Form 6 rural Health Workforce Development

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 3 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 Workforce Development 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. For example, if the network focuses its mission on serving a particular population such as women, migrant and seasonal farmworkers, children, etc., then this target population may be a subset of the total population within the service area. Please include the number of entire, as well as partial counties served, within the service are. If your service area is only a fraction of a county, please count that as one (1) county.

If the total 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.

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

Table 2: POPULATION DEMOGRAPHICS

Table Instructions: Population Demographics

Please provide the total number of people within the target population (or service area) served by race, ethnicity, and age. The target population may or may not be the total population residing within the service area. For example, if the network focuses its mission on serving a particular population such as women, migrant and seasonal farmworkers, children, etc., then this target population may be a subset of the total population within the service area.

The total for each of the following questions should be equal to the “number of people” provided in the previous section (Access to Care section). If the total number in the target population that are Hispanic or Latino 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.

For the number of people in target population 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
	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
	Children (0-12)
	Adolescents (13-17)
	Adults (18-64)
	Elderly (65 and over)
	Unknown

Table 3: STAFFING

Table Instructions: Staffing

Please provide the number of clinical preceptors recruited on the program by type 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.

6	Number of New Clinical Preceptors Recruited to Work on the Program for Each Type:	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
7	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 4: WORKFORCE/ RECRUITMENT & RETENTION

Table Instructions: Workforce/ Recruitment and Retention

Traineeships:

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

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.

For your program, please provide the types of trainee primary care focus areas and disciplines; please check all that apply. Please keep in mind that psychiatrists, like other physicans, 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 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.

8	Number of New Students/Residents Recruited to Work on the Program:	Number
	New Students
	Existing Students
	All Students	Number (automatically calculated by the system)
	New Residents
	Existing Residents
	All Residents	Number (automatically calculated by the system
	Of the total number of students recruited, how many completed the training/rotation
	Of the total number of students that complete the training/rotation, how many plan to practice in a rural area
	Percentage of students trained that plan to practice in a rural area	Percent (automatically calculated by the system)
	Of the total number of students that complete the training/rotation, how many returned to formally practice in rural areas	Number/DK
	Percentage of students trained that return to formally practice in rural areas	Percent (automatically calculated by the system)
	Of the total number of residents recruited, how many completed the training/rotation
	Of the total number of residents that complete the training/rotation, how many plan to practice in a rural area
	Percentage of residents trained that plan to practice in a rural area	Percent (automatically calculated by the system)
	Of the total number of residents that complete the training/rotation, how many returned to formally practice in rural areas	Number/DK
	Percentage of residents trained that return to formally practice in rural areas	Percent (automatically calculated by the system)
9	Trainee Primary Care Focus Area(s): (Please check all that apply)	Selection list
	Medical
	Mental/Behavioral Health
	Oral Health
10	Trainee Discipline Type(s): (Please check all that apply)	Selection list
	Allied Health Professional– Please specify type(s)
	Dentist
	Mid-Level Provider – Please specify type(s)
	Nurse – Please specify type(s)
	Physician (DO)
	Physician (MD)
11	Number of New Trainings/Rotations:	Number
	Number of New Trainings/Rotations provided
12	Number of Training Site(s) by Type:	Number
	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)

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; check all that apply. Please indicate a number for each identified category. Please provide the total number of member organizations in the consortium or network. Of the total number of member organizations, please provide the total number of new member organizations acquired within the budget year.

13	Type(s) of Member Organizations in the Consortium / Network	Selection list
	Non-Profit Organization: (Check all that apply)
	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(s):
	TOTAL Types for Non-Profit Organization	Number (automatically calculated by the system)
	For-Profit Organization: (Check all that apply)
	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(s):
	TOTAL Types for For-Profit Organization	Number (automatically calculated by the system)
14	Total Number of Member Organizations in the Consortium/Network:	Number
15	Total Number of New Member Organizations in the Consortium/Network:	Number

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

• The estimated amount of savings incurred due to participation in a network/consortium

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

16	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
17	Sources of Revenue: (Check all that apply)	Selection list
	Network/Consortium revenue
	In-Kind Contributions
	Member Fees
	Fundraising
	Contractual Services
	Other Grants
	Other – Specify Type(s):
	None
	Has a sustainability plan been developed using sources of funding besides grants?	Y/N
18	Sustainability Activities: (Check all that apply)	Selection list
	Business Plan Development
	Communication Plan Development
	Community Engagement Activities
	Consolidation of activities, services and purchases
	Economic Impact Analysis
	Incorporation
	Local, State and Federal Policy Changes
	Marketing Plan Development
	Media Campaigns
	Organization Bylaws
	Return on Investment Analysis
	SWOT Analysis
	Other – Specify Activity:
19	Did you use the HRSA Economic Impact tool?	Y/N
20	If yes, what was the ratio for Economic Impact vs. HRSA Program Funding	Number
21	Will the Network/Consortium sustain?	Y/N
22	Will any of the activities of the Network/Consortium sustain after the grant period?	Y/N
23	Have the objectives of the Network/Consortium been met?	Y/N

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

Allied Health Professionals: Allied health care practitioners/workers with formal education and clinical training who are credentialed through certification, registration and/or licensure. Allied Health professionals are involved with the delivery of health or related services pertaining to the identification, evaluation and prevention of diseases and disorders; dietary and nutrition services; rehabilitation and health systems management, among others.

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

Existing Trainee: A health professions student or resident that has prior exposure to rural areas. This prior exposure may stem from either previously engaging in a training or rotation within a rural area as a part of their certificate/degree/residency program and/or self identifying as “having lived”/ “living”/ “claiming residence” within a rural area.

New Trainee: A health professions student or resident that has never engaged in a training or rotation within a rural community as a part of their certificate/degree/residency program and/or does not self identify as “having lived”/ “living”/ “claiming residence” within a rural area.

Medical Home: provides patients with continuous access to services.

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

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