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 program is 0915-0319. Public reporting burden for this collection of information is estimated to be 3.12 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.
Delta States Rural Development Network Grant Program
Table 1: ACCESS TO CARE
Instructions:
Information collected in this table provides an aggregate count of the number of people served through program. Please refer to the detailed definitions and guidelines in answering the following measures. Please indicate a numerical figure if applicable, N/A if not applicable and DK if unknown.
Number of counties served
Denotes the total 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 population
Denotes the number of people in your target population (not necessarily the number of people who availed your services). For example, if a grantee organization’s target population is females in county A, then the grantee organization reports the number of females that resides in county A.
Number of Direct Unduplicated Encounters
Denotes the number of unique individuals in the target population who have received documented services provided directly to the patient (patient visits, health screenings etc.)
Denotes the number of people served in your target population
Number of Indirect Encounters
Denotes the number of people reached through mass communication methods, such as mailings, posters, flyers, brochures, etc.
Number of Direct Duplicated Encounters
Denotes the total number of activities done through the program.
Type(s) of services provided through program funding
Please check the box that applies to your program
Table 1: ACCESS TO CARE
1 |
Number of counties served |
Number |
2 |
Number of people in the target population |
Number |
3 |
Number of direct unduplicated encounters |
Number |
4 |
Number of direct duplicated encounters |
Number |
5 |
Number of indirect encounters |
Number (automatically calculated by the system) |
6 |
Type(s) of services provided through grant funding. (Check all that apply) |
Selection list |
|
Cardiovascular Disease (CVD) |
|
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 |
|
|
Mental/Behavioral Health |
|
|
Nutrition |
|
|
Oral Health |
|
|
Pharmacy |
|
|
Primary Care |
|
|
Substance abuse treatment |
|
|
Telehealth/telemedicine |
|
|
|
Transportation |
|
|
Workforce |
|
|
Other |
|
Table 2: POPULATION DEMOGRAPHICS
Instructions: Please provide the total number of people served by race, ethnicity, and age. The total for each of the following questions should equal to the total of the number of direct unduplicated encounters provided in the previous section (Access to Care section). Please indicate a numerical figure. There should not be a N/A (not applicable) response since all measures are applicable.
Number of people served 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.)
7 |
Number of people served through the program by ethnicity: |
Number |
|
Hispanic or Latino |
|
|
Not Hispanic or Latino |
|
|
Unknown |
|
8 |
Number of people served by race: |
Number |
|
American Indian/Alaska Native |
|
Asian |
|
|
Black or African American |
|
|
Native Hawaiian/Other Pacific Islander |
|
|
White |
|
|
More than one race |
|
|
Unknown |
|
|
9 |
Number of people served by age group |
Number |
|
Children (0-12) |
|
Adolescents(13-17) |
|
|
Adults (18-64) |
|
|
Elderly (65 and over) |
|
|
|
Unknown |
|
Table 3: UNDER & UNINSURED
Instructions:
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
The response should be based of the total number of direct unduplicated encounters provided on ‘Access to Care’ section
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 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
If your grant program was not funded to provide these services, please type N/A for not applicable.
Table 3: UNINSURED
10 |
Number of under/uninsured people receiving preventive and/or primary care. |
Number |
11 |
Number of total people enrolled for public assistance, i.e., Medicare, Medicaid, SCHIP, or state sponsored insurance. |
Number |
12 |
Number of people who use private third-party payments to pay for services received. |
Number |
13 |
Number of people who pay out of pocket for services received. |
|
14 |
Number of people who received health services free of charge. |
Number |
Table 4: STAFFING
Instructions:
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 indicate a numerical figure. There should not be a N/A (not applicable) response since all questions are applicable.
Table 4: Staffing
15 |
Type(s) of new Clinical staff recruited to work on the program: |
Number |
|
Dental Hygienist |
|
Dentist |
|
|
Health Educator / Promotoras |
|
|
Licensed Clinical Social Worker |
|
|
Nurse |
|
|
Pharmacist |
|
|
Physician Assistant |
|
|
Physician, General |
|
|
Physician, Specialty |
|
|
Psychologist |
|
|
Technicians (medical, pharmacy, laboratory, etc) |
|
|
Therapist (Behavioral, PT, OT, Speech, etc) |
|
|
Other – Specify Type(s) |
|
|
None |
Selection list |
|
16 |
Type(s) of new Non-Clinical staff recruited to work on the program: |
Number |
|
HIT/CIO |
|
Case Manager |
|
|
Medical Biller / Coder |
|
|
Translator |
|
|
Enrollment Specialist |
|
|
Other |
|
|
None |
|
|
17 |
Number of staff positions shared between two or more Network partners. |
Number |
Table 5: NETWORK
Instructions:
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.
18 |
Type(s) of member organizations in the consortium/network. (Check all that apply) |
Selection list |
Non-profit Organization
|
AHEC |
|
Community College |
|
|
Community Health Center |
|
|
Critical Access Hospital |
|
|
Faith-Based Organization |
|
|
For-profit organization |
|
|
Health Department |
|
|
Hospital |
|
|
Private Practice |
|
|
Rural Health Clinic |
|
|
School District |
|
|
Social Services Organization |
|
|
University |
|
|
Other |
|
|
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 |
|
|
Health Department |
|
|
Hospital |
|
|
Migrant Health Center |
|
|
Non-profit Organization |
|
|
Private Practice |
|
|
Rural Health Clinic |
|
|
School District |
|
|
Social Services Organization |
|
|
University |
|
|
Other |
|
|
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 Members in the Consortium/Network ( for current report year) |
Number |
Table 6: SUSTAINABILITY
Instructions:
Please provide the annual program award based on box 12a of your Notice of Grant Award (NGA).
Please provide the amount of annual revenue the program has made through the services offered through the program. If the total amount of annual revenue made is zero (0), please put zero in the appropriate section. Do not leave any sections blank.
Please provide the amount of additional funding secured to sustain the program. 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 provide the estimated amount of savings incurred due to participation in a network/consortium. If the total amount of savings incurred is zero (0), please put zero in the appropriate section. Do not leave any sections blank.
Select the type(s) of sources of funding for sustainability. Please check all that apply.
Please indicate if you have a sustainability plan and select your sustainability activities. 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 programs that are in Year 3 of grant funding, please indicate the following:
Please indicate if your current network/consortium will sustain after the grant period is over
Please indicate if any of your program’s activities will sustain after the grant period.
21 |
Annual program award |
Dollar amount |
22 |
Annual program revenue |
Dollar amount |
23 |
Additional funding secured to assist in sustaining the project |
Dollar amount |
24 |
Estimated amount of cost savings due to participation in network/consortium |
Dollar amount |
25 |
Sources of Sustainability |
Selection list |
|
Program Revenue |
|
|
In-kind Contributions |
|
|
Member fees |
|
|
Fundraising |
|
|
Contractual Services |
|
|
Other grants |
|
|
Other – specify type |
|
|
None |
|
26 |
Has a sustainability plan been developed using sources of funding besides grants? |
Y/N |
27 |
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 |
|
|
SWOT Analysis |
|
|
Other – Specify activity |
|
28 |
Did you use the HRSA Economic Impact Analysis tool |
Y/N |
29 |
If yes, what was ratio for Economic Impact vs. HRSA Program Funding |
Number |
30 |
Will the network/consortium sustain |
Y/N |
31 |
Will the program’s activities be sustained after the grant period |
Y/N |
Table 7: HEALTH INFORMATION TECHNOLOGY
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 services, please select none.
32 |
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 |
|
|
None |
|
Table 8: QUALITY IMPROVEMENT
Instructions:
Report the number of quality improvement clinical guidelines/benchmarks adopted and the number of network members using shared standardized benchmarks. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.
33 |
Number of quality improvement clinical guidelines / benchmarks adopted by network/consortium |
Number |
34 |
Number of network/consortium members using shared standardized quality improvement benchmarks |
Number |
Table 9: PHARMACY
Instructions:
Report the overall annual dollars saved by joint purchasing of drugs through your network/consortium. Report the number of people receiving prescription drug assistance and the annual average amount of dollars saved per patient through prescription drug assistance. If your grant program did not fund these services, please type N/A for not applicable.
35 |
Average amount of dollars saved per patient through prescription drug assistance annually |
Dollar Amount |
36 |
Number of people receiving prescription drug assistance annually |
Number |
Table 10: HEALTH PROMOTION/DISEASE MANAGEMENT
Instructions:
Number of health promotion/disease management activities offered to the public through this program
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.
Number of people referred to health care provider/s
Report the number of people that were referred to a health care provider. The response to this question should be based on the number reported in the previous question (Number of health promotion/disease management activities offered to the public through this program). Therefore, the number reported here should not be more than the number reported in the previous question.
Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.
37 |
Number of health promotion/disease management activities offered to the public through this program. |
Number |
38 |
Number of people referred to health care provider/s |
Number |
Table 11: MENTAL/BEHAVIORAL HEALTH
Instructions: Report the number of people receiving mental and/or behavioral health services through your program and the number of network members integrating primary and mental health services. If your grant program did not fund these services, please type N/A for not applicable.
Table 11: MENTAL/BEHAVIORAL HEALTH
39 |
Number of people receiving mental and/or behavioral health services in target area. |
Number |
40 |
Number of network members integrating primary and mental health services. |
Number |
Table 12: ORAL HEALTH
Instructions:
Report the number of people receiving dental/oral health services in target area, select the appropriate types of services and provide the number of network members integrating oral health services. Please check all that apply. If your grant program did not fund these services, please type N/A for not applicable.
41 |
Number of people receiving dental/oral health services in target area. |
Number |
42 |
Type(s) of dental / oral health services provided. (Check all that apply) |
Selection list |
|
Screenings / Exams |
|
Sealants |
|
|
Varnish |
|
|
Oral Prophylaxis |
|
|
Restorative |
|
|
Extractions |
|
|
Other |
|
|
Not Applicable |
|
|
43 |
Number of network members integrating primary and dental / oral health services. |
Number |
Table 14: CLINICAL MEASURES
Instructions:
Please refer to the specific instructions for each field below. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.
Measure 1:
Numerator: Patients from the denominator that have the most recent blood pressure less than 140/190 mm Hg, within the last 12 months.
Denominator: All patients 18-85 years of age seen at least once during the last 12 months with a diagnosis of hypertension within 6 months after measurement start date.
Measure 2
Numerator:
Number of adult patients in the target population that have been
screened for depression.
Denominator: All patients
≥ 18 years of age in the target population.
Measure 3:
Numerator: Number of patients 18-75 years of age whose most recent hemoglobin A1c level during the measurement year is less than 8.0%
Denominator: Number of patients 18-75 years of age during measurement year with a diagnosis of type 1 or type 2 diabetes.
Measure 4:
Numerator: Number of patients 18-75 years of age with diabetes (type 1 or type 2) who had blood pressure less than 140/90 mm/Hg
Denominator:
All patients 18-75 years of age during measurement year with a
diagnosis of type 1 or 2 diabetes.
Measure 5:
Numerator: Patients in the denominator with Body Mass Index (BMI) percentile documentation, counseling for nutrition, counseling for physical activity during the measurement year
Denominator: All patients 2-17 years of age
Measure 6:
Numerator: Patients in denominator with (1) Body Mass Index (BMI) charted and (2) follow-up plan documented if patient is overweight and underweight
Denominator: All patients age 18 years or older
Measure
7:
Numerator:
Number of children who have received four diphtheria, tetanus and
acellular pertussis (DTaP); three polio (IPV); one measles, mumps and
rubella (MMR); two H influenza type B (HiB); three hepatitis B
(HepB); one chickenpox (VZV); four pneumococcal conjugate (PCV); two
hepatitis A (Hep A); two or three rotavirus (RV); and two influenza
(flu) vaccines by their second birthday. The measure calculates
a rate for each vaccine and nine separate combination
rates.
Denominator: Number of children who turn two years
of age during the measurement year.
Measure 8:
Numerator:
Number of adolescents who have received a second MMR, completion of
three hepatitis B (HepB) and Varicella (VZV).
Denominator:
Number of adolescents who are 13 years of age during measurement
year.
|
|
Numerator |
Denominator |
Percent |
1 |
Percentage of adult patients, 18 -85 years of age, who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year
|
Number |
Number |
Automatically calculated by system |
2 |
Percent of adult patients in the target population who have been screened for depression
|
Number |
Number |
Automatically calculated by system |
3 |
Percent of adult patients, 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c less than 8.0%
|
Number |
Number |
Automatically calculated by system |
4 |
Percent of patients 18-75 years of age with diabetes (type 1 or type 2) who had blood pressure less than 140/90 mm/Hg
|
Number |
Number |
Automatically calculated by system |
5 |
Percent of patients 2-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or OB/GYN and who had evidence of Body Mass Index (BMI) percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year
|
Number |
Number |
Automatically calculated by system |
6 |
Percent of patients aged 18 years and older with a calculated Body Mass Index (BMI) in the past six months or during the current visit documented in the medical record and if the most recent BMI is outside parameters, a follow-up is documented
|
Number |
Number |
Automatically calculated by system |
7 |
Percent of children by 2 years of age with appropriate immunizations (please see types of immunizations as listed in the instructions)
|
Number |
Number |
Automatically calculated by system |
8 |
Percent of adolescents 13 years of age with appropriate immunizations documented according to age group
|
Number |
Number |
Automatically calculated by system |
File Type | application/msword |
File Title | Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of info |
Author | HRSA |
Last Modified By | administrator |
File Modified | 2011-07-28 |
File Created | 2010-11-10 |