Form 6 rural Health Workforce Development

Rural Health Community-Based Grant Program

Workforce Program PIMS Measures--FINAL

Rural Health Workforce Development Program

OMB: 0915-0319

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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 3 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 Workforce Development 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. For example, if the network 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. Please include the number of entire, as well as partial counties served, within the service are. If your service area is only a fraction of a county, please count that as one (1) county.


If the total 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.



1

Number of Counties:

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

Number


Number of counties served in project


2

Number of People:

Number


Number of people in the target population (service area)




Table 2: POPULATION DEMOGRAPHICS


Table Instructions: Population Demographics

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 network 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 be equal to the “number of people” provided in the previous section (Access to Care 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.


For the number of people in target population 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

  

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


Children (0-12)


Adolescents (13-17)


Adults (18-64)


Elderly (65 and over)


Unknown





Table 3: STAFFING


Table Instructions: Staffing

Please provide the number of clinical preceptors recruited on the program by type 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.



6

Number of New Clinical Preceptors Recruited to Work on the Program for Each Type:

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

7

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 4: WORKFORCE/ RECRUITMENT & RETENTION


Table Instructions: Workforce/ Recruitment and Retention


Traineeships:

If your grant funds support traineeships, please provide the number of new and existing trainees by type (student or resident).


Trainees are considered “New” if:

  1. They have never engaged in a training/rotation within a rural community as a part of their certificate/degree/residency program and/or

  2. They do not self identify as “having lived”/ “living”/ “claiming residence” within a rural area.


Trainees are considered “Existing” if:

  1. They have had prior exposure to rural areas by either engaging in a training/rotation within a rural area as a part of their certificate/degree/residency program prior to the respective budget year and/or

  2. They self identify as “having lived”/ “living”/ “claiming residence” within a rural area.


(Please refer to the Definition of Key Rural Health Community-Based Grant Programs to view the detailed definition for “New Trainees” and “Existing Trainees”.)


Please provide the number of trainees by type that complete the trainings/rotations; this figure should not exceed the total number of all trainees recruited by type. Please also provide the number of trainees by type that plan to practice in a rural area after completing their trainings/rotations. If appropriate, of those trainees that completed their trainings/rotations, please specify the number that return to formally practice in rural areas; for this measure, please indicate a numerical figure or type DK for do not know. For example, if there are zero (0) students that completed their trainings/rotations and returned to formally practice in a rural area, 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.


For your program, please provide the types of trainee primary care focus areas and disciplines; please check all that apply. Please keep in mind that psychiatrists, like other physicans, are either allopathic (MD) or osteopathic (DO) physicians. Also, please specify the types of Mid-Levels, Nurses, and Allied Health Professionals as appropriate. For example, Physician Assistants, Nurse Practitioners, Certified Nurse Mid-Wives, and Certified Registered Nurse Anesthesiologists are considered Mid-Level providers. Allied health professionals, to name a few, include dental hygienists, diagnostic medical sonographers, dietitians, medical technologists, occupational therapists, physical therapists, pharmacists, radiographers, respiratory therapists, community health workers, and speech language pathologists. If the targeted trainee does not fall under the categories listed, please refer to the detailed definition for Allied Health Professionals and specify the discipline(s) in the Allied Health Professionals category.


Please provide the number of trainings/rotations provided during the respective budget period as well as the number of training sites by type where the trainings/rotations were conducted. Please indicate a numerical figure. If the total number of trainings/rotations is zero (0), please put zero in the appropriate section. Do not leave any sections blank.


8

Number of New Students/Residents Recruited to Work on the Program:

Number


New Students


Existing Students


All Students

 Number (automatically calculated by the system)

New Residents


Existing Residents


All Residents

 Number (automatically calculated by the system


Of the total number of students recruited, how many completed the training/rotation



Of the total number of students that complete the training/rotation, how many plan to practice in a rural area



Percentage of students trained that plan to practice in a rural area

Percent (automatically calculated by the system)


Of the total number of students that complete the training/rotation, how many returned to formally practice in rural areas

Number/DK


Percentage of students trained that return to formally practice in rural areas

Percent (automatically calculated by the system)


Of the total number of residents recruited, how many completed the training/rotation



Of the total number of residents that complete the training/rotation, how many plan to practice in a rural area


Percentage of residents trained that plan to practice in a rural area

Percent (automatically calculated by the system)

Of the total number of residents that complete the training/rotation, how many returned to formally practice in rural areas

Number/DK

Percentage of residents trained that return to formally practice in rural areas

Percent (automatically calculated by the system)

9

Trainee Primary Care Focus Area(s):

(Please check all that apply)

Selection list


Medical



Mental/Behavioral Health



Oral Health


10

Trainee Discipline Type(s):

(Please check all that apply)

Selection list


Allied Health Professional– Please specify type(s)



Dentist



Mid-Level Provider – Please specify type(s)



Nurse – Please specify type(s)



Physician (DO)



Physician (MD)


11

Number of New Trainings/Rotations:

Number


Number of New Trainings/Rotations provided


12

Number of Training Site(s) by Type:

Number


Critical Access Hospital



Other Rural Hospital



Clinic



Rural Health Clinic



Community Health Center


Federally Qualified Health Center (FQHC)


Health Department


Indian Health Service (IHS) or Tribal Health Sites



Migrant Health Center (MHC)



Other Community Based Site – Please specify type(s)




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; check all that apply. Please indicate a number for each identified category. Please provide the total number of member organizations in the consortium or network. Of the total number of member organizations, please provide the total number of new member organizations acquired within the budget year.


13

Type(s) of Member Organizations in the Consortium / Network

Selection list


Non-Profit Organization:

(Check all that apply)


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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(s):

 

TOTAL Types for Non-Profit Organization

 Number (automatically calculated by the system)


For-Profit Organization:

(Check all that apply)



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(s):


TOTAL Types for For-Profit Organization

 Number (automatically calculated by the system)

14

Total Number of Member Organizations in the Consortium/Network:

Number

15

Total Number of New Member Organizations in the Consortium/Network:

Number



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

  • The estimated amount of savings incurred due to participation in a network/consortium

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



16

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


17

Sources of Revenue:

(Check all that apply)

Selection list

 

 

 

 

 

 

Network/Consortium revenue

 

In-Kind Contributions

 

Member Fees

 

Fundraising


Contractual Services

 

Other Grants


Other – Specify Type(s):

 

None


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

Y/N

18

Sustainability Activities:

(Check all that apply)

Selection list


Business Plan Development


Communication Plan Development


Community Engagement Activities


Consolidation of activities, services and purchases


Economic Impact Analysis


Incorporation


Local, State and Federal Policy Changes


Marketing Plan Development


Media Campaigns


Organization Bylaws


Return on Investment Analysis


SWOT Analysis


Other – Specify Activity:


19

Did you use the HRSA Economic Impact tool?

Y/N

20

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

Number

21

Will the Network/Consortium sustain?

Y/N

22

Will any of the activities of the Network/Consortium sustain after the grant period?

Y/N

23

Have the objectives of the Network/Consortium been met?

Y/N



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



Allied Health Professionals: Allied health care practitioners/workers with formal education and clinical training who are credentialed through certification, registration and/or licensure. Allied Health professionals are involved with the delivery of health or related services pertaining to the identification, evaluation and prevention of diseases and disorders; dietary and nutrition services; rehabilitation and health systems management, among others.


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.



Existing Trainee: A health professions student or resident that has prior exposure to rural areas. This prior exposure may stem from either previously engaging in a training or rotation within a rural area as a part of their certificate/degree/residency program and/or self identifying as “having lived”/ “living”/ “claiming residence” within a rural area.


New Trainee: A health professions student or resident that has never engaged in a training or rotation within a rural community as a part of their certificate/degree/residency program and/or does not self identify as “having lived”/ “living”/ “claiming residence” within a rural area.


Medical Home: provides patients with continuous access to services.


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







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