Form 2 Rhnd

Rural Health Community-Based Grant Program

Network Development Program PIMS Measures--FINAL

Rural Health Network Development

OMB: 0915-0319

Document [docx]
Download: docx | pdf

OMB No. 0915-0319

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 0915-0319. Public reporting burden for this collection of information is estimated to be 2.75 hours 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.


Rural Health Network Development Grant Program


Table 1: ACCESS TO CARE

Table Instructions: Access to Care

Information collected in this table provides an aggregate count of the number of counties within the service area and the number of people targeted within the service area, which may or may not be the total population residing within the service area. Please indicate a numerical figure or DK for do not know, if applicable.

Number of counties

  • Denotes the number of counties served through the program. Please include entire, as well as partial counties served through the grant program. If your program is serving only a fraction of a county, please count that as one (1) county.

Number of people in target people in target population

  • Denotes the number of people in your target population (not necessarily the number of people who availed your services). For example, if the network focuses its mission on serving a particular population such as migrant and seasonal farm workers, then the migrant and seasonal farm workers may be a subset of the total population within the service area.


1

Number of counties:

(If you serve a sub-county area please count this as 1)

Number/DK


Number of counties served in program


2

Number of people:

Number/DK


Number of people in the target population (service area)




Table 2: POPULATION DEMOGRAPHICS

Table Instructions: Population Demographics

Please provide the number of people in target population by race, ethnicity, and age. The target population may or may not be the total population residing within the service area. If the number of people is zero (0), please put zero in the appropriate section, do not leave any sections blank.

Number of people served through program by ethnicity (Hispanic or Latino/Not Hispanic or Latino)

  • Hispanic or Latino origin includes Mexican, Mexican American, Chicano, Puerto Rican, Cuban and other Hispanic, Latino or Spanish origin (i.e. Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard etc.)


3

Number in target population by ethnicity:

Number





Hispanic or Latino






Not Hispanic or Latino






Unknown





4

Number in target population by race:

Number

DK



American Indian/Alaska Native





  

Asian





Black or African American





Native Hawaiian/Other Pacific Islander

 




White





More than one race





Unknown

 




5

Number in target population by age group:

Number

0

DK

 

 

 

 

Children (0-12)

 




Adolescents (13-17)

 




Adults (18-64)

 




Elderly (65 and over)

 





Unknown







Table 3: UNINSURED

Table Instructions: Uninsured

This table indicates the number of uninsured users receiving preventative and primary care as a result of your Network activities. Please respond to the following questions based on these guidelines:


Number of uninsured people receiving preventive and /or primary care

  • Uninsured is defined as those without health insurance and those who have coverage under the Indian Health Service only

Number of total people enrolled in public assistance (i.e. Medicare, Medicaid, SCHIP or any State-sponsored insurance)

  • Denotes the number of people who are uninsured but are enrolled in any of these public assistance insurance programs

Number of people who use private third-party payments to pay for the services received

  • Denotes number of people who use private third-party payers such as employer-sponsored or private non-group insurance to pay for health services

Number of people who pay out-of-pocket for the services received

  • Denotes the number of people who are uninsured, not enrolled in any public assistance (i.e. Medicare, Medicaid, SCHIP or State-sponsored insurance), not enrolled in private third party insurance (i.e. employer-sponsored insurance or private non-group insurance) and does not receive health services free of charge

Please indicate a numerical figure or DK if you do not know. If your grant program was not funded to provide these services, please type N/A for not applicable.


6

Number of uninsured people receiving preventive and/or primary care.

Number /DK/NA

7

Number of total people enrolled for public assistance, i.e., Medicare, Medicaid, SCHIP, state-sponsored insurance.

Number /DK/NA

8

Number of people who use private third-party payments to pay services received, i.e. employer-sponsored, private non-group.

Number /DK/NA

9

Number of people who pay out-of-pocket for services received.

Number /DK/NA

10

Number of people who receive health services free of charge, i.e. no public or private third party payers.

Number/DK/NA



Table 4: STAFFING

Please provide the number of clinical and non-clinical staff recruited on the program and the number of staff that are shared between two or more Network partners. Please provide the number of new staff that are recruited and retained for at least six months during the respective budget year. If a number is zero (0), please put zero in the appropriate section. Do not leave any sections blank. There should not be a N/A (not applicable) response since all measures are applicable.


11

Number of new clinical staff recruited to work on the program:

Number


Dentist

 


Dental Hygienist

 


Health Educator / Promotoras

 


Licensed Clinical Social Worker

 



Nurse

 


Pharmacist

 


Psychologist

 


Physician, General

 


Physician, Specialty

 


Physician Assistant

 


Therapist (Behavioral, PT, OT, Speech, etc)

 


Technicians (medical, pharmacy, laboratory, etc)

 


Other – Specify type

 


None

 Selection List

12

Number of new non-clinical staff recruited to work on the program:

Number


Case Manager

 


Enrollment Specialist

 


HIT/CIO

 


Medical Biller / Coder

 


Translator

 


Other – Specify Type

 


None

 Selection List

13

Number of all staff positions

Number


Number of staff positions shared between two or more Network Partners



Number of new staff recruited by the Network



Number of new staff retained by the Network for at least six months



Percentage of new staff retained

Percent (automatically calculated by the system)


Table 5: WORKFORCE/ RECRUITMENT & RETENTION

Table Instructions: Workforce/ Recruitment and Retention

If your grant funds support traineeships, please provide the number of trainees by type, select the trainee primary care focus area and select the types of training sites. If your grant funds support traineeships, please indicate either a numerical figure, DK for do not know or N/A for not applicable.


14

Number of new trainees by each type

Number/NA/DK


Students

 


Residents

 

15

Trainee primary care focus area(s):

(Please check all that apply)

Selection list


Medical



Mental/Behavioral Health



Oral Health


16

Types of training site(s):

Selection list


Clinic



Community Health Center



Critical Access Hospital



Federally Qualified Health Center (FQHC)



Health Department



Indian Health Service (IHS) or Tribal Health Sites



Migrant Health Center (MHC)


Rural Health Clinic



Other Rural Hospital



Other Community Based Site – Please specify



Unknown




Table 5: NETWORK

Table Instructions: Network

Please identify the types of formal member organizations in the consortium or network by non-profit and for-profit status for your program. Please indicate a number for each category. Please provide the total number of member organizations in the consortium or network. Then, out of the total number of organizations in consortium/network, please provide the total number of new member organizations acquired within the budget year.  Please refer to the detailed definitions for consortium/networks, as defined in the program guidance. Please select the focus area(s) of the consortium/network for the budget year.


18

Type(s) of member organizations in the Consortium / Network

Number

Non-Profit Organization:

Area Health Education Center (AHEC)


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Community College

 

Community Health Center

 

Critical Access Hospital

 

Faith-based organization

 

Free Clinic

 

Health Department

 

Hospital

 

Migrant Health Center

 

Private Practice

 

Rural Health Clinic

 

School District

 

Social Services Organization

 

University

 

Other – Specify Type:

 

TOTAL for Non-Profit Organization

 Number (automatically calculated by the system)

For-Profit Organization: 

Community College



Community Health Center


Critical Access Hospital



Faith-based organization


Organization Free Clinic



Health Department


Hospital



Migrant Health Center


Private Practice



Rural Health Clinic


School District



Social Services


University



Other – Specify Type:


TOTAL for For-Profit Organization

 Number (automatically calculated by the system)

19

Total number of member organizations in the Consortium/Network:

Number

20

Total number of new member organizations in the Consortium/Network:

Number

21

Focus area(s) of the Consortium/Network (Check all that apply)

Selection list


Cardiovascular Disease



Case Management



Diabetes/Obesity Management



Elderly Geriatric Care



Emergency Medical Services (EMS)



Health Education



Health Literacy/Translation Services



Health Promotion/Disease Prevention



Maternal and Child Health/Women’s Health School Board



Mental/Behavioral Health



Network Development Activities



Nutrition



Oral Health



Pharmacy



Primary Care



Substance Abuse Treatment



Telehealth/Telemedicine



Transportation



Workforce



Other – Specify Type:



Table 6: SUSTAINABILITY

Table Instructions: Sustainability:

Please provide the following funding/revenue amounts:

  • The annual program award based on box 12a of your Notice of Grant Award (NGA).

  • The amount of annual revenue (if any) for the Network.

  • The amount of additional funding secured to sustain the program.

  • Please provide the estimated amount of savings incurred due to participation in a network/consortium

  • Please indicate if you have a sustainability plan and select your sustainability activities.

If the total amount of additional funding secured is zero (0), please put zero in the appropriate section. Do not leave any sections blank.


Please identify the sources(s) of revenue for sustainability and indicate if you have developed a sustainability plan. Please identify the types of sustainability activities that the network/consortium engaged in during the respective budget year; please check all that apply.


Please indicate if you used HRSA’s Economic Impact Analysis Tool (website TBD). If so, please provide the ratio for Economic Impact vs. HRSA Program Funding.


For networks/consortiums in Year 3 of grant funding, please indicate the following:

  • If your current network/consortium will sustain after the grant period is over

  • If any of your network’s/consortium’s activities will sustain after the grant period

  • If your network’s/consortium’s objectives have been met as a result of grant funding


22

Funding/Revenue:

Dollar Amount


Annual program award



Annual network revenue



Additional funding secured to assist in sustaining the program



Estimated amount of cost-savings due to participation in the network


23

Sources of Revenue:

(Check all that apply)

Selection list

 

 

 

 

 

 

Network/Consortium revenue

 

In-Kind Contributions

 

Member Fees

 

Fundraising


Contractual Services

 

Other – Specify Type:

 

Other grants


None


Has a sustainability plan been developed using sources of funding besides grants?

Y/N

24

Sustainability Activities:

(Check all that apply)

Selection list


Local, State and Federal policy changes



Media campaigns



Consolidation of activities, services and purchases



Communication plan development



Economic impact analysis



Return on investment analysis



Marketing plan development



Community engagement activities



Business plan development



Incorporation



Organization bylaws



SWOT analysis



Other – Specify activity:


25

Did you use the HRSA Economic Impact tool?

Y/N

26

If yes, what was ratio for Economic Impact vs. HRSA Program Funding

Number

27

Will the Network/Consortium sustain?

Y/N

28

Will any of the activities of the Network/Consortium sustain?

Y/N

29

Have the objectives of the Network/Consortium been met?

Y/N



Table 7: HEALTH INFORMATION TECHNOLOGY

Table Instructions: Health Information Technology (HIT)

Please select all types of technology implemented, expanded or strengthened through this program. If your grant program did not fund these activities, please select “Not Applicable. Please select all of the Meaningful Use Stage criteria achieved through this program. Please specify the Health Information Technology (HIT) Meaningful Use Stage (1, 2, or 3) that the network/consortium organization as a whole has attained. If the network/consortium has been funded to do these activities but has not acquired HIT, please mark “None”. Please refer to the detailed definition for consortium/networks, as defined by program guidance and please refer to the detailed definition for HIT Meaningful Use Stage.


26

Type(s) of technology implemented, expanded or strengthened through this program: (Check all that apply)

Selection list


Computerized laboratory functions

 


Computerized pharmacy functions



Electronic clinical applications



Electronic medical records

 


Health Information Exchange

 


Patient/Disease Registry

 


Telehealth/Telemedicine

 


Other – Please specify criteria

 


None

 


Not Applicable


27

HIT Meaningful Use Stage implementation criteria through this program (Check all that apply)

Selection list


Meaningful Use Stage 1

 


Initiating the reporting of clinical quality measures and public health information



Electronically capturing health information in a coded format



Using health information to track key clinical conditions



Communicating health information for care coordination purposes



Establishing the functionalities in certified EHR technology allowing for continuous quality improvement and information exchange ease



Other – Please specify criteria



None



Not Applicable



Meaningful Use Stage 2



Disease management



Clinical decision support



Medication management



Quality measurement and research



Other – Please specify criteria



Meaningful Use Stage 3



Achieving improvements in quality, safety and efficiency



Decision support for national high priority conditions



Patient access to self-management tools



Access to comprehensive patient data



Improving population health outcomes



Other – Please specify criteria



None



Not Applicable


28

Consortium/Network Classification by HIT Meaningful Use Stage:

(Please check one)

Selection list


Stage 1



Stage 2



Stage 3



None



Not applicable




Table 8: FOCUS AREAS


29

Number of quality improvement clinical guidelines / benchmarks adopted by network

Number

30

Number of network members using shared standardized quality improvement benchmarks

Number

31

Average amount of dollars saved per patient through joint purchasing of drugs by Network

Dollar Amount

32

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

Number

33

Number of network members integrating primary and mental health services.

Number

34

Number of network members integrating primary and dental / oral health services.

Number


Table Instructions: Focus Areas

Report the number of quality improvement clinical guidelines/benchmarks adopted and the number of network members using shared standardized benchmarks. Report the average amount of dollars saved by joint purchasing of drugs by network. Report the number of health promotion/disease management activities offered to the public through this program. Some examples include: health screenings, health education, immunizations, etc. Report the number of network members integrating primary and mental health services. Report the number of network members integrating oral health services. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.





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 program’s goals and objectives. Specifically respond only for the formal member organizations, for the purposes of your grant program.



HIT Meaningful Use Stage: *Meaningful Use Criteria as proposed by the Centers of Medicare and Medicaid Services (CMS). Eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs), which participate in Medicare and Medicaid programs, that adopt and successfully demonstrate meaningful use of certified electronic health record (EHR) technology may receive CMS incentive payments. CMS incentives are linked to each Meaningful Use Stage and a timeframe for completion. Each Stage Criteria and its respective timeframe are as follows:

  • Stage 1 Criteria* (up through 2013)

    • Electronically capturing health information in a coded format

    • Using that information to track key clinical conditions

    • Communicating that information for care coordination purposes

    • Initiating the reporting of clinical quality measures and public health information. (25 objectives/measures for eligible providers and 23 objectives/measures for eligible hospitals)

    • Establishing the functionalities in certified EHR technology allowing for continuous quality improvement and information exchange ease

  • Stage 2 Criteria* (met by end of 2014)

    • Disease management

    • Clinical decision support

    • Medication management

    • Support for patient access to their health information

    • Transitions in care

    • Quality measurement and research

    • Bi-directional communication with public health agencies

  • Stage 3 Criteria* (met by end of 2015)

    • Achieving improvements in quality, safety and efficiency

    • Decision support for national high priority conditions

    • Patient access to self-management tools

    • Access to comprehensive patient data

    • Improving population health outcomes


Medical Home: provides patients with continuous access to services.


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





27


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePublic Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of info
AuthorHRSA
File Modified0000-00-00
File Created2021-02-01

© 2024 OMB.report | Privacy Policy