Form 1 Delta States Rural Network Development Grant Program Per

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

Section I: Services

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.

Direct Services are defined as a documented interaction between a patient/client and a clinical or non-clinical health professional that has been funded with ORHP grant dollars. Examples of direct services include (but are not limited to) patient visits, counseling, and education.

For the purposes of this data collection activity, indirect services will be limited to:

1. billboards,

2. flyers,

3. health fairs and

4. mailings/newsletters

5. Other mass media (radio, television, newspaper and social media)*

*For radio, television and newspaper please report total circulation. For social media, please report reach (number of followers).

1	Direct Services Please provide the number of clients that your program served through direct services (i.e. clinical patients)	Number
2	Indirect Services Please provide the number of individuals that your program reached through the following indirect services: billboards, flyers, health fairs, mailings/newsletters	Number

3	Number of counties served	Number
4	Type(s) of services provided through Delta grant funding. (Check all that apply)	Selection list
	Behavioral/mental health
	Cancer Care Management
	Cardiovascular Disease (CVD) Care Management
	Diabetes Care Management
	Emergency Medical Services (EMS)
	Health Education/Health Promotion/Prevention
	Health Screenings
	HIV/AIDS
	Hypertension Care Management
	Language Interpretation
	Maternal and Child Health
	Obesity Care Management
	Patient Centered Medical Home
	Pediatric Care
	Pharmacy Assistance
	Primary Care Services
	Specialty Care Services
	Substance abuse treatment
	Women’s Health
	Workforce Development
	Transportation
	Other: Specify

Section II: POPULATION DEMOGRAPHICS

Table Instructions:

Please provide the total number of people served by race, ethnicity, and age. The total for each of the following questions should be 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.)

5	Number of people served through the program by ethnicity:	Number
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown
6	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
7	Number of people served by age group	Number
	Children (0-12)
	Adolescents(13-17)
	Adults (18-64)
	Elderly (65 and over)
	Unknown

Section III: 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 on the total number of people served through direct services 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 do 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

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

section Iv: Staffing

Table Instructions:

Please provide the number of clinical and non-clinical positions funded (all or in part) by this grant. Please indicate a numerical figure, even if that number is zero. There should not be a N/A (not applicable) response since all questions are applicable.

13	Number of positions funded by grant dollars	Part-Time	Full-Time
	Clinical
	Non-Clinical

section V: Consortium/Network

Table Instructions:

Please provide information about the consortium or network members, if applicable. Please limit responses to those entities that are participating in grant-funded activities. Consortium or network members are defined as separately owned organizations. The consortium or network can be formal or informal.

14	Type(s) of member organizations in the consortium/network. (Check all that apply)	Selection list
	AHEC
	Community College
	Community Health Center
	Critical Access Hospital
	Faith-Based Organization
	Health Department
	Hospital
	Private Practice
	Rural Health Clinic
	School District
	Social Services Organization
	University
	Tribal Entity
	Migrant Health Center
	Private Practice
	Rural Health Clinic
	School District
	Social Services Organization
	University
	Other
15	Total Number of Member Organizations in the Consortium/Network	Number
16	Total Number of New Members in the Consortium/Network ( for current report year)	Number

section VI: Sustainability

Table Instructions:

• Select your sustainability activities.

• The definition of sustainability is “programs or services continue because they are valued and draw support and resources”.

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

• Use HRSA’s Economic Impact Tool to provide the ratio for Economic Impact vs. HRSA Program Funding.

17	Annual program award Please provide the annual program award based on box 12a of your Notice of Award (NOA).	Dollar amount
18	Annual program revenue Please provide the amount of annual program revenue made through the services offered through the program. Program revenue is defined as payments received for the services provided by the program that the grant supports. These services should be the same services outlined in your grant application work plan. Please do not include donations. If the total amount of annual revenue made is zero (0), please put zero in the appropriate section. Do not leave any sections blank.	Dollar amount
19	Additional funding secured to assist in sustaining the project	Dollar amount

20	Sources of Sustainability Select the type(s) of sources of funding for sustainability. Please check all that apply.	Selection list
	Network/Consortium revenue
	In-kind Contributions (In-Kind contributions are defined as donations of anything other than money, including goods or services/time.)
	Membership fees/dues
	Fundraising/ Monetary donations
	Contractual Services
	Other grants
	Fees charged to individuals for services
	Reimbursement from third-party players (e.g. private insurance, Medicare, Medicaid)
	Product sales
	Government (non-grant)
	Other – specify type
	None

21	Sustainability Activities: Which of the following activities have you engaged in to enhance your sustainability?  Check all that apply.	Selection list
	Local, State and Federal Policy changes
	Media Campaigns
	Community Engagement Activities
	Other – Specify activity
22	Have you developed any of the following:	(Y/N)
	Sustainability Plan
	Business Plan
	Communications Plan
	Fundraising Plan

23	What is your ratio for Economic Impact vs. HRSA Program Funding? Use the HRSA’s Economic Impact Analysis Tool to identify your ratio. (http://www.raconline.org/econtool/)	Ratio
24	Will the network/Consortium sustain, if applicable? Please indicate if your current network/consortium will sustain after the grant period is over	(Y/N)
25	Will any of the program’s activities be sustained after the grant period?	All/Some/None

SECTION VII: QUALITY IMPROVEMENT

Table 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.

26	Number of quality improvement clinical guidelines / benchmarks adopted by network/consortium	Number
27	Number of network/consortium members using shared standardized quality improvement benchmarks	Number

SECTION VIII: PHARMACY

Table Instructions:

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.

28	Average amount of dollars saved per patient through prescription drug assistance annually	Dollar Amount
29	Number of people receiving prescription drug assistance annually	Number

SECTION IX: 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.

30	Number of health promotion/disease management activities offered to the public through this program.	Number
31	Number of people referred to health care provider/s as a result of health promotion activities.	Number

SECTION X: MENTAL/BEHAVIORAL HEALTH

Table 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.

31	Number of people receiving mental and/or behavioral health services in target area as a result of Delta States Program grant funding	Number
32	Number of network members integrating primary and mental health services.	Number

SECTION XI: ORAL HEALTH

Table 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.

33	Number of people receiving dental/oral health services in target area.	Number
34	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
35	Number of network members integrating primary and dental / oral health services.	Number

Table 14: CLINICAL MEASURES

Instructions:

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. Please indicate a numerical figure or N/A for not applicable for your specific grant activities.

Measure 1:

Numerator: Patient’s screening for clinical depression is documented and follow up plan is documented.

Denominator: All patients 12 years or older of age in the target population.

Measure 2

Numerator: The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.

Denominator: Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.

Measure 3:

Numerator: Patients whose HbA1c level is <8.0% during the measurement year.

Denominator: Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.

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: Percentage of adult patients with diabetes aged 18-75 years receiving at least one lipid profile (or ALL component tests) during the measurement year.

Denominator: Members 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.

Measure 6:

Numerator: Members whose most recent LDL-C test is <100 mg/dL during the measurement year.

Denominator: Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or during the year prior to the measurement year.

Measure 7:

Numerator: Body mass index (BMI) percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.

Denominator: Patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or OB-GYN.

Measure 8:

Numerator: Adolescents who had documentation of a blood pressure screening and whether results are abnormal at least once in the measurement year or the year prior to the measurement year.

Denominator: Adolescents with a visit who turned 18 years old in the measurement year.

Measure 9:

Numerator: Children who had documentation of a blood pressure screening and whether results are abnormal at least once in the measurement year or the year prior to the measurement year.

Denominator: Children with a visit who turned 13 years old in the measurement year.

Measure 10:

Numerator: Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, follow-up is documented during the encounter or during the previous six months of the encounter with the BMI outside of normal parameters

Denominator: All patients aged 18 years and older

Measure 11:

Numerator: Patients who were screened for tobacco use* at least once during the two-year measurement period AND who received tobacco cessation counseling intervention** if identified as a tobacco user

*Includes use of any type of tobacco

** Cessation counseling intervention includes brief counseling (3 minutes or less), and/or pharmacotherapy

Denominator: All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the two year measurement period

19	Clinical Measures	Numerator (Number)	Denominator (Number)	Percent (Automatically calculated by system)
1	NQF 0418: Screening for clinical depression: Percentage of patients aged 12 years and older screened for clinical depression using a standardized tool and follow up plan documented.
2	The number of patients in the denominator whose most recent BP is adequately controlled (<140/90) during the measurement year.
3	NQF 0575: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%): Percent of adult patients, 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c less than 8.0%
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
5	Percentage of adult patients with diabetes aged 18-75 years receiving at least one lipid profile (or ALL component tests) during the measurement year.
6	Members whose most recent LDL-C test is <100mg/dL during the measurement year.
7	NQF 0024: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Percentage of patients 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of the following during the measurement year: - Body mass index (BMI) percentile documentation - Counseling for nutrition - Counseling for physical activity
8	The percentage of adolescents who turn 18 years of age in the measurement year who had a blood pressure screening with results.
9	The percentage of adolescents who turn 13 years of age in the measurement year who had a blood pressure screening with results
10	NQF 0421: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up: Percentage of patients aged 18 years and older 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.
11	NQF 0028: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention: Percentage of patients aged 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received cessation counseling intervention if identified as a tobacco user