| Data Field Explanations |
| Data Field |
Data field Description |
Data - description |
| Client Data |
| Location |
Program Site/ Facility Site |
open response- location by name or by site number |
| Client number |
Internal patient identifier (if applicable) |
sequential numbers |
| Qualifying Chronic Condition |
This data field describes a list of chronic conditions which the patient may have. There may be more than one response listed. |
|
| Diabetes Mellitus Type II (DM) |
Type of chronic condition |
"Yes" or "No" |
| Cardiovascular Disease (CVD) including hypertension |
Type of chronic condition |
"Yes" or "No" |
| Congestive Heart Failure (CHF) |
Type of chronic condition |
"Yes" or "No" |
| Coronary Artery Disease (CAD) |
Type of chronic condition |
"Yes" or "No" |
| Chronic Obstructive Pulmonary Disease (COPD) |
Type of chronic condition |
"Yes" or "No" |
| Other influential Conditions |
Other conditions that influence a client's participation and intervention design |
Free text |
| Payer |
This data field describes the type and number of payers that a patient may be using. There may be more than one positive response listed. |
|
| Medicare |
Type of payer of medical insurance |
"Yes" or "No" |
| Medicaid |
Type of payer of medical insurance |
"Yes" or "No" |
| Private/commercial insurer |
Type of payer of medical insurance |
"Yes" or "No" |
| Other (open text) |
Type of payer of medical insurance |
"Yes" or "No" |
| None |
Type of payer of medical insurance |
"Yes" or "No" |
| Intervention Start Date |
Date which the patient started the intervention |
mm/dd/yyyy |
| Intervention Goal |
This data field describes the patient's goal in participating in the program. |
Free text |
| Intervention Activities/ Design |
This data field describes the patient's intervention activities and/ or design of the patient's intervention |
Free text |
| Update on achievement of goal |
This data field is a description of the improvement or achievement of intervention goal's |
Free text |
| Partners involved in intervention |
This data field is a list of partners involved in the intervention including [ list examples] |
Free text |
| Were any additional resources used? |
This data field describes any additional resources beyond the grant that were used in the client's intervention. |
"Yes" or "No" |
| Financial |
This data field describes any additional financial resources used to provide client interventions. List sources, amounts, and use of financial resources. |
free text, any response indicates "Yes" |
| Equipment |
This data field describes any additional equipment resources used to provide client interventions. List type, volume, and value (if possible) of equipment. |
free text, any response indicates "Yes" |
| Volunteer work |
This data field describes any volunteer/labor used to provide client interventions. List type (e.g. position and/or task performed), volume (e.g., number of hours), and value (if possible) of volunteer/unpaid labor |
free text, any response indicates "Yes" |
| Other (explain) |
This data field describes any resources used to provide client intervention but that cannot be described as financial, equipment, or volunteer work. |
free text, any response indicates "Yes" |
| Intervention Completion Date |
This is the date at which the intervention was complete |
mm/dd/yyyy |
| Intervention Completion Status |
This set of data fields refer to why the intervention was ended. |
|
| Achieved intervention goal |
This data field is filled in if the patient achieved their goal |
"Yes" or "No" |
| Loss of interest by client |
Indicate "Yes" if the patient did not complete due to loss of interest |
"Yes" or "No" |
| Moved |
Indicate "Yes" if the patient did not complete due to moving away |
"Yes" or "No" |
| Death |
Indicate "Yes" if the patient did not complete due to death |
"Yes" or "No" |
| Other |
Indicate "Yes" if the patient did not complete due to other reasons |
Free text |
| Design and Implentation Data |
| Client recruitment attempts |
Number of patients that the CHW attempted to recruit during the observation quarter |
Number |
| Source of attempts |
The source from which the CHW identified the patients that s/he attempted to recruit. |
Free text |
| Method(s) of recruitment |
This data field describes how the patient was recruited |
Free text |
| Number of new enrollments |
The number of new clients recruited to the observation quarter |
Number |
| Understood reason(s) for unsuccessful attempts |
This data field records the reasons provided by recruited patients to CHWs for declining to participate in the program |
Free text |
| Total hours spent by CHWs on program? |
This data field is the total number of hours that the CHW spent working on the program |
Number |
| Were any additional resources used? |
This data field answers whether any resources beyond the grant were used to conduct non-intervention aspects of the program. |
"Yes" or "No" |
| Financial - source (open text) |
This data field describes any additional financial resources provided to conduct the program. List sources, amounts, and uses of additional financial resources. |
free text, any response indicates "Yes" |
| Equipment - describe and source (open text) |
This data field describes any additional equipment (not purchased with grant funds) that was used by program and its staff to conduct the program. List type, volume, and value (if possible) of equipment |
free text, any response indicates "Yes" |
| Volunteer work - explain (open text) |
This data field describes any additional volunteer/unpaid labor that was used to conduct the program. List type (e.g. position and/or task performed), volume (e.g., number of hours), and value (if possible) of volunteer/unpaid labor |
free text, any response indicates "Yes" |
| Other (explain) |
This data field describes any resources used to conduct the program but that cannot be described as financial, equipment, or volunteer work |
free text, any response indicates "Yes" |
| Exhibit 4: Potential Data Elements for Monthly Submissions by Grantee Sites |
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Chronic Condition |
|
Payer |
Intervention Characteristics |
Additional Resources Required |
Intervention Completion Information |
| Location |
Client No |
Qualifying Chronic Condition: (DM) Diabetes Mellitus Type II |
Qualifiying Chronic Condition: Cardiovascular Disease (CVD) including hypertension |
Qualifying Chronic Condition: Congestive Heart Failure (CHF) |
Qualifiying Chronic Condition: Coronary Artery Disease (CAD) |
Qualifiying Chronic Condition: Chronic Obstructive Pulmonary Disease (COPD) |
Other Influential Condition(s) |
Payer: Medicare |
Payer: Medicaid |
Payer: Private/commercial insurer |
Payer: Other (free text) |
Payer: None |
Intervention Start Date |
Intervention Goal |
Intervention Activities/ Design |
Update on achievement of goal |
Partners involved in intervention |
Were any additional resources used? |
Financial - source (free text) |
Equipment - describe and source (free text) |
Volunteer work - explain (free text) |
Other (explain) |
Intervention Completion Date |
Reason for Completion: Achieved intervention goal |
Reason for Completion: Loss of interest by client |
Reason for Completion: Moved |
Reason for Completion: Death |
Reason for Completion: Other |