Form rh4

OMB No. 0915-xxxx

Expiration Date:

Office of Rural Health Policy: Rural Health

Community-Based Grant Programs

Performance Improvement and Measurement System (PIMS) Database

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-xxxx. Public reporting burden for this collection of information is estimated to be 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

Small Health Care Provider Quality Improvement Grant Program

Table 1: ACCESS TO CARE

1	Total number of people (unduplicated encounters) served.	Number
2	Total number of encounters.	Number
3	Number of people in the target population.	Number
4	Number of people in the target population with access to new/expanded programs/services.	Number
5	Number of new and/or expanded services provided.	Number
6	Type(s) of new and/or expanded services provided. (Check all that apply)	Selection list
	Primary Care
	Mental / Behavioral Health
	Oral Health
	Telehealth / Telemedicine
	Health Literacy / translation services
	Pharmacy
	Case Management
	Diabetes / Obesity Management
	Substance Abuse Treatment
	Health Promotion / Disease Prevention
	Health Education
	Transportation
	Nutrition
	Other

Table Instructions: Access to Care

Information collected in this table provides an aggregate count of the number of people served (unduplicated encounters) and the total number of encounters the program is providing. Please refer to the detailed definitions for encounters.

Provide the total number of people served (unduplicated encounters); the total number of encounters, and the total number of people in the target population as defined by your project and the number of people in the target population that has access to new or expanded services and/or programs. Please provide the total number of new and/or expanded services provided and then select the type(s) of services. Please check all that apply.

If your grant project was not funded to specifically provide these services, please do not select them, even is your organization offers those services.

Table 2: POPULATION DEMOGRAPHICS

7	Number of people served by ethnicity:	Number
	Hispanic or Latino
	Not Hispanic or Latino
8	Number of people served by race:	Number
	Black or African American
	Asian
	American Indian or Alaska Native
	Native Hawaiian or Other Pacific Islander
	White
	More than one race
	Unknown
9	Number of people served by age group that received services:	Number
	Children (0-12)
	Teens (13-17)
	Adults (18-64)
	Elderly (64 and over)

Table Instructions: Population Demographics

Please provide the total number of people served by race, ethnicity, and age.

Table 3: UNDER & UNINSURED

10	Number of total people enrolled for public assistance, i.e., Medicare, Medicaid, and SCHIP.	Number
11	Number of people who pay out-of-pocket for all or part of the services received.	Number
12	Number of people who use third-party payments to pay for all or part of the services received.	Number
13	Number of people who receive charity care.	Number

Table Instructions: Underinsured & Uninsured

For your project, please provide the total number of under/uninsured people enrolled in public assistance, pay out-of-pocket, use third-party payments or receive charity care. Please refer to the detailed definitions for underinsured.

Table 4: WORKFORCE/ RECRUITMENT & RETENTION

14	Type(s) of new Clinical staff recruited to work on the project:	Number
	General Physician
	Specialty Physician
	Physician Assistant
	Dentist
	Dental Hygienist
	Psychologist
	Pharmacist
	Nurse
	Health Educator / Promotoras
	Licensed Clinical Social Worker
	Therapist (Behavioral, PT, OT, Speech, etc)
	Technicians (medical, pharmacy, laboratory, etc)
	Other
	None
15	Type(s) of new Non-Clinical staff recruited to work on the project:	Number
	HIT/CIO
	Case Manager
	Medical Biller / Coder
	Translator
	Enrollment Specialist
	Other
	None
16	Number of people trained.	Number

Table Instructions: Workforce/ Recruitment and Retention

Please provide the number of clinical and non-clinical staff recruited and trained on the project. If your grant project funds did not contribute to recruitment or retention of these staff, please type N/A for not applicable.

Table 5: SUSTAINABILITY

17

Annual project revenue made through the new or expanded services offered through the project.

Dollar amount

Table Instructions: Sustainability:

Please provide the amount of annual revenue the project has made through new and expanded services. If your grant project has not received any additional funding, please type N/A for not applicable.

Table 6: QUALITY

18

Number of clinical guidelines / benchmarks adopted

Number

Table Instructions: Quality

Report the number of clinical guidelines/benchmarks adopted. If your grant project did not fund this, please type N/A for not applicable.

Table 7: HEALTH PROMOTION/DISEASE MANAGEMENT

19

Number of health promotion/disease management activities offered to the public through this project.

Number

Table Instructions: Health Promotion and Disease Management

Report the number of health promotion/disease management activities offered to the public through this project. If your grant project did not fund these services, please type N/A for not applicable.

Table 8: CLINICAL MEASURES

1	Average HbA1c for diabetic patients in the electronic patient registry system (Goal: Average HbA1c of less than 7 percent)	Number
2	Percent of Patients with blood pressure less than 130/80 mm/Hg (Goal: less than 40 percent of patients with a diagnosis of diabetes mellitus have blood pressure of less than 130/80 mm/Hg.)	Number
3	Percent of Patients with LDL less than 100 mg/dL (Goal: Greater than 70% of patients with a diagnosis of diabetes mellitus have LDL <100mm/dL.)	Number
4	Percent of Patients with blood pressure <140/90 mm/Hg (Goal: Greater than 40% of patients with a diagnosis of cardiovascular disease have blood pressure of <140/90 mm/Hg.)	Number
5	Percent of Patients with LDL <130 mg/dL (Goal: Greater than 70% of patients with a diagnosis of cardiovascular disease have LDL <130mm/dL.)	Number
6	Percent of Patients who are current smokers (Goal: Less than 12% of patients with a diagnosis of cardiovascular are current smokers.)	Number

Table Instructions: Clinical Measures

Please use your electronic patient registry system to extract clinical data requested. Please refer to the specific definitions for each field below.

Measure 1: On the last workday of each month, search the clinical information system for all patients with a diagnosis of DM who have had an HbA1c in the past 12 months. Add all of these patients’ most recent HbA1c values together and divide by the number of such persons.

Measure 2:

The number of diabetic patients in the clinical information system with blood pressure reading less than 130/80 at last reading within the past 12 months, divided by the diabetic patients in the clinical information system with a documented blood pressure in the last 12 months. Multiply by 100 to get percentage.

Measure 3:

The number of diabetic patients in the clinical information system whose most recent fasting LDL was less than 100 (in the last 12 months), divided by the number of patients with a fasting LDL in the past 12 months. Multiply by 100 to get percentage.

Measure 4:

The number of patients with a diagnosis of cardiovascular disease in the clinical information system with blood pressure reading less than 140/90 at last reading within the past 12 months, divided by the patients in the clinical information system with a documented blood pressure in the last 12 months. Multiply by 100 to get percentage.

Measure 5:

The number of patients with a diagnosis of cardiovascular disease in the clinical information system whose most recent fasting LDL was less than 130 (in the last 12 months), divided by the number of patients with a fasting LDL in the past 12 months. Multiply by 100 to get percentage.

Measure 6:

The number of patients with a diagnosis of cardiovascular disease in the registry who are current smokers (documented within the last 12 months), divided by the total number of patients in the registry with smoking status documented within the last 12 months. Multiply by 100 to get percentage.

Definition of Key Terms for Rural Health Community-Based Grant Programs

Charity Care: any services provided free of cost or reimbursement

Consortium/Network: Comprised of at least 3 separately owned organizations that are working together towards the project’s goals and objectives. Specifically respond only for the formal member organizations, for the purposes of your grant project.

Medical Home: provides patients with continuous access to services.

Target Population: The population identified by the grant project to receive services.

Total Encounters: The number of documented services provided to all individuals.

Total Non Duplicated Encounters: The number of unique individual users who have received documented services.

Underinsured: A person who has health insurance but face significant cost sharing or limits on benefits that may affect its usefulness in accessing or paying for needed health services and/or who may lack continuous access to health insurance coverage.