Form 1 Rural Outreach Counseling Performance Measures Form

OMB Number: 0906-XXXX

Expiration date: XX/XX/201X

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 currently valid OMB control number.  The OMB control number for this project is 0906-XXXX.  Public reporting burden for this collection of information is estimated to average 2 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 10C-03I, Rockville, Maryland 20857.

Rural Outreach Benefits Counseling Grant Program

Section I: ACCESS TO CARE

Table Instructions: This table collects information about an aggregate count of the number of people served through the program. Please report responses using a numeric figure. If the total number is zero (0), please put zero in the appropriate section. Do not leave any sections blank. There should not be an N/A (not applicable) response since all measures are applicable to all grantees.

Please refer to these detailed definitions and guidelines in providing your answers to the following measures:

Number of counties served in project and number of people in target population should be consistent with the figures your program reported in your grant application. The number of counties served should reflect your project’s service area.

Direct Services are defined as a documented interaction between a consumer/patient/client and a clinical or non-clinical health professional that has been funded with FORHP grant dollars. Direct services include health insurance benefits counseling and health insurance outreach, education and enrollment.

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

1. billboards,

2. flyers,

3. health fairs,

4. mailings/newsletters, and

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

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

		Baseline	End of Budget Period
1	Number of counties served in project
2	Number of people in the target population (this is the number of people in your target population, but not the number of people who actually received your direct services)
3	Number of unique individuals who received direct services during this budget period Please report the number of unique (i.e. unduplicated count) consumers/patients/clients who received direct services with this grant
4	Number of individuals who received indirect services during this budget period Please report the total estimated number of individuals your organization reaches through the following indirect services: billboards, flyers, health fairs, mailings/newsletters, and other mass media (including social media). NOTE: You can add together estimated totals across the various indirect services you have completed. These estimates may be obtained from vendors, health fair organizers, etc. and added together to generate an estimated total number of persons reached.
5	Report the number of indirect services by type of activity
	Billboards
	Radio spots aired
	TV ads aired
	Newspaper ads
	Other – Please specify

SECTION II: POPULATION DEMOGRAPHICS

Table Instructions: This table collects information about an aggregate count of the people served by race, ethnicity, age, and insurance status. The total for each of the following questions should equal the total of the number of unique individuals who received direct services reported in the previous section. Note: Please do not include counts for indirect services here. Do not leave any sections blank. There should not be an N/A (not applicable) response since all measures are applicable to all grantees. If the count for a particular category is zero (0), please enter zero in the appropriate section (e.g., if the total number that is Hispanic or Latino is zero (0), enter zero in that section).

Number of people served through program by ethnicity (Hispanic or Latino/Not Hispanic or Latino) is defined as:

• 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.)

		Baseline	End of Budget Period
6	Number of people directly served by ethnicity:
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown
	Total (automatically calculated)	Equal to the total of the number of unique individuals who received direct services	Equal to the total of the number of unique individuals who received direct services
7	Number of people directly served by race:
	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Other Pacific Islander
	White
	More than one race
	Unknown
	Total (automatically calculated)	Equal to the total of the number of unique individuals who received direct services	Equal to the total of the number of unique individuals who received direct services
8	Number of people directly served, by age group:
	Children (0-12)
	Adolescents (13-17)
	Young adults (18-25)
	Adults (26-64)
	Elderly (65 and over)
	Unknown
	Total (automatically calculated)	Equal to the total of the number of unique individuals who received direct services	Equal to the total of the number of unique individuals who received direct services

SECTION III: STAFFING

Table Instructions: This table collects information about the staff supported by this grant. Please do not leave any sections blank. There should not be a N/A (not applicable) response since all measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section.

Please refer to these detailed definitions and guidelines in providing your answers to the following measures:

• Outreach and enrollment assistance workers are defined as individuals who completed federal and/or state training and certified to help the uninsured (or newly insured) understand their new health coverage options, apply for financial help with coverage and enroll (or re-enroll) in health plans.

• General educators are defined as individuals who did not complete any training and their primary responsibility is to do education and raise awareness about health insurance options.

		Baseline	End of Budget Period
9	Report on number of trained outreach and enrollment assistance workers funded by this grant by FTE status:
	Full time
	Part time (less than 1.0 FTE)
10	Report on number of general educators funded by this grant by FTE status:
	Full time
	Part time (less than 1.0 FTE)

Section IV: Outreach and education

Table Instructions: This table collects information about the grantee’s outreach and education efforts supported by this grant. Please do not leave any sections blank. If the number for a particular category is zero (0), please put zero in the appropriate section.

Please refer to these guidelines in providing your answers to the following measures:

• External outreach focuses on proactively seeking out people in the community, helping them find health care coverage and connecting them to care at an appropriate health care provider entity.

		Baseline	End of Budget Period
11	Total number of external outreach events conducted
12	Total number of attendance at external outreach events that were conducted
13	How many unique individuals were educated on health insurance options through one-on-one consumer counseling?
14	How many unique individuals were assisted with enrollment by a trained Outreach and enrollment assistance worker through one-on-one consumer counseling?

Section V: Eligibility Determination

Table Instructions: This table collects information about the grantee’s efforts on consumer’s eligibility determination. Please do not leave any sections blank. There should not be a N/A (not applicable) response since all measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section.

Please refer to these guidelines in providing your answers to the following measures:

• Only report on the number of individuals who received eligibility determination by a trained outreach and enrollment assistance worker

• An individual can be eligible for more than 1 option.

15	Report on the number of individuals who received eligibility determination by health insurance category
	Health insurance category	Baseline	End of Budget Period
	Qualified health plans offered through the Federal Health Insurance Marketplace	Number	Number
	Qualified health plans offered through the State Insurance Marketplace
	Qualified health plans offered through the Federal-State Insurance Marketplace
	Medicaid
	Medicare
	Medicare Advantage
	Medicare Part D
	Children’s Health Insurance Program (CHIP)
	Veteran’s Choice Program
	Private health insurance plans (outside the ones offered through the Health Insurance Marketplace)
	Total number of individuals who received eligibility determination (automatically calculated by the system)

Section VI: Enrollment

Table Instructions: This table collects information about the grantee’s enrollment efforts supported by this grant. There should not be a N/A (not applicable) response since all measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section.

Please refer to these guidelines in providing your answers to the following measures:

• Only report on the number of individuals who were enrolled by a trained outreach and enrollment assistance worker

• An individual is considered to be enrolled if they chose an insurance plan and/or submitted payment for coverage

• Qualified life event includes, but not limited to, getting married, having a baby or moving outside the coverage area

• If an individual enrolled others, include those additional enrollees in the count.

16	Report on the number of individuals who enrolled for the first time by health insurance category
	Health insurance category	Baseline	End of Budget Period
	Qualified health plans offered through the Federal Health Insurance Marketplace	Number	Number
	Qualified health plans offered through the State Insurance Marketplace
	Qualified health plans offered through the Federal-State Insurance Marketplace
	Medicaid
	Medicare
	Medicare Advantage
	Medicare Part D
	Children’s Health Insurance Program (CHIP)
	Veteran’s Choice Program
	Private health insurance plans (outside the ones offered through the Health Insurance Marketplace)
	Total number of individuals who enrolled (automatically calculated by the system)
17	Report on the number of individuals who enrolled for the first time by enrollment period type
	Annual open enrollment period (consumers can enroll during a certain time period)
	Special enrollment period
	Year-round open enrollment (consumers can enroll at any time)
	Total number of individuals who enrolled by enrollment period type (automatically calculated by the system)
18	Report on the number of individuals who already are insured at the time of service by health insurance category
	Health insurance category	Baseline	End of Budget Period
	Qualified health plans offered through the Federal Health Insurance Marketplace	Number	Number
	Qualified health plans offered through the State Insurance Marketplace
	Qualified health plans offered through the Federal-State Insurance Marketplace
	Medicaid
	Medicare
	Medicare Advantage
	Medicare Part D
	Children’s Health Insurance Program (CHIP)
	Veteran’s Choice Program
	Private health insurance plans (outside the ones offered through the Health Insurance Marketplace)
	Total number of individuals who already is insured (automatically calculated by the system)
19	Percentage of individuals who retained/renewed	Numerator: Number of individuals who retained/renewed insurance	Denominator: Number of individuals who already are insured (this should match the total in question #18)

Section VII: Post-Enrollment

Table Instructions: This table collects information about the grantee’s post-enrollment efforts supported by this grant. There should not be a N/A (not applicable) response since all measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section.

Please refer to these guidelines in providing your answers to the following measures:

• These measures are for activities conducted after a consumer has already enrolled into a health insurance plan

		Numerator	Denominator
20	% of newly insured individuals who are accessing primary/preventative services	Number of newly insured individuals who are accessing primary/preventative services (as a result of enrollment)	Number of unique individuals who has health insurance for the first time (this should match the total in question #16)
21	% of newly insured individuals who selected a primary care provider	Number of newly insured individuals who selected a primary care provider	Number of unique individuals who has health insurance for the first time (this should match the total in question #16)

SECTION VIII: CONSORTIUM/NETWORK

Table Instructions: This table collects information about an aggregate count of the types and number of consortium/network members. Consortium/network members are defined as members who have signed a Memorandum of Understanding or Memorandum of Agreement for this grant project. There should not be a N/A (not applicable) response since all measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section.

22	Identify the types and number of organizations in the consortium/network for your project:
		Type of Member Organizations in the Consortium/Network	End of Budget Period
	Non-Profit Organization	Area Health Education Center	Number
		Behavioral/Mental Health Organization
		Community College
		Community Health Center
		Critical Access Hospital
		Faith-based organization
		Free Clinic
		Health Department
		Hospice
		Hospital
		Migrant Health Center
		Private Practice
		Rural Health Clinic
		School District
		Social Services Organization
		University
		Other – Specify type
		TOTAL for non-profit organization	(Automatically calculated by system)
	For-Profit Organization	Critical Access Hospital
		Hospice
		Private Practice
		Rural Health Clinic
		Other – Specify Type
		TOTAL for-profit organization	(Automatically calculated by system)

SECTION IX: SUSTAINABILITY

Table Instructions: This table collects information/data about the grant’s programmatic sustainability. There should not be a N/A (not applicable) response since all measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section.

In Year 3 of grant funding, grantees will need to report on the additional measures:

• Question #26 – Sources of sustainability

• Question #27 - The ratio impact for Economic Impact vs. HRSA Program Funding using HRSA’s Economic Impact Analysis Tool (http://www.raconline.org/econtool/)

• Question #28 - If your current consortium/network will sustain after the grant project period is over

• Question #29 - If any of the activities will sustain after the grant project period is over

		End of Budget Period
23	Annual program award Please report the annual program award based on box 12a of your Notice of Award (NOA).	Enter Dollar amount
24	Annual program revenue Please report 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.	Enter Dollar amount
25	Additional funding leveraged as a result of this grant	Dollar amount
26	Sources of Sustainability Select the type(s) of sources of funding for sustainability. Please check all that apply.
	Program 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
27	What is your ratio for Economic Impact vs. HRSA Program Funding? Use the HRSA’s Economic Impact Analysis Tool (http://www.raconline.org/econtool/) to identify your ratio.	Ratio
28	Will the consortium/network sustain?	y/n
29	Will any of the program’s activities be sustained after the project period?	y/n

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