Form 4 Small Health Care Provider Quality Improvement

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 8 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.

Small Health Care Provider Quality Improvement Grant Program

Table 1: ACCESS TO CARE

Table Instructions:

Information collected in this table provides an aggregate count of the number of people served through the program. Please refer to the detailed definitions and guidelines in answering the following measures. Please indicate a numerical figure or DK for unknown, if applicable.

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 the target population

Denotes the number of people in your target population (not necessarily the number of people who used your services). For example, if a grantee organization’s target population is females in county A, then the grantee organization reports the number of women that reside in county A.

Total 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.). Provide the registry size for total number of people served, the registry size for diabetes mellitus, and the registry size for cardiovascular disease

Total Number of Direct Duplicated Encounters

Calculated automatically by the system

Total Number of Indirect Encounters

Denotes the number of people reached through mass communication methods, such as mailings, posters, flyers, brochures, etc.

Type(s) of services provided through grant funding

Please check all boxes that apply to your program

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

1	Number of counties served	Number
2	Number of people in the target population.	Number
3	Total number of direct unduplicated encounters served (Registry size). Number of DM Patients Number of CVD Patients	Number
4	Total number of direct duplicated encounters.	Number
5	Total number of indirect encounters.
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	Grantee will specify

Table 2: POPULATION DEMOGRAPHICS

Table Instructions:

Please provide the total number of people within the target population (or service area) served by race, ethnicity, and age. The target population may or may not be the total population residing within the service area. For example, if the program focuses its mission on serving a particular population such as women, migrant and seasonal farmworkers, children, etc., then this target population may be a subset of the total population within the service area.

The total for each of the following questions should equal to the total of the number of direct unduplicated encounters (“registry”) provided in the previous section. If the total number in the target population that are Hispanic or Latino 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.

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.)

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

Table 3: UNINSURED

Table 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 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 for unknown, if applicable. If your grant program was not funded to provide these services, please type N/A for not applicable.

9	Number of uninsured people receiving preventive and/or primary care	Number
10	Number of total people enrolled for public assistance, i.e., Medicare, Medicaid, SCHIP, or any State-sponsored insurance	Number
11	Number of people who use private third-party payments to pay for services received	Number
12	Number of people who pay out-of-pocket for services received	Number
13	Number of people who receive health care services free of charge	Number

Table 4: STAFFING

Table Instructions:

Please provide the number of clinical and non-clinical staff recruited to work on the program. Please indicate a numerical figure. There should not be a N/A (not applicable) response since all questions are applicable.

14	Number 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:
	None	Selection list
15	Number of new Non-Clinical staff recruited to work on the program:	Number
	Case Manager
	Enrollment Specialist
	Medical Biller / Coder
	HIT/CIO
	Translator
	Other – Specify Type:
	None	Selection list
16	How many clinical and non-clinical staff received continuing education or training?	Number

Table 5: SUSTAINABILITY

Table 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

• 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 implementation of quality improvement programs.

• Select the type(s) of sources of funding for sustainability.

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

• Please indicate if any of your program’s activities will sustain your program’s activities will sustain after the grant period.

• 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.

17	Revenue
	Annual Program Award	Dollar amount
	Annual program revenue	Dollar amount
	Additional funding secured to assist in sustaining the program	Dollar amount
	Estimated amount of cost-savings due to implementation of quality improvement programs.	Dollar amount
18	Sources of Sustainability: (Check all that apply)	Selection List
	Program revenue
	In-Kind Contributions
	Member Fees
	Fundraising
	Contractual Services
	Other Grant Funding
	Other – Specify Type
	None
	Has a sustainability plan been developed using sources of funding besides grants?	Y/N
19	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
20	Did you use the HRSA Economic Impact Analysis Tool?	Y/N
21	If yes, what was the ratio for Economic Impact vs. HRSA Program Funding	Number
22	Will the program’s activities be sustained after the grant period?	Y/N

Table 6: 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 services, please select none.

23	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
	None
	Other

Table 7: QUALITY IMPROVEMENT

Table Instructions:

Report the number of quality improvement clinical guidelines/benchmarks adopted. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

Report the number of health care providers using the electronic patient registry and indicate if your organization uses an electronic medical record/electronic health record with the registry.

24	Number of quality improvement clinical guidelines / benchmarks adopted	Number
25	Number of health care providers using the electronic patient registry	Number
26	Do you currently use an EMR/EHR with the electronic patient registry?	Y/N

Table 8: HEALTH PROMOTION/DISEASE MANAGEMENT

Table 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.

27	Number of health promotion/disease management activities offered to the public through this program.	Number
28	Number of people referred to health care provider/s	Number

Table 9: CLINICAL MEASURES

Table Instructions:

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

Measure 1:

Numerator: All patients from the denominator whose most recent hemoglobin A1c level was less than 8.0%, within the last 12 months.

Denominator: Number of patients 18-75 years of age with a diagnosis of type 1 or type 2 diabetes who have received care for diabetes in the last 2 years.  

Measure 2:

Numerator: All patients from the denominator whose most recent blood pressure was less than 140/90 mmHg within the last 12 months.

Denominator: Number of patients 18-75 years of age with a diagnosis of type 1 or type 2 diabetes who have received care for diabetes in the last 2 years.

Measure 3:

Numerator: All patients from the denominator whose most recent fasting LDL was less than 100 mg/dL within the last 12 months.

Denominator: Number of patients 18-75 years of age with a diagnosis of type 1 or type 2 diabetes who have received care for diabetes in the last 2 years.

Measure 4:

Numerator: Patients from the denominator with BMI outside parameters and follow-up plan is documented in patient chart.

Denominator: Patients age 18 years and older, with diabetes (type 1 or type 2) who received care for diabetes in the last 2 years with a calculated BMI in the past 6 months or during the current visit.

Measure 5:

Numerator: Patients from the denominator that have the most recent blood pressure less than 140/90 mm Hg, within the last 12 months.

Denominator: All patients 18 years of age and older seen at least once during the last 12 months with a diagnosis of hypertension within 6 months after measurement start date.

Measure 6:

Numerator: Patients from the denominator with the most recent LDL less than 100 mg/dL, within the last 12 months.

Denominator: Number of patients age 18 years and older who have a diagnosis of coronary artery disease seen at least twice during the last 12 months.

Measure 7:

Numerator: Patients in the denominator who have been queried about tobacco use in the past 2 years.

Denominator: Number of patients age 18 years and older seen at least twice during the last 12 months.

Measure 8

Numerator: Patients in the denominator who received cessation intervention for tobacco use.

Denominator: All patients aged 18 years and older with diagnosed tobacco use.

Measure 9

Numerator: Patients from the denominator with BMI outside parameters and follow-up plan is documented in patient chart.

Denominator: Patients age 18 years and older with a diagnosis of cardiovascular disease who have a calculated BMI in the past 6 months or during the current visit.

		Numerator	Denominator	Percent
1	Percent of adult patients, 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c less than 8.0%
2	Percent of adult patients, 18-75 years of age with diabetes (type 1 or type 2) who had blood pressure less than 140/90 mmHg
3	Percent of adult patients, 18- 75 years of age with diabetes (type 1 or type 2) who had LDL less than 100 mg/dL
4	Percentage of patients aged 18 years and older with diabetes (type 1 or type 2) with a calculated 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 plan is documented.
5	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
6	Percent of adult patients with coronary artery disease who had LDL less than 100 mg/dL
7	Percentage of patients aged 18 years or older who have been seen for at least 2 office visits, who were queried about tobacco use one or more times within 24 months
8	Percentage of patients aged 18 years and older identified as tobacco users within the past 24 months who received cessation intervention
9	Percentage of patients aged 18 years and older with cardiovascular disease with a calculated 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 plan is documented

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