Form 3 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

Table 1: ACCESS TO CARE

Instructions:

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 if applicable, N/A if not applicable and DK if unknown.

 

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.)

• Denotes the number of people served in your target population

Number of Indirect Encounters

• Denotes the number of people reached through mass communication methods, such as mailings, posters, flyers, brochures, etc.

Number of Direct Duplicated Encounters

• Denotes the total number of activities done through the program.

 Type(s) of services provided through program funding

• Please check the box that applies to your program

Table 1: ACCESS TO CARE

1	Number of counties served	Number
2	Number of people in the target population	Number
3	Number of people served through direct services	Number
4		Number
5	Number of people served through indirect services	Number (automatically calculated by the system)
6	Type(s) of services provided through Delta grant funding. (Check all that apply)	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

Table 2: POPULATION DEMOGRAPHICS

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.)

7	Number of people served through the program by ethnicity:	Number
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown
8	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
9	Number of people served by age group	Number
	Children (0-12)
	Adolescents(13-17)
	Adults (18-64)
	Elderly (65 and over)
	Unknown

Table 3: UNDER & UNINSURED

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 of 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

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

Table 4: STAFFING

Instructions:

Please provide the number of clinical and non-clinical staff recruited on the program. Provide 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.

Table 4: Staffing

15	Type(s) of new Clinical staff recruited to work on the program during the current grant year:	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
16	Type(s) of new Non-Clinical staff recruited to work on the program:	Number
	HIT/CIO
	Case Manager
	Medical Biller / Coder
	Translator
	Enrollment Specialist
	Other
	None
17	Number of staff positions shared between two or more Network partners.	Number

 

Table 5: NETWORK

Instructions:

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.

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

Table 6: SUSTAINABILITY

Instructions:

• Please provide the annual program award based on box 12a of your Notice of Grant Award (NGA).

• Please provide the amount of annual revenue the program has 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.

• 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.

• 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.

• Select the type(s) of sources of funding for sustainability. Please check all that apply.

• Please indicate if you have a sustainability plan, and select your sustainability activities. 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 programs that are in Year 3 of grant funding, please indicate the following:

• Please indicate if your current network/consortium will sustain after the grant period is over

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

21	Annual program award	Dollar amount
22	Annual program revenue	Dollar amount
23	Additional funding secured to assist in sustaining the project	Dollar amount
24	Estimated amount of cost savings due to participation in network/consortium	Dollar amount
25	Sources of Sustainability	Selection list
	Program Revenue
	In-kind Contributions
	Member fees
	Fundraising
	Contractual Services
	Other grants
	Other – specify type
	None
26	Has a sustainability plan been developed using sources of funding besides grants?	Y/N
27	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
	SWOT Analysis
	Other – Specify activity
28	Did you use the HRSA Economic Impact Analysis tool	Y/N
29	If yes, what was ratio for Economic Impact vs. HRSA Program Funding	Number
30	Will the network/consortium sustain	Y/N
31	Will the program’s activities be sustained after the grant period	Y/N

Table 7: QUALITY IMPROVEMENT

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.

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

Table 9: PHARMACY

Instructions:

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. If your grant program did not fund these services, please type N/A for not applicable.

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

Table 10: HEALTH PROMOTION/DISEASE MANAGEMENT

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.

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

Table 11: MENTAL/BEHAVIORAL HEALTH

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.

Table 11: MENTAL/BEHAVIORAL HEALTH

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

Table 12: ORAL HEALTH

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.

41	Number of people receiving dental/oral health services in target area.	Number
42	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
43	Number of network members integrating primary and dental / oral health services.	Number

Table 14: CLINICAL MEASURES

Instructions:

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.

Measure 1:

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.

Measure 2

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.

Measure 3:

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.  

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: 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

Measure 6:

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

Measure 7:

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.   

Measure 8:

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.      

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