Form 1 Small Health Care Provider Quality Program PIMS Measures

OMB Number: 0915-0387

Expiration Date: 7/31/2017

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 currently valid OMB control number. The OMB control number for
this project is 0915-0387. Public reporting burden for this collection of information is estimated to average 8 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.

Small Health Care Provider Quality Improvement Grant Program
Table 1: ACCESS TO CARE
Information collected in this table provides an aggregate count of the number of people served
through the program. Please refer to the detailed definitions and guidelines in answering the
following measures. Please indicate a numerical figure.
Direct Services are defined as an interaction between a patient/client and a clinical or nonclinical health professional. Please include the number of patients served through this program,
funded by Federal Office of Rural Health Policy (ORHP) grant dollars. Examples of direct
services include (but are not limited to) patient visits, counseling, and education.
For the purposes of this data collection activity, indirect services will be limited to:
1) billboards,
2) flyers,
3) health fairs and
4) mailings/newsletters.
5) Other mass media (e.g., radio, television, social media)
1  Direct Services

Number

Please provide the number of patients or clients your
organization serves through direct services (e.g., patient visits,
counseling, and education)
2  Indirect Services
Please provide the number of individuals your organization
reaches through the following indirect services: billboards,
flyers, health fairs, mailings/newsletters, other mass media

Number

OMB Number: 0915-0387
Expiration Date: 7/31/2017

Table 2: POPULATION DEMOGRAPHICS
Table Instructions:
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 of the number of people served through
Direct Services provided in the previous section. If the total number in any category 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.
Number of people served through program by ethnicity 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.)
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Number of people served by ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Number of people 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
Number of people served, by age group:
Children (0-12)
Adolescents (13-17)
Adults (18-64)
Elderly (65 and over)
Unknown

Number

Number

Number

Table 3: INSURANCE STATUS/COVERAGE
Table Instructions:
Please respond to the following questions based on these guidelines:



Uninsured is defined as those without health insurance.
Medicare is defined as Federal insurance for the aged, blind, and disabled (Title XVIII of
the Social Security Act).
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




Medicaid is defined as State-run programs operating under the guidelines of Titles XIX
(and XXI as appropriate) of the Social Security Act.
The Children’s Health Insurance Program (CHIP) provides primary health care coverage
for children.
Other state-sponsored or public assistance program includes State and/or local
government programs.
Private insurance is health insurance provided by commercial and not for profit
companies. Individuals may obtain insurance through employers or on their own.

Each patient should be counted once. The total for this table should equal to the total number of
people served through Direct Services.
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Number of uninsured people
Number of people covered through Medicare
Number of people covered through Medicaid
Number of people covered through the Children’s Health
Insurance Program (CHIP)
Number of people covered through other state-sponsored
insurance or public assistance program
Number of people covered by private insurance
Unknown

Number
Number
Number
Number
Number
Number
Number

Table 4: STAFFING
Table Instructions:
Please provide the number of clinical and non-clinical positions funded by this grant. Please
indicate a numerical figure. There should not be a N/A (not applicable) response since all
questions are applicable.
Clinical staff includes, but is not limited to, physician (general or specialty), physician assistant,
nurse, nurse practitioner, dentist, dental hygienist, psychiatrist, social worker, pharmacist,
technician (medical, pharmacy, laboratory, etc.), therapist (behavioral, physical, occupational,
speech, etc.), health educator, community health worker, promotora, case manager,
interpreter/translator.
Non-clinical staff includes management (CEO, CFO, CIO, etc.), support staff, fiscal and billing
staff, information technology (IT).
NOTE: Please report each staff person who is funded by this program only once. In the case of
an individual whose time is split between clinical and non-clinical activities, please report them
in the category that reflects the majority of their time.

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Number of positions funded by grant
dollars
Clinical
Non-Clinical

Full-Time (1.0 FTE)

How many staff received continuing education or training?

Part-Time (less than
1.0 FTE)

Number

Table 5: SUSTAINABILITY
Table Instructions:
 The definition of sustainability is “programs or services continue because they are valued
and draw support and resources”.
 Select your sources of sustainability and sustainability activities.
 Please indicate if any of your program’s activities will sustain after the grant period.
 Use HRSA’s Economic Impact Tool provide the ratio for Economic Impact vs. HRSA
Program Funding.
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Annual program award
Please provide the annual program award based on box 12a of your
Notice of Award (NOA).
Annual program revenue
Please provide 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. Do not leave any sections blank.

Dollar amount

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Additional funding secured to assist in sustaining the project

Dollar amount

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

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Dollar amount

Selection
list

Network/Consortium 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
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Reimbursement from third-party payers (e.g. private insurance, Medicare,
Medicaid)
Product sales
Government (non-grant)
Other – specify type
None
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Sustainability Activities:
Which of the following activities have you engaged in to enhance your
sustainability? Please select all that apply.
Local, State and Federal Policy changes

Selection
list

Media Campaigns
Community Engagement Activities
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Other – Specify activity
Have you developed any of the following:
Please select all that apply.
Sustainability Plan

(Y/N)

Business Plan
Communications Plan
Fundraising Plan
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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.
Will the network/consortium sustain, if applicable?
If you are participating in this program as a network or consortium,
please indicate if your current network/consortium will continue after
the grant period is over
Will any of the program’s activities be sustained after the grant
period?

Ratio

(Y/N)

All/Some/None

TABLE 6: CONSORTIUM/NETWORK (OPTIONAL)
Table Instructions:
If you are participating in this program as a network or consortium, please complete this section.
Please provide information about the consortium or network members, if applicable. A
consortium or network is defined as collaboration between two or more separately owned
organizations.
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Number of member organizations in the Consortium/Network
Area Agency on Aging

Number

Area Health Education Center (AHEC)
Business
Community Health Center/ Federally Qualified Health Center (FQHC)
Critical Access Hospital
Emergency Medical Service
Faith-Based Organization
Health Department
HIT Regional Extension Center
Hospice
Hospital, not Critical Access
Long Term Care Facility
Mental Health Center
Migrant Health Center
Pharmacy
Private Practice (Medical and/or Dental)
Professional Association
Public Health Department
Rural Health Clinic
School District
Social Services Organization
Tribal Entity
University/College/Community College/Technical College
Other – Specify Type:

Table 7: HEALTH INFORMATION TECHNOLOGY
Table Instructions: Health Information Technology (HIT)
Please select all types of technology implemented, expanded or strengthened through this
program.
Type(s) of technology implemented, expanded or strengthened
25 through this program: (Please check all that apply)
Computerized provider order entry (CPOE)
Electronic entry of prescriptions/e-prescribing

Selection list

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Electronic medical records/electronic health records
Health information exchange (HIE)
Patient/disease registry
Telehealth/telemedicine
None
Other – please specify
Have your organization and/or any of your organization’s
providers attested to Meaningful Use?
26 If yes, please select all that apply.
Stage 1
Stage 2
Stage 3
If no, is your organization and/or providers planning to attest in the
next 12 months?
If yes, have your organization and/or providers received incentive
payments?

Y/N

Table 8: QUALITY IMPROVEMENT
Table Instructions:
Please report on quality improvement activities and initiatives implemented, expanded or
strengthened through this program.
.
 An Accountable Care Organization (ACO) is a group of doctors, hospitals, and other
health care providers, who come together voluntarily to give coordinated high quality
care to Medicare patients.
 A Medical Home is defined as comprehensive and continuous medical care to patients
with the goal of obtaining maximized health outcomes. To become a medical home an
organization generally gains a level of certification from an accrediting body.
 Care coordination is defined as the deliberate organization of patient care activities
between two or more participants (including the patient) involved in a patient’s care to
facilitate the appropriate delivery of health care services.
 The Partnership for Patients is a public/private partnership focused on making hospital
care safer, more reliable, and less costly through two goals: reducing preventable
hospital-acquired conditions and improving care transitions.
(http://partnershipforpatients.cms.gov/)
 Million Hearts is a national initiative to prevent 1 million heart attacks and strokes by
2017. (http://millionhearts.hhs.gov/index.html)
 The Medicare Beneficiary Quality Improvement Project (MBQIP) is a Flex Grant
Program activity within the core area of quality improvement for Critical Access
Hospitals (CAH).
(http://www.hrsa.gov/ruralhealth/about/hospitalstate/medicareflexibility_.html)

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Participation in Accountable Care Organization (ACO)
Is your organization participating in an ACO? (If yes, please check
all that apply)
Medicare Shared Savings Program
Advanced Payment ACO Model
Pioneer ACO Model
Other – specify
Participation in Medical Home
Is your organization participating in a Medical Home or Patient
Centered Medical Home (PCMH) initiative?
If yes, have you achieved or are you pursuing certification or
recognition? (If yes, please check all that apply)
National Committee for Quality Assurance (NCQA)
Accreditation Association for Ambulatory Health Care (AAAHC)
The Joint Commission
State/Medicaid Program
Other – specify
Care Coordination Activities
Referral tracking system
Patient support and engagement
Integrated care delivery system (agreements with specialists,
hospitals, community organizations, etc. to coordinate care)
Case management
Care plans
Medication management
Other – specify
Participation in Partnership for Patients
Participation in Million Hearts
Critical Access Hospitals: Participation in Medicare Beneficiary
Quality Improvement Project (MBQIP)
Other – please specify

Yes/No
(Selection List)

Yes/No
Yes/No
(Selection List)

Yes/No
(Selection List)

Yes/No
Yes/No
Yes/No

Table 9: CLINICAL MEASURES
Table Instructions:
Please use your health information technology system to extract the clinical data requested.
Please refer to the specific definitions for each measure.
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Measure 1: The percentage of patients 18 - 75 years of age with diabetes (type 1 and type 2)
whose most recent HbA1c level is <8.0% during the measurement year.
Numerator: Patients whose HbA1c level is <8.0% during the measurement year.
Denominator: Patients 18-75 years of age by the end of the measurement year who had a
diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the
measurement year.

Measure 2: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2)
whose most recent LDL-C test is <100 mg/dL during the measurement year.
Numerator: Patients whose most recent LDL-C test is <100 mg/dL during the measurement year.
Denominator: Patients 18-75 years of age by the end of the measurement year who had a
diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the
measurement year.
Measure 3: Percentage of patients aged 18 years and older with a documented BMI during
the current encounter or during the previous six months AND when the BMI is outside of
normal parameters, a follow-up plan is documented during the encounter or during the
previous six months of the encounter. (Normal Parameters: Age 65 years and older BMI >
or = 23 and < 30; Age 18 – 64 years BMI > or = 18.5 and < 25)
Numerator: Patients with a documented BMI during the encounter or during the previous six
months, AND when the BMI is outside of normal parameters, follow-up is documented during
the encounter or during the previous six months of the encounter with the BMI outside of normal
parameters
Denominator: All patients aged 18 years and older
Measure 4: The percentage of patients 18 to 85 years of age who had a diagnosis of
hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90)
during the measurement year.
Numerator: The number of patients in the denominator whose most recent BP is adequately
controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and
diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately
controlled, the representative BP must be identified.
Denominator: Patients 18 to 85 years of age by the end of the measurement year who had at
least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months
of the measurement year.
Measure 5: Percentage of patients aged 18 years and older who were screened for tobacco
use at least once during the two-year measurement period AND who received cessation
counseling intervention if identified as a tobacco user
Numerator:
Patients who were screened for tobacco use* at least once during the two-year measurement
period AND who received tobacco cessation counseling intervention** if identified as a tobacco
user
*Includes use of any type of tobacco
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** Cessation counseling intervention includes brief counseling (3 minutes or less), and/or
pharmacotherapy
Denominator: All patients aged 18 years and older who were seen twice for any visits or who
had at least one preventive care visit during the two year measurement period
Measure 6: Percentage of patients aged 12 years and older screened for clinical depression
using an age appropriate standardized tool AND follow-up plan documented
Numerator: Patient’s screening for clinical depression using an age appropriate standardized tool
AND follow-up plan is documented
Denominator: All patients aged 12 years and older
Measure 7: Percentage of patients aged 6 months and older seen for a visit between
October 1 and March 31 who received an influenza immunization OR who reported
previous receipt of an influenza immunization
Numerator: Patients who received an influenza immunization OR who reported previous
receipt* of an influenza immunization
*Previous receipt can include: previous receipt of the current season’s influenza immunization
from another provider OR from same provider prior to the visit to which the measures is applied
(typically, prior vaccination would include influenza vaccine given since August 1st).
Denominator: All patients aged 6 months and older seen for a visit between October 1 and
March 31

Numerator

Denominator

Percent

NQF 0575: Comprehensive Diabetes Care:
Hemoglobin A1c (HbA1c) Control (<8.0%): The
percentage of patients 18 - 75 years of age with
diabetes (type 1 and type 2) whose most recent
HbA1c level is <8.0% during the measurement
1 year.
NQF 0064: Comprehensive Diabetes Care: LDL-C
Control <100 mg/dL: Percent of adult patients,
18- 75 years of age with diabetes (type 1 or type 2)
2 who had LDL-C less than 100 mg/dL
NQF 0421: Preventive Care and Screening: Body
Mass Index (BMI) Screening and Follow-Up:
Percentage of patients aged 18 years and older
with a documented BMI during the current
encounter or during the previous six months AND
when the BMI is outside of normal parameters, a
follow-up plan is documented during the
encounter or during the previous six months of the
3 encounter.

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NQF 0018: Controlling High Blood Pressure: The
percentage of patients 18 to 85 years of age who
had a diagnosis of hypertension (HTN) and whose
blood pressure (BP) was adequately controlled
(<140/90) during the measurement year.
NQF 0028: Preventive Care & Screening: Tobacco
Use: Screening & Cessation Intervention:
Percentage of patients aged 18 years and older
who were screened for tobacco use at least once
during the two-year measurement period AND
who received cessation counseling intervention if
identified as a tobacco user
NQF 0418: Screening for clinical depression:
Percentage of patients aged 12 years and older
screened for clinical depression using an age
appropriate standardized tool AND follow-up
plan documented
NQF 0041: Influenza immunization: Percentage of
patients aged 6 months and older seen for a visit
between October 1 and March 31 who received an
influenza immunization OR who reported
previous receipt of an influenza immunization

OPTIONAL CLINICAL MEASURES
The following clinical measures are OPTIONAL. You are encouraged to include them,
especially if your program has a focus on pediatric populations.
Please use your health information technology system to extract the data requested. Please refer
to the specific definitions for each measure.
Optional Measure 1: Weight Assessment and Counseling for Nutrition and Physical
Activity for Children/Adolescents
Numerator: Body mass index (BMI) percentile documentation, counseling for nutrition and
counseling for physical activity during the measurement year.
Denominator: Patients 3-17 years of age with at least one outpatient visit with a primary care
physician (PCP) or OB-GYN.
Optional Measure 2: Hemoglobin A1c (HbA1c) Testing for Pediatric Patients
Numerator: Patients who had an HbA1c test performed during the measurement year.
Denominator: Patients aged 5-17 years old with a diagnosis of diabetes and/or notation of
prescribed insulin or oral hypoglycemic/antihyperglycemics for at least 12 months.

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Optional Measure 3: Blood Pressure Screening by 13 Years of Age

Numerator: Children who had documentation of a blood pressure screening and whether results
are abnormal at least once in the measurement year or the year prior to the measurement year.
Denominator: Children with a visit who turned 13 years old in the measurement year.
Numerator

Denominator

Percent

NQF 0024: Weight Assessment and Counseling
for Nutrition and Physical Activity for
Children/Adolescents: Percentage of patients 3-17
years of age who had an outpatient visit with a
primary care physician (PCP) or an OB/GYN and
who had evidence of the following during the
measurement year:
- Body mass index (BMI) percentile
documentation
- Counseling for nutrition
1 - Counseling for physical activity
NQF 0060: Hemoglobin A1c (HbA1c) Testing for
Pediatric Patients: Percentage of pediatric
patients aged 5-17 years of age with diabetes who
received an HbA1c test during the measurement
2 year.
NQF 1552: Blood Pressure Screening by 13 Years
of Age: The percentage of adolescents who turn 13
years of age in the measurement year who had a
3 blood pressure screening with results

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