Form 1 Rural Health Care Services Outreach Program Performance

Rural Health Care Services Outreach Program

Performance Improvement Measurement System (PIMS)

1. DEMOGRAPHICS

ACCESS TO CARE

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 or DK for do not know, if applicable.

	Baseline	1st year Data
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.)
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 the box that applies to your program	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 Specify:	

POPULATION DEMOGRAPHICS

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 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:	Baseline	1st Year Data
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.)
Not Hispanic or Latino
Unknown
TOTAL (automatically calculated by the system)

Number of people served by race:	Baseline	1st Year Data
American Indian/Alaska Native
Asian
Asian Indian
Black or African American
Native Hawaiian/Other Pacific Islander
White
More than one race
Unknown
TOTAL (automatically calculated by the system)

Number of people served by age group	Baseline	1st Year Data
Children (0-12)
Adolescents (13-17)
Adults (18-64)
Elderly (65 and over)
Unknown
TOTAL (automatically calculated by the system)

UNINSURED

Please respond to the following questions based on these guidelines. Please indicate a numerical figure or DK for do not know, if applicable. If your grant program was not funded to provide these services, please type N/A for not applicable.

	Baseline	1st Year Data
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 do not receive health services free of charge
Number of people who receive health services free of charge

STAFFING

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.

Number of new clinical staff recruited to work on the program:
	1st Year Data
	Full-time	Part-time
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)

Number of new non-clinical staff recruited to work on the program for each type:
	1st Year Data
	Full-time	Part-time
HIT/CIO
Case Manager
Medical Biller / Coder
Translator
Enrollment Specialist
Other – Specify Type:

Number of staff positions shared between two or more Network partners

WORKFORCE/ RECRUITMENT & RETENTION

Traineeships:

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

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

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.

	STUDENTS			RESIDENTS
	Baseline	1st Year Data		Baseline	1st Year Data
Number of New
Number of Existing
TOTAL (Number (automatically calculated by the system)
Of the total number recruited, how many completed the training/rotation
Of the total number that complete the training/rotation, how many plan to practice in a rural area
Percentage trained that plan to practice in a rural area (automatically calculated by the system)
Of the total number that complete the training/rotation, how many returned to formally practice in rural areas
Percentage trained that return to formally practice in rural areas (automatically calculated by the system)

Trainee Primary Care Focus Area(s):	Please check all that apply
Medical
Mental/Behavioral Health
Oral Health

Trainee Discipline Type(s): Please keep in mind that psychiatrists 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 check all that apply	Please check all that apply
Allied Health Professional– Please specify type(s)
Dentist
Mid-Level Provider – Please specify type(s)
Nurse – Please specify type(s)
Physician (DO)
Physician (MD)

	Baseline	1st Year Data
Number of New Trainings/Rotations provided: 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.
Number of Training Site(s) by Type:
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)

2. ENVIRONMENT & TECHNOLOGY

NETWORK

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.

Non-Profit Organizations
Type(s) of member organizations in the consortium / network (Check all that apply)	Number
Area Health Education Center (AHEC)
Community College
Community Health Center
Critical Access Hospital
Faith-Based Organization
Health Department
Hospital
Migrant Health Center
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 Organizations
Type(s) of member organizations in the consortium / network (Check all that apply)	Number
Community College
Community Health Center
Critical Access Hospital
Faith-Based Organization
Health Department
Hospital
Migrant Health Center
Private Practice
Rural Health Clinic
School District
Social Services Organization
University
Other
TOTAL for For-Profit Organization	Number (automatically calculated by the system)
Total Number of Member Organizations in the Consortium/Network	Number
Total Number of New Members in the Consortium/Network	Number

Sustainability

Funding/Revenue:
Annual program award Please provide the annual program award based on box 12a of your Notice of Grant Award (NGA).	Dollar amount
Annual program revenue Please provide the amount of annual revenue 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.	Dollar amount
Additional funding secured to assist in sustaining 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.	Dollar amount
Estimated amount of cost savings due to participation in network/consortium 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.	Dollar amount

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	
Member fees	
Fundraising	
Contractual Services	
Other grants	
Other – specify type	
None	
Has a sustainability plan been developed using sources of funding besides grants? Please indicate if you have developed a sustainability plan	Y/N

Sustainability Activities: Please select your 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	
Incorporation	
Organization Bylaws	
Business Plan Development	
SWOT Analysis	
Other – Specify activity	

Did you use the HRSA Economic Impact Analysis tool? 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.	Y/N
Will the network/Consortium sustain? Please indicate if your current network/consortium will sustain after the grant period is over	Y/N
Will any of the activities of the Network/Consortium sustain? Please indicate if any of your program’s activities will sustain after the grant period	Y/N

Health Information Technology

Please select all types of technology implemented, expanded or strengthened through this program. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

Type(s) of technology implemented, expanded or strengthened through this program: (Check all that apply)	Baseline	1st Year Data (Selection list)
Computerized laboratory functions		
Computerized pharmacy functions		
Electronic clinical applications		
Electronic medical records		
Health Information Exchange		
Patient/Disease Registry		
Telehealth/Telemedicine		
None		
Other		

QUALITY IMPROVEMENT

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.

	Baseline	1st year data
Number of quality improvement clinical guidelines / benchmarks adopted by network/consortium
Number of network/consortium members using shared standardized quality improvement benchmarks

PHARMACY

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. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

	Baseline	1st Year data
Average amount of dollars saved per patient through joint purchasing of drugs annually
Number of people receiving prescription drug assistance annually
Average amount of dollars saved per patient through prescription drug assistance annually

HEALTH PROMOTION/DISEASE MANAGEMENT

Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

	Baseline	1st Year Data
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.

MENTAL/BEHAVIORAL HEALTH

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. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

	Baseline	1st Year data
Number of people receiving mental and/or behavioral health services in target area.
Number of network members integrating primary and mental health services.

ORAL HEALTH

Report the number of people receiving dental/oral health services in target area.

	Baseline	1st Year Data
Number of people receiving dental / oral health services in target area.
Type(s) of dental / oral health services provided. Please select the appropriate types of services and provide the number of network/consortium members integrating oral health services. Please check all that apply. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this. Check all that apply.
	Baseline	1st Year Data
Screenings / Exams
Sealants
Varnish
Oral Prophylaxis
Restorative
Extractions
Other
Number of network members integrating primary and dental / oral health services.

3. MEASURES

CLINICAL MEASURES

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.

	Baseline				1st Year data
	Numerator	Denominator	Percent (Automatically calculated by the system)		Numerator	Denominator	Percent (Automatically calculated by the system)
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 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.
Percent of adult patients in the target population who have been screened for depression 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.
Percent of adult patients, 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c less than 8.0% 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.
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 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.
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 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
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 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
Percent of children by 2 years of age with appropriate immunizations (please see types of immunizations as listed in the instructions) 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.
Percent of adolescents 13 years of age with appropriate immunizations documented according to age group 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.

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