Form 1 Delta Draft PIMS

O MB Number: 0915-0386

Expiration date: XX/XX/XXXX

DRAFT PLEASE DO NOT DISTRIBUTE DRAFT

Federal Office of Rural Health Policy: Rural Health

Community-Based Programs

Performance Improvement and Measurement Systems (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 0915-0386.  Public reporting burden for this collection of information is estimated to average 1.66 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 14N-39 Rockville, Maryland, 20857.

Delta States Rural Development Network Program

Section 1: ACCESS TO CARE (applicable to all Delta grantees)

Table Instructions: This table collects information about an aggregate count of the number of people served through the program and the types of services that were provided during this budget period. 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:

Direct Services are defined as a documented interaction between a patient/client and a clinical or non-clinical health professional that has been funded with FORHP grant dollars. Examples of direct services include (but are not limited to) patient visits, counseling, and education.

		Baseline	End of Budget Period
1	Direct Services Please report the number of unique (i.e. unduplicated count) patients/clients that received direct services from your organization
2	Type (s) of services provided though Delta grant funding. (Check all that apply)	Selection list
		Baseline	End of Budget Period
	Behavioral/Mental Health
	Cancer Care Management
	Cardiovascular Disease (CVD) Care Management
	Chronic Obstructive Pulmonary Disease (COPD) Prevention
	Chronic Obstructive Pulmonary Disease (COPD) Treatment and Management
	Case Management
	Diabetes Care Management
	Emergency Medical Service (EMS)
	Health Education/Health Promotion/Prevention
	Health Screenings
	HIV/AIDS
	Maternal Child Health
	Pediatric Care
	Pharmacy Assistance
	Primary Care Services
	Substance Abuse Treatment and/or Education
	Telehealth/Telemedicine
	Transportation
	Women’s Health
	Workforce Development
	All other new and/or expanded services Specify:

SECTION 2: POPULATION DEMOGRAPHICS (applicable to all Delta grantees)

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 only direct services reported in the previous section. Please do not leave any sections blank. There should not be a N/A (not applicable) response since the measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section (e.g., if the total number that is Hispanic or Latino is zero (0), enter zero in that section).

Note: It is expected that each grantee organization will collect baseline data, and then again report at the end of the budget period.

Hispanic or Latino Ethnicity

• Column A (Hispanic/Latino): Report the number of persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, broken down by their racial identification and including those Hispanics/Latinos born in the United States. Do not count persons from Portugal, Brazil, or Haiti whose ethnicity is not tied to the Spanish language.

• Column B (Non-Hispanic/Latino): Report the number of all other people except those for whom there are neither racial nor Hispanic/Latino ethnicity data. If a person has chosen a race (described below) but has not made a selection for the Hispanic /non-Hispanic question, the patient is presumed to be non-Hispanic/Latino.

• Column C (Unreported/Refused to Report): Only one cell is available in this column. Report on Line 7, Column C only those patients who left the entire race and Hispanic/Latino ethnicity part of the intake form blank.

People who self-report as Hispanic/Latino but do not separately select a race must be reported on Line 7, Column A as Hispanic/Latino whose race is unreported or refused to report. Health centers may not default these people to “White,” “Native American,” “more than one race,” or any other category.

Race

All people must be classified in one of the racial categories (including a category for persons who are “Unreported/Refused to Report”). This includes individuals who also consider themselves to be Hispanic or Latino. People who self-report race, but do not separately indicate if they are Hispanic or Latino, are presumed to be non-Hispanic/Latino and are to be reported on the appropriate race line in Column B.

People sometimes categorized as “Asian/Other Pacific Islander” in other systems are divided into three separate categories:

• Line 1, Asian: Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Indonesia, Thailand, or Vietnam

• Line 2a, Native Hawaiian: Persons having origins in any of the original peoples of Hawaii

• Line 2b, Other Pacific Islander: Persons having origins in any of the original peoples of Guam, Samoa, Tonga, Palau, Truk, Yap, Saipan, Kosrae, Ebeye, Pohnpei or other Pacific Islands in Micronesia, Melanesia, or Polynesia

• Line 2, Total Native Hawaiian/Other Pacific Islander: Must equal lines 2a+2b

American Indian/Alaska Native (Line 4): Persons who trace their origins to any of the original peoples of North and South America (including Central America) and who maintain Tribal affiliation or community attachment.

More than one race (Line 6): “More than one race” should not appear as a selection option on your intake form. Use this line only if your system captures multiple races (but not a race and an ethnicity) and the person has chosen two or more races. This is usually done with an intake form that lists the races and tells the person to “check one or more” or “check all that apply.” “More than one race” must not be used as a default for Hispanics/Latinos who do not check a separate race. They are to be reported on Line 7 (Unreported/Refused to Report), as noted above.

3		Line	Number of People Served By Race	Hispanic/Latino (a)		Non-Hispanic/Latino (b)	Unreported/ Refused to Report Ethnicity (c)		Total (d) (Sum Columns a+b+c)
		1	Asian
		2a.	Native Hawaiian
		2b.	Other Pacific Islander
		2.	Total Native Hawaiian/Other Pacific Islander (Sum lines
		3.	Black/African American
		4.	American Indian/ Alaska Native
		5.	White
		6.	More than one race
		7.	Unreported/Refused to report race
		8.	Total of individuals served (Sum Line 1+2+3 to 7)						Equal to the total number of unique individuals who receive direct services
					Baseline			End of Budget Period
4	Number of people served, by age group:
	Children (0-12)
	Adolescents (13-17)
	Adults (18-64)
	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
5	Number of people by health insurance status:
	Self-pay
	None/Uninsured
	Dual Eligible (covered by both Medicaid and Medicare)
	Medicaid/CHIP only
	Medicare only
	Other third party
	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 3: SUSTAINABILITY (applicable to all Delta grantees)

Table Instructions: This table collects information/data about the grant’s programmatic sustainability. There should not be a N/A (not applicable) response since the measures are applicable to all grantees. For the purposes of this report, sustainability efforts will be reported on at the end of each budget period (once per year).

Annual 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.

Addition Funding is defined as funding already secured to assist in sustaining the project. Donations should be included in this section.

In Year 3 of grant funding, grantees are required to report on these additional measures:

• Question #9 - The ratio impact for Economic Impact vs. HRSA Program Funding using HRSA’s Economic Impact Analysis Tool (http://www.raconline.org/econtool/)

• Question #10 - If any of the activities will sustain after the grant project period is over

7	Select the type(s) of sources of funding for sustainability. Please include the dollar amount obtained by each source.
	Source of Sustainability		Annual Program Revenue (Dollar Amount)	Additional Funding (Dollar Amount)
	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 payers (e.g. private insurance, Medicare, Medicaid)
	Product sales
	Government (non-grant)
	Other – specify type
	None
			TOTAL for Annual Program Revenue (automatically calculated by the system)	TOTAL Additional Funding (automatically calculated by the system)
8		Which of the following activities have you engaged in to enhance your sustainability?  Check all that apply.		Selection list
		Local, State and Federal Policy changes
		Media Campaigns
		Community Engagement Activities
		Other – Specify activity
9		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
10		Will any of the program’s activities be sustained after the project period?		(Some/None/All)

Does your grant program fund health promotion/disease management activities? (If respondents choose “Y”, question 11 will become available to answer. If respondents choose “N”, the system will move onto the next section.)

Y/N

SECTION 5: HEALTH PROMOTION/DISEASE MANAGEMENT

Table Instructions: Number of patient referrals through health promotion/disease management activities offered to the public through this program.

Number of people referred to health care provider/s

• Report the number of people that were referred to a health care provider as a result of health promotion and disease management activities.

Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

		Baseline	End of Budget Period
11	Number of people referred to health care provider/s as a result of health promotion activities.

Does your grant program fund mental/behavioral health services? (If respondents choose “Y” question 12 will become available to answer. If respondents choose “N”, the system will move onto the next section.)

Y/N

SECTION 6: MENTAL/BEHAVIORAL HEALTH

Table 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.

		Baseline	End of Budget Period
12	Number of people receiving mental and/or behavioral health services in target area.

Does your grant program fund dental/oral health services? (If respondents choose “Y” questions 13 and 14 will become available to answer. If respondents choose “N”, the system will move onto the next section.)

Y/N

SECTION 7: ORAL HEALTH

Table 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.

		Baseline	End of Budget Period
13	Number of people receiving dental/oral health services in target area.

14	Number of people that receive the following type(s) of dental /oral health services provided. (Check all that apply)	Selection list
		Baseline	End of Budget Period
	Screenings / Exams
	Sealants
	Varnish
	Oral Prophylaxis
	Restorative
	Extractions
	Other
	Not Applicable

Does your grant program fund obesity services for children (aged 2-17)? (If respondents choose “Y” questions 15 and 16 will become available to answer. If respondents choose “N”, the system will move onto the end of the survey.)

Y/N

SECTION 8: CHILDHOOD OBESITY

Table Instructions: Report on the number of people aged 2 through 17 receiving a body mass index (BMI) assessment through your program. If your grant program did not fund these services, please type N/A for not applicable. Please use CDC’s BMI Calculator for Child and Teen (https://nccd.cdc.gov/dnpabmi/calculator.aspx) to calculate BMI. BMI is calculated using the child’s weight and height and is then used to find the corresponding BMI-for-age percentile for the child’s age and sex.

BMI-for-age percentile shows how the child’s weight compares to that of other children of the same age and sex. For example, a BMI-for-age percentile of 65% means that the child’s weight is greater than that of 65% of other children of the same age and sex.

		Baseline	End of Budget Period
15	Number of children that received a BMI assessment in target area.

		Baseline	End of Budget Period
16	Of the number of children reported in #15, how many are: Please use CDC’s BMI Calculator for Child and Teen (https://nccd.cdc.gov/dnpabmi/calculator.aspx) to calculate BMI
	Underweight
	Healthy weight
	Overweight
	Obese

Does your grant program collect clinical data? (If respondents choose “Y” question 17 will become available to answer. If respondents choose “N”, the system will move onto the end of the survey.)

Y/N

SECTION 9: CLINICAL MEASURES

Table Instructions:

Each of the clinical measures below are based on the National Quality Forum’s (NQF) measures. Please use your electronic patient registry system to extract the clinical data requested for patients served through the grant program. Please refer to the specific definitions for each field below. Please indicate a numerical figure or N/A for not applicable for your specific grant activities.

Measure 1: Depression

NQF 0418: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Numerator: Number of patients screened for clinical depression using an age appropriate standardized tool and follow-up plan is documented.

Denominator: All patients aged 12 years and older.

Measure 2: Blood Pressure

NQF 0018: Controlling High Blood Pressure

Numerator: The number of patients in the denominator whose most recent blood pressure (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 3: Diabetes (HbA1C)

NQF 0575: Comprehensive Diabetes Care Hemoglobin A1c (HbA1c) Control (<8.0%)

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 4: Diabetes (Blood pressure)

NQF 0061: Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg)  

Numerator: Patients whose most recent blood pressure level was <140/90 mm Hg during the measurement year.

The outcome being measured is a blood pressure reading of <140/90 mm Hg, which indicates adequately controlled blood pressure. Adequately controlled blood pressure in patients with diabetes reduces cardiovascular risks and microvascular diabetic complications.

Denominator: All patients 18-75 years of age during measurement year with a diagnosis of type 1 or 2 diabetes.  

Measure 5: Body mass index (weight assessment and counseling)

NQF 0024: 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.

Measure 6: Body mass index (screening and follow-up)

NQF 0421: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

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 7: Tobacco use

NQF 0028: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention

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

** 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.

17	Clinical Measures	Numerator (Number)	Denominator (Number)	Percent (Automatically calculated by system)
Measure 1: Depression	NQF 0418: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan: Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow up plan documented.
Measure 2: Blood Pressure	NQF 0018: Controlling High Blood Pressure: The number of patients 18 to 85 years of age who has a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90) during the measurement year.
Measure 3: Diabetes (HbA1c)	NQF 0575: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%): Percent of adult patients, 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c less than 8.0%
Measure 4: Diabetes (Blood Pressure)	NQF 0061: Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg): Percent of patients 18-75 years of age with diabetes (type 1 or type 2) whose most recent blood pressure level taken during the measurement year is less than 140/90 mm/Hg
Measure 5: Body mass index (Weight Assessment and Counseling)	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 - Counseling for physical activity
Measure 6: Body mass index (Screening and Follow-Up)	NQF 0421: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up: Percentage of patients aged 18 years and older with a calculated 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 plan is documented.
Measure 7: Smoking Use	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

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