive Care












Prenatal Services





















Blood Pressure Screening





















Vision Screening





















Audiology Testing





















Tuberculosis (PPD) Testing





















Glucose Screening





















Cholesterol Testing





















Pap Smear (or similar test)





















Mammography





















Bone Density Testing





















Colon Cancer Screening





















Immunizations (including influenza vaccinations)





















Smoking Cessastion Counseling





















STD Education (includes HIV/AIDS)





















Weight Reduction Programs





















Nutrition counseling





















Domestic Violence Counseling





















Other (list): ________________





















Other (list): ________________





















Other (list): ________________





















Specialty Care (includes any sub-specialty service provided at the RFCC or RFCC-affiliated health care provider)












Obstetrics (Labor and Delivery)





















Gynecology





















Psychiatry / Mental Health





















Endocrinology (Diabetes, Hypothyroidism)





















Cardiology (Hypertension, Heart Disease)





















Infectious Disease (HIV/AIDS, TB)





















Dentistry





















Other (list): ________________





















Other (list): ________________





















Other (list): ________________





















Enabling Service (indicate total number of RFCC patients and family members (if applicable) who used these services.












Transportation: Free passes or vouchers





















Transportation: Pickup / Transport service





















Language translation services (list language(s): ___________________)





















Child Care Service





















Home Care Visits





















Medication Assistance Program





















Other (list): ________________





















Other (list): ________________



































































Comments:














































































Sheet 3: Prof Ed & Training

RFCC NAME: ____________________________ REPORT DATE: _______________ QUARTER: ___________________








TRAINING OF LAY, ALLIED HEALTH AND HEALTH CARE PROVIDERS






Health care providers, include, but are not limited to, counselors or therapists, physicians, nurses, and allied health care providers.






Lay providers include, but are not limited to doulas and promotores.






Please list, by topic, each training activity that your RFCC participated in or coordinated during this quarter. Please indicate the type of health care provider (i.e. professional, lay, or allied health). Provide a description of health care provider that provides training to or on behalf of the RFCC and indicate if the provider is a partner organization (P). For each training activity, describe the goals and provide a description of the training and how it was developed. Indicate the date the training occurred and year the training was first offered to participants. Also include the number of training activities conducted during the last quarter and indicate the average number of training participants per activity.
*Be sure to include any activities conducted by your community partners for the RFCC program.*






TRAINING TOPIC TYPE OF HEALTH CARE TRAINER DESCRIPTION OF HEALTH CARE TRAINING PROVIDER (P = partner, NP = non-partner) GOAL AND DESCRIPTION OF TRAINING (Include method of training used and a description of any partners' involved in the training effort.) DATE OF TRAINING YEAR TRAINING FIRST OFFERED NUMBER OF TRAINING ACTIVITIES (this quarter) NUMBER OF TRAINING PARTICIPANTS (this quarter)
Example: Doula Training Certified Nurse Midwife Partner Goal: To provide comprehensive training that will enable students to achieve doula certification. 1/26/2006 2006 5 15
Description: Curriculum developed by Doulas of North American (DONA) International. Courses are being taught by CNM from XYZ Hospital and local certified doula.
























































































COMMENTS:

Sheet 4: Research

RFCC NAME: ___________________________ REPORT DATE: _____________________ QUARTER: ____ ______________
























RFCC COMMUNITY-BASED RESEARCH ACTIVITIES











In the table below, please list each community-based research activity your RFCC was involved in during the last quarter; include any activities conducted by your community partners for the RFCC program. List research activites by start date, with the most recent initiative first, and indicate what the project's status is (new or ongoing). For research activities being lead by organizations other than the RFCC, indicate the name of the organization leading the project. Provide a brief title for each research activity and an estimated length or duration (begin and end dates). Describe the study's purpose, identify primary outcome measures, and highlight the major demographic characteristics of the target population being studied. Indicate the number of study participants enrolled and provide an explanation for any significant changes in the number of enrollees in the comment section. List all collaborating organizations (in addition to RFCC entities) that are involved in the research activity. Provide a percent estimate of their involvement in the project, as well as any money or in-kind contributions made by the organizations (indicate what the contribution was). Lastly, summarize any interim findings to date for each research activity, as well as any major challenges encountered that may affect the completion of the research activity.
PROJECT STATUS (New or Ongoing) & START DATE PROJECT LEADER (name of organization) RESEARCH ACTIVITY / PROGRAM TITLE EXPECTED DURATION OF RESEARCH ACTIVITY PRIMARY GOAL(S) of RESEARCH ACTIVITY1 DEMOGRAPHIC CHARACTERISTICS OF TARGET RFCC POPULATION BEING STUDIED2 PRIMARY OUTCOME MEASURES NUMBER OF ENROLLEES COLLABORATING ORGANIZATIONS INTERIM STUDY FINDINGS / MAJOR CHALLENGES ENCOUNTERED
NAME PERCENT INVOLVEMENT MONETARY FUNDING (dollar amount) IN-KIND CONTRIBUTION(S) (type of contribution)
New (01/15/06) RFCC XYZ Example: Domestic Violence Reporting in Native American Women (01/15/06 -06/30/06) Goal: To identify barriers to domestic violence reporting in Native American women, and develop programs to address these barriers Native American women
50 University of XYZ 70% $50,000 none INTERIM STUDY FINDINGS : Population lacks knowledge of available resorces
MAJOR CHALLENGES ENCOUNTERED: Difficult retaining study participants. Large gaps in follow up data.















































































































































COMMENTS:











1Provide a brief description of the research activity, including its purpose and the outcome measures being investigated.











2Such as Elderly, Hispanics, etc.












Sheet 5: Education & Outreach

RFCC NAME: ____________________________ REPORT DATE: _______________ QUARTER: ___________________























PUBLIC EDUCATION AND OUTREACH





















Please list each educational activity and provide a brief description of each activity your RFCC participated in or coordinated during this quarter. For each activity, include the year your RFCC first offered or participated in the activity, list the organizations (in addition to the RFCC) that are involved in conducting, coordinating, or holding the education/outreach effort (indicate if the organization is a partner (P) or non-partner (NP)). Include the number of times the activity was conducted during this quarter. Estimate the total number of attendees, as well as total attendees by gender and percentage in each age group where possible (age groups: 0-17, 18-30, 31-45, 46-55, 56-70, and 70+). Also estimate, to the best of your ability, the percent of participation by race/national origin (C=Caucasian, non-Hispanic, AA=African American, non-Hispanic, A=Asian, P= Native Hawaiian or Other Pacific Islander, HC=Hispanic Caucasian, HA=Hispanic African American, O=Other (describe 'Other' in the comments section)). The Comments row (located at the bottom of this page) may include more specific information about the education or outreach event and/or the group targeted to receive the education. Also list the types of materials distributed during the activity.

*Be sure to include any activities conducted by your community partners for the RFCC program.*





















ACTIVITY DESCRIPTION YEAR RFCC FIRST OFFERED ACTIVITY PARTICIPATING ORGANIZATIONS (P = partner, NP = non-partner) NUMBER OF ACTIVITIES (This Qtr) NUMBER OF ATTENDEES (estimate) AGE GROUPS RACE/ NATIONAL ORIGIN MATERIALS DISTRIBUTED





Male Female 0-17 18-29 30-44 45-54 55-69 70+ C AA A P H HC HA O

Example: Health Fair Focus on women’s preventive care 2005 Wellness Center (P) 1 3 62 0% 50% 25% 25% 0% 0% 95% 5% 0% 0% 0% 0% 0% 0% Breast Cancer screening brochure
Example: Presentation Healthy Living 2005 Hospital (NP) 1 17 20 0% 3% 55% 30% 10% 2% 0% 100% 0% 0% 0% 0% 0% 0% Daybooks, pamphlets




















































































































































































































































































COMMENTS:






Sheet 6: Leadership

RFCC NAME: ____________________________ REPORT DATE: _______________ QUARTER: ___________________












LEADERSHIP DEVELOPMENT AND ADVOCACY TRAINING










For each leadership development activity listed in the far left column, please provide a description of the type(s) of activities conducted this quarter (include the goal of the activity). Include the year your RFCC first offered the activity, the number of participants by race/national origin (C=Caucasian, non-Hispanic, AA=African American, non-Hispanic, A=Asian, P= Native Hawaiian or Other Pacific Islander, HC=Hispanic Caucasian, HA=Hispanic African American, O=Other) and the audience type (such as high school students, expectant mothers, or senior citizens).
Please include only one activity per row. If your RFCC provides more than one program for any of the activities listed in the left hand column, then copy and paste the activity in a new row and complete the row per the above instructions. *Be sure to include any activities conducted by your community partners for the RFCC program.*
ACTIVITY DESCRIPTION/ GOALS YEAR RFCC FIRST OFFERED ACTIVITY NUMBER OF ATTENDEES AUDIENCE



C AA A P H HC HA O
Example: Women's Leadership Institute Training Session Goal: To empower nurse practitioners to be leaders in rural areas by presenting the importance of their role in delivering services in underserved areas. 2005 0 5 0 5 0 0 0 0 Nurse practitioners
Description: Training session for nurse practitioners on their role in the delivery of women's healthcare services in rural areas. Curriculum developed by XYZ organization.
Example: Mentoring and recruitment of women in health professions Goal: To educate high school students on careers in healthcare. 2005 13 11 0 0 9 0 0 0 High school students
Description: Two hour class that combined lecture and question and answer session on current issues and problems with women's healthcare in the community and various workforce positions that are needed.








































































COMMENTS:
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