Form 1 PIMS Measures

Radiation Exposure Screening and Education Program Performance Improvement and Measurement System (PIMS)

PIMS Measures_RESEP Final DRAFT

Radiation Exposure Screening and Education Program Measures

OMB: 0906-0012

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OMB Number (0906-0012)

Expiration date:

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 0906-0012.  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 14N39, Rockville, Maryland, 20857.


HRSA-17-025

Radiation Exposure Screening and Education Program

Performance Measures


Goal:

Funded eligible entities to carry out programs to develop educational programs; disseminate information on radiogenic diseases and the importance of early detection; screen eligible individuals for cancer and other radiogenic diseases; provide appropriate referrals for medical treatment; and facilitate documentation of Radiation Exposure Compensation Act (RECA) claims.

Tables/Categories:

  1. Demographics

  2. Annual Program Data Screening

  3. Annual Program Date Outreach

Measures:

DEMOGRAPHICS

Instructions:

Please provide the number of RESEP program users in your service population by age, gender, race and ethnicity. The number of individuals recorded within each category of this measure is reflective of the total population who have sought services from your organization’s RESEP facility and/or facilities.

If the number of people is zero (0), please put zero (0) 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 total users by race.


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.


Demographics

Number

1

Age Group – Number of Medical Users



Under 40



40-44



45-49



50-54



55-59



60-64



65-69



70-74



75-79



80-84



85+


2

Gender – Number of Total Users



Male



Female


3

Number of users by Race

Hispanic/Latino

(a)

Non-Hispanic/Latino

(b)

Unreported/ Refused to Report Ethnicity

(c)

Total

(d)

Asian





Native Hawaiian/Other Pacific Islander





Black/African American





American Indian/ Alaska Native





White





More than one race





Unreported/Refused to report race





Total of individuals served (automatically calculated)





Equal to the total of the number of individuals in the target population





ANNUAL PROGRAM DATA SCREENING


Instructions:

Please refer to each category description for completing reporting for this measure.


Screening by Type

4a Screening: Please provide the number of initial medical encounters of eligible individuals who receive an employment history and physical examination by a health care provider.


4b Re-Screening: Please provide the number of medical encounters that occur at least one year after the initial physical examination of an eligible individual by a health care provider.


4c Screening Follow-Up Contacts:

Please provide the number of users who have received a follow-up contact (face-to-face, calls and letters) with patients, and primary care providers and specialists regarding issues related to follow up after a screening. This also includes case management, general screening follow-up contacts, contacts regarding patients’ questions about their screening exam or results, contacts as a result of a screening exam or test that were done, referral for additional diagnostic testing or treatment, and any other activities related to a RESEP screening.


4

Screening by Type

Number

4a

Screening


4b

Re-Screening


4c

Screening Follow-Up Contacts



Referral by Type

5a Medical Referrals: Please provide the number of all referrals (inclusive and exclusive of RECA eligibility) for diagnosis and/or treatment made as a result of a RESEP screening exam.


5b Medical Referrals for RECA Diagnostic: Please provide the total number of referrals made, this is the number of patients referred for additional diagnostic testing of a RECA eligible disease or cancer.


5c Medical Referrals for RECA Treatment: Please provide the total number of referrals made, this is the number of patients referred for treatment of a RECA eligible disease or cancer.


5

Referrals by Type

Number

5a

All Medical Referrals


5b

Medical Referrals for RECA Diagnostic


5c

Medical Referrals for RECA Treatment




Other Type of Program Services

6a Depression Screening: Positive Test and Referral: Please provide the total number of RESEP patients that test positive for depression (according to the two question instrument in the RESEP guidance under Depression Screening) and were referred for treatment of, either to their primary care, behavioral health or mental health provider.


6b RECA Eligibility Assistance Encounters: Please provide the total number of all RECA related encounters including: one-on-one counseling or assistance provided to individuals about eligibility for the RECA program, including information about patient claims, required documentation (e.g., medical, residency, and work history), application instructions, filing and approval processes, possible compensation, and referral for legal services. RECA eligibility assistance can be provided to individuals screened through the RESEP clinic, individuals who contact clinics for information about RECA eligibility without being screened at that clinic, family members of RECA-eligible individuals (living or deceased), and individuals with legal representation. This also includes repeat counseling sessions for RECA eligibility. This assistance can be provided through face to- face interactions, telephone encounters, or individual RECA claims assistance.


6

Other Type of Program Services

Number

6a

Depression Screening: Positive Test and Referral


6b

RECA Eligibility Assistance Encounters



ANNUAL PROGRAM DATA OUTREACH


Sessions or Distributed Items

7a Presentations: Please provide the number of formal or informal sessions held (e.g. Community meetings, forums, events, health fairs, education classes) that include information about RESEP (may also include information about RECA).


7b Individuals Attending Presentations: Please provide the number of individuals who attended the presentations as described above


7c Pamphlets/Brochures/Letters Distributed: Please provide the number of items distributed that included information about RESEP (may also include information about RECA). This category can include materials distributed at: community meetings, forums, health fairs or education classes. Letters counted in this category should only be those related to outreach and education, not letters related to screening results or referrals.


7d Other: Please provide the number of other media types (e.g. e-mails, posters or flyers) disseminated to inform a target audience about RESEP. The number of items goes in the box. Also, please enter the description of which items and the quantity of each "Other" category item disseminated.


7

Sessions or Distributed Items

Number

7a

Presentations


7b

Individuals Attending Presentations


7c

Pamphlets/Brochures/Letters Distributed


7d

Other



Individual Encounters

8a Face to Face: Please provide the number of one-on-one encounters with individuals regarding general, nonmedical questions about RESEP. These face-to-face encounters can include interactions focused on facilitating access and/or informing clients of available RESEP services. These face-to-face encounters can be the result of a range of education and outreach efforts, including RESEP presentations, media activity, publications, or word of mouth.


8b Telephone/General: Please provide the number of telephone encounters with individuals regarding general, nonmedical questions about RESEP. These telephone encounters can include interactions focused on facilitating access and/or informing clients of available RESEP services. These telephone encounters can be the result of a range of education and outreach efforts, including RESEP presentations, media activity, publications, or word of mouth.


8

Individual Encounters

Number

8a

Face to Face


8b

Telephone/General



Sessions or Distributed Items by Media Type

9a Radio: Please provide the number of advertisements, feature stories, or other radio announcements that inform the target audience about RESEP.


9b TV Spots: Please provide the number of advertisements, feature stories, or other television announcements that inform the target audience about RESEP.


9c Newspaper: Please provide the number of advertisements or articles that run in printed publications with the aim of reaching the target audience.


9d Letter: Please provide the number of letter distributed that included information about RESEP or RECA related to outreach and education, not letters related to screening results or referrals.


9e Social Media: Please provide the number of advertisements or articles that run on Social Media with the aim of reaching the target audience.


9f Other: Please provide the number of other media types (e.g. e-mails, posters or flyers) disseminated to inform a target audience about RESEP. The number of items goes in the box. Also, please enter the description of which items and the quantity of each "Other" category item disseminated.


9g Geographic Regions Reached via Media Efforts: Please provide the geographic regions reached via your media efforts (ie counties, communities, neighborhoods)



9

Sessions or Distributed Items by Media Type

Number

9a

Radio


9b

TV Spots


9c

Newspaper


9d

Letters


9e

Social Media


9f

Other


9g

Geographic Regions Reached via Media Efforts (up to 500 characters)




RECA-ELIGIBLE DISEASES BY EXPOSURE CATEGORY


Instructions:

Please refer to each category description for completing reporting for this measure.


10 Exposure Activities for Malignant Diseases: Please provide the total number of RECA-eligible malignant diseases by exposure activity discovered during the reporting period.


11 Exposure Activities for Non-Malignant Diseases: Please provide the total number of RECA-eligible non-malignant disease by exposure activity discovered during the reporting period.


10

Exposure Activities for Malignant Diseases


Uranium Mining

Uranium Milling

Ore Transporting

Downwinder

Onsite Participant

Multiple Activities

Total

Multiple Myeloma








Non-Hodgkin’s Lymphomas








Leukemia








Lung Cancer








Renal Cancer








Thyroid Cancer








Breast Cancer








Esophagus Cancer








Stomach Cancer








Pharynx Cancer








Bile Duct Cancer








Gall Bladder Cancer








Salivary Gland Cancer








Urinary Bladder Cancer








Brain Cancer

Colon Cancer








Ovarian Cancer








Liver Cancer








Kidney Cancer











11

Exposure Activities for Non-Malignant Diseases

Uranium Mining

Uranium Milling

Ore Transporting

Downwinder

Onsite Participant

Multiple Activities

Total

Respiratory Diseases








Chronic Renal Disease








Lung Disease Pulmonary Fibrosis








Fibrosis Cor Pulmonale








Renal Cancer








Silicosis








Pneumoconiosis










OTHER DISEASES (NOT-ELIGIBLE FOR RECA)


Instructions:

Please refer to each category description for completing reporting for this measure.


12 Malignant Diseases Number: Please specify the type of malignant diseases (Not-Eligible for RECA) and the total number discovered.


13 Non-Malignant Diseases Number: Please specify the type of non-malignant diseases (i.e., those diseases not eligible for RECA) and the number discovered.


14 Please provide comments on the Annual Program Data Screening and Outreach Form (500 word limit).


12

Malignant Diseases:

Number


Pituitary Adenoma



Uterine Cancer



Endometrial Cancer



Prostate Cancer



Cervical Cancer


13

Non-Malignant Diseases:

Number

 

 

 

 

 

 

Depression


Kidney Mass


Pneumonia


Irregular Heart Beat


Hematuria


Dysphagia


Hypertension



Hypothyroid



BPH



Dementia



Pernicious Anemia



Liver Nodules


14

Annual Program Data Screening and Outreach Form Comments




TELEHEALTH (This section is only applicable to projects utilizing telehealth services)


Table Instructions: Telehealth is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance. If your RESEP grant program utilizes telehealth please fill out the following table.


In the table, enter the names of each consultant site (hub site) in column 1 and each originating site (patient data site) in column 2. For many programs, the telehealth provider site will be serving all your remote sites. We ask that you still list the telehealth provider (hub) site in column 1.


Estimate the distance between the two (in miles) and enter this number into column 3. This information can be obtained by using Google maps (https://www.google.com/maps) or other mapping resources.


Enter the number of patient care sessions between the two locations in column 5. For group sessions/clinics, each patient should be counted separately, as each would have had to travel for these sessions. For simplicity reasons (and to avoid collecting information from each patient) the distance a patient travels from their home to the remote site is intentionally omitted. Home patients should be excluded from this entire reporting sheet. Patients being stabilized prior to transport should be excluded as well, as their travel is not averted, only delayed.


Columns 4 and 6 will fill in automatically. You do not need to enter anything into these cells.


Definitions:

Consultant or Hub site: Site at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications system.


Originating Site/Patient Data Site: Site at which the patient is located or where patient data is collected at the time the service is provided via telecommunications system.


Patient-Care Sessions: Include therapy and counseling (including nutritional, group, etc.) but NOT didactic education, community meetings or administrative sessions.


Question 15

1

2

3

4

5

6

Consultant Site

Patient/Patient-data Site

Distance Between (miles)

Miles Roundtrip
('column 3' X 2)

# Patient Care Sessions

Miles Saved
('column 4' X 'column 5')

 

 

 

0

 

0

 

 

 

0

 

0

 

 

 

0

 

0

 

 

 

0

 

0

 

 

 

0

 

0



Total:

0

0

0


26



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