Form 2 Rural Health Network Development Program Performance Imp

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 2.75 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 Network Development Grant 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. Please indicate a numerical figure or DK for do not know, if applicable.

Number of counties

• Denotes the 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 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 the network focuses its mission on serving a particular population such as migrant and seasonal farm workers, then the migrant and seasonal farm workers may be a subset of the total population within the service area.

1	Number of counties: (If you serve a sub-county area please count this as 1)	Number/DK
	Number of counties served in program
2	Number of people:	Number/DK
	Number of people in the target population (service area)

Table 2: POPULATION DEMOGRAPHICS

Table Instructions: Population Demographics

Please provide the number of people in target population by race, ethnicity, and age. The target population may or may not be the total population residing within the service area. If the number of people is zero (0), please put zero in the appropriate section, do not leave any sections blank.

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.)

3	Number in target population by ethnicity:	Number
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown
4	Number in target population by race:	Number	DK
	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	0	DK
	Children (0-12)
	Adolescents (13-17)
	Adults (18-64)
	Elderly (65 and over)
	Unknown

Table 3: UNINSURED

Table Instructions: Uninsured

This table indicates the number of uninsured users receiving preventative and primary care as a result of your Network activities. 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

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

6	Number of uninsured people receiving preventive and/or primary care.	Number /DK/NA
7	Number of total people enrolled for public assistance, i.e., Medicare, Medicaid, SCHIP, state-sponsored insurance.	Number /DK/NA
8	Number of people who use private third-party payments to pay services received, i.e. employer-sponsored, private non-group.	Number /DK/NA
9	Number of people who pay out-of-pocket for services received.	Number /DK/NA
10	Number of people who receive health services free of charge, i.e. no public or private third party payers.	Number/DK/NA

Table 4: 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 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.

11	Number of new clinical staff recruited to work on the program:	Number
	Dentist
	Dental Hygienist
	Health Educator / Promotoras
	Licensed Clinical Social Worker
	Nurse
	Pharmacist
	Psychologist
	Physician, General
	Physician, Specialty
	Physician Assistant
	Therapist (Behavioral, PT, OT, Speech, etc)
	Technicians (medical, pharmacy, laboratory, etc)
	Other – Specify type
	None	Selection List
12	Number of new non-clinical staff recruited to work on the program:	Number
	Case Manager
	Enrollment Specialist
	HIT/CIO
	Medical Biller / Coder
	Translator
	Other – Specify Type
	None	Selection List
13	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 5: WORKFORCE/ RECRUITMENT & RETENTION

Table Instructions: Workforce/ Recruitment and Retention

If your grant funds support traineeships, please provide the number of trainees by type, select the trainee primary care focus area and select the types of training sites. If your grant funds support traineeships, please indicate either a numerical figure, DK for do not know or N/A for not applicable.

14	Number of new trainees by each type	Number/NA/DK
	Students
	Residents
15	Trainee primary care focus area(s): (Please check all that apply)	Selection list
	Medical
	Mental/Behavioral Health
	Oral Health
16	Types of training site(s):	Selection list
	Clinic
	Community Health Center
	Critical Access Hospital
	Federally Qualified Health Center (FQHC)
	Health Department
	Indian Health Service (IHS) or Tribal Health Sites
	Migrant Health Center (MHC)
	Rural Health Clinic
	Other Rural Hospital
	Other Community Based Site – Please specify
	Unknown

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. 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. Please select the focus area(s) of the consortium/network for the budget year.

17	Type(s) of member organizations in the Consortium / Network	Number
Non-Profit Organization:	Area Health Education Center (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:
	TOTAL for Non-Profit Organization	Number (automatically calculated by the system)
For-Profit Organization:	Community College
	Community Health Center
	Critical Access Hospital
	Faith-based organization
	Organization Free Clinic
	Health Department
	Hospital
	Migrant Health Center
	Private Practice
	Rural Health Clinic
	School District
	Social Services
	University
	Other – Specify Type:
	TOTAL for For-Profit Organization	Number (automatically calculated by the system)
18	Total number of member organizations in the Consortium/Network:	Number
19	Total number of new member organizations in the Consortium/Network:	Number
20	Focus area(s) of the Consortium/Network (Check all that apply)	Selection list
	Cardiovascular Disease
	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 School Board
	Mental/Behavioral Health
	Network Development Activities
	Nutrition
	Oral Health
	Pharmacy
	Primary Care
	Substance Abuse Treatment
	Telehealth/Telemedicine
	Transportation
	Workforce
	Other – Specify Type:

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.

• Please provide the estimated amount of savings incurred due to participation in a network/consortium

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

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

21	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
22	Sources of Revenue: (Check all that apply)	Selection list
	Network/Consortium revenue
	In-Kind Contributions
	Member Fees
	Fundraising
	Contractual Services
	Other – Specify Type:
	Other grants
	None
	Has a sustainability plan been developed using sources of funding besides grants?	Y/N
23	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
	Incorporation
	Organization bylaws
	SWOT analysis
	Other – Specify activity:
24	Did you use the HRSA Economic Impact tool?	Y/N
25	If yes, what was ratio for Economic Impact vs. HRSA Program Funding	Number
26	Will the Network/Consortium sustain?	Y/N
27	Will any of the activities of the Network/Consortium sustain?	Y/N
28	Have the objectives of the Network/Consortium been met?	Y/N

Table 7: 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 activities, please select “Not Applicable. Please select all of the Meaningful Use Stage criteria achieved through this program. Please specify the Health Information Technology (HIT) Meaningful Use Stage (1, 2, or 3) that the network/consortium organization as a whole has attained. If the network/consortium has been funded to do these activities but has not acquired HIT, please mark “None”. Please refer to the detailed definition for consortium/networks, as defined by program guidance and please refer to the detailed definition for HIT Meaningful Use Stage.

29	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
	Other – Please specify criteria
	None
	Not Applicable
30	HIT Meaningful Use Stage implementation criteria through this program (Check all that apply)	Selection list
	Meaningful Use Stage 1
	Initiating the reporting of clinical quality measures and public health information
	Electronically capturing health information in a coded format
	Using health information to track key clinical conditions
	Communicating health information for care coordination purposes
	Establishing the functionalities in certified EHR technology allowing for continuous quality improvement and information exchange ease
	Other – Please specify criteria
	None
	Not Applicable
	Meaningful Use Stage 2
	Disease management
	Clinical decision support
	Medication management
	Quality measurement and research
	Other – Please specify criteria
	Meaningful Use Stage 3
	Achieving improvements in quality, safety and efficiency
	Decision support for national high priority conditions
	Patient access to self-management tools
	Access to comprehensive patient data
	Improving population health outcomes
	Other – Please specify criteria
	None
	Not Applicable
31	Consortium/Network Classification by HIT Meaningful Use Stage: (Please check one)	Selection list
	Stage 1
	Stage 2
	Stage 3
	None
	Not applicable

Table 8: FOCUS AREAS

32	Number of quality improvement clinical guidelines / benchmarks adopted by network	Number
33	Number of network members using shared standardized quality improvement benchmarks	Number
34	Average amount of dollars saved per patient through joint purchasing of drugs by Network	Dollar Amount
35	Number of health promotion/disease management activities offered to the public through this program	Number
36	Number of network members integrating primary and mental health services.	Number
37	Number of network members integrating primary and dental / oral health services.	Number

Table Instructions: Focus Areas

Report the number of quality improvement clinical guidelines/benchmarks adopted and the number of network members using shared standardized benchmarks. Report the average amount of dollars saved by joint purchasing of drugs by network. 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. Report the number of network members integrating primary and mental health services. Report the number of network members integrating oral health services. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

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

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 program’s goals and objectives. Specifically respond only for the formal member organizations, for the purposes of your grant program.

HIT Meaningful Use Stage: *Meaningful Use Criteria as proposed by the Centers of Medicare and Medicaid Services (CMS). Eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs), which participate in Medicare and Medicaid programs, that adopt and successfully demonstrate meaningful use of certified electronic health record (EHR) technology may receive CMS incentive payments. CMS incentives are linked to each Meaningful Use Stage and a timeframe for completion. Each Stage Criteria and its respective timeframe are as follows:

• Stage 1 Criteria* (up through 2013)

  • Electronically capturing health information in a coded format

  • Using that information to track key clinical conditions

  • Communicating that information for care coordination purposes

  • Initiating the reporting of clinical quality measures and public health information. (25 objectives/measures for eligible providers and 23 objectives/measures for eligible hospitals)

  • Establishing the functionalities in certified EHR technology allowing for continuous quality improvement and information exchange ease

• Stage 2 Criteria* (met by end of 2014)

• Disease management

• Clinical decision support

• Medication management

• Support for patient access to their health information

• Transitions in care

• Quality measurement and research

• Bi-directional communication with public health agencies

• Stage 3 Criteria* (met by end of 2015)

• Achieving improvements in quality, safety and efficiency

• Decision support for national high priority conditions

• Patient access to self-management tools

• Access to comprehensive patient data

• Improving population health outcomes

Medical Home: provides patients with continuous access to services.

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

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