2 Telehealth Performance Measurement Report

Evidence Based Telehealth Network Program Measures

FORM_Telehealth Performance Measurement Report

Telehealth Performance Measurement Report

OMB: 0906-0043

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0906-XXXX XX/XX/20XX

Shape1

Form 1: Priorities



Did you provide services to patients in any of the following categories because of any EB THNP funding during this reporting period?


Yes

No

Mental Health



Substance Abuse Treatment







Form 2: Originating and Distant Sites

Complete Form 1. Priorities before inputting data in this form. Only sites that are eligible for and receiving EB THNP funding should be included.

List of Selected Sites (Modify the List of Sites if Needed) and Settings (Modify the List of Settings if Needed)

Site Name

Street Address

City/Town

County

State

Zip Code

Originating or Distant Site (O/D)

Rural or Urban Site (R/U)

Setting

[grantee generated list]








[choose from menu]

[grantee generated list]








[choose from menu]



Number of Each Type of Site in this Reporting Period

Originating Sites

[#] auto-populate

Distant Sites

[#] auto-populate






Form 3: Specialties and Services, by Site

Complete Form 2. Originating and Distant Sites before inputting data in this form. Only sites and specialties that are eligible for and receiving EB THNP funding should be included.

List of Sites (Modify the List of Sites if Needed)/ List of Specialties (Modify the List of Specialties if Needed)

Originating Site

Specialty(s) actively available at this site through telehealth

Was specialty available in your community prior to this EB THNP funding?

[grantee generated site]

[choose from menu]

[yes/no radio button]

[choose from menu]

[yes/no radio button]

[grantee generated site]

[choose from menu]

[yes/no radio button]

[choose from menu]

[yes/no radio button]



Number of sites that have access to [specialty from configure report] services where access did not exist in your community prior to this EB THNP funding

[#] auto-populate

Number of sites that have access to [specialty from configure report] services where access did not exist in your community prior to this EB THNP funding

[#] auto-populate







Form 4: Volume of Services, by Site and Specialty

Complete Form 3. Specialties and Services, by Site before inputting data in this form.

Only unique patients seen and encounters occurring as the result of receiving EB THNP funding should be included.

Real-Time Encounters are encounters that are live, two-way interactions between a person and a provider using audiovisual telecommunications technology. Store-and-Forward Encounters, also called asynchronous, are the transmission of health information through digital images or pre-recorded videos through electronic communication to a practitioner who uses the information to make an evaluation.

Enter 0 if there is no data to report.



Originating Site

Setting

Specialty

Unique Patients

Number of Real-Time Encounters

Number of Store-an-Forward Encounters

Total Encounters

[grantee generated list]

[grantee generated list]

[grantee generated list]

[#]

[#]

[#]

[#]

[grantee generated list]

[grantee generated list]

[grantee generated list]

[#]

[#]

[#]

[#]



Total Number of Unique Patients Served because of EB THNP funding

[#] auto- populate

Total Number of Encounters because of EB THNP funding

[#] auto-populate







Form 5: Patient Travel Miles Saved

Complete Form 4: Volume of Services, by Site and Specialty before inputting data in this form.

Only sites and specialties that are eligible for and receiving EB THNP funding should be included.

For group sessions/clinics, each patient should be counted separately, as each would have had to travel for these sessions.



Originating Site

Specialty

Name of location where patient would have been referred in absence of telehealth

Distance Between Originating (patient) Site to the location where the patient would have been referred in the absence of telehealth (Miles)

Miles Roundtrip

Total Encounters

Miles Saved

[grantee generated list]

[grantee generated list]


[#]

[#]

[#]

[#]

[grantee generated list]

[grantee generated list]


[#]

[#]

[#]

[#]



Total Miles Saved

[#]







Form 6: Other Uses of the Telehealth Network

Complete Form 5. Patient Travel Miles Saved before inputting data in this form.

Provide required data in the tables below. Enter 0 if there is no data to report.

Enter ‘DK’ if ‘Total Number of People’ is unknown.


Categories

Number of Sessions

Administrative Meetings

[#]

Distance Learning

[#]

Other

[#]



Formal and Informal Education

Total Number of Sessions

Total Number of People

Formal Education (sessions are used to fulfill formal education, licensure or certification requirements)

[#]

[#]

Informal Education (sessions used to meet regulatory practice requirements, as well as supervision/advice requested by remote practitioners)

[#]

[#]



Form 7: Diabetes

Complete form 6: Other Uses of the Telehealth Network before inputting data in this form. Only patients seen and encounters occurring as a result of of receiving EB THNP funding should be included. Provide required data in the tables below. Enter 0 if there is no data to report.

Number of unduplicated patients with diabetes served for at least three months during the reporting period

[grantee reported #]

Number of patients with diabetes (who received services for at least three months during the reporting period) whose most recent Hemoglobin A1c (HbA1c) level is 7.0% or less.

[grantee reported #]

Number of patients with diabetes (who received services for at least three months during the reporting period) whose most recent Hemoglobin A1c (HbA1c) level is between 7.1% and 9.0%.

[grantee reported #]

Number of patients with diabetes (who received services for at least three months during the reporting period) whose most recent Hemoglobin A1c (HbA1c) level during the measurement year was greater than 9.0% (poor control), or if an HbA1c test was not done during the reporting period.

[grantee reported #]



Form 8: Mental Health

Complete form 67: Diabetes before inputting data in this form. Only patients seen and encounters occurring as a result of of receiving EB THNP funding should be included. Provide required data in the tables below. Enter 0 if there is no data to report.

Number of sites that have access to mental health services where access did not exist prior to the TNGP grant

[#]

Number of sites that have access to mental health services for pediatric and adolescent populations where access not exist prior to the TNGP grant

[#]

Number of sites that have access to mental health services for adult populations where access did not exist prior to the TNGP grant

[#]































Setup Forms:

Configure Sites:

Indicate the Sites in which you had activity during this reporting period. Only sites that are eligible for and receiving EB THNP funding should be included.

For the purposes of this grant program, rural is defined as all counties that are not designated as parts of metropolitan areas (MAs) by the Office of Management and Budget (OMB). In addition, we use Rural Urban Commuting Area Codes (RUCAs) to designate rural areas within MAs. This rural definition can be accessed at https://datawarehouse.hrsa.gov/tools/analyzers/geo/Rural.aspx. If the county is not entirely rural or urban, follow the link for “Check Rural Health Grants Eligibility by Address” to determine if a specific site qualifies as rural based on its specific census tract within an otherwise urban county.


Originating (or spoke) sites are the sites where a patient is located and receiving care. Distant (or hub) sites are the sites where the specialist is located and working.


When you are finished entering in data, click "Add" to add it to the table. Then click the "Save" button to move to

the next screen.



Site Name:


Street Address:


City/Town:


County:


State:


Zip Code:


Originating or Distant Site (O/D):


Rural or Urban Site (R/U):


HPSA:


MUA:


HCPN:


Primary Taxonomy:


NPI (Site):


EIN (if non-profit):


Site URL:




Select Specialty Areas

Indicate the Specialties for which you had activity during this reporting period. Only Specialties that are eligible for and receiving EB THNP funding should be included.

If you require a Specialty which is not available on this list, please contact the HRSA Project officer for your grant.





Select Settings

Indicate the Settings for which you had activity during this reporting period. Only Settings that are eligible for and receiving EB THNP funding should be included.

If you require a Settings which is not available on this list, please contact the HRSA Project officer for your grant.

Menu for Form 1 (Settings)

  • School Based Health Center

  • Community Health Center (including FQHCs)

  • Health Care Provider in Private Practice

  • Clinic (including RHC)

  • Local Health Department

  • Hospital (including CAH)

  • Long Term Care Provider

  • Home Health Service Provider

  • Outpatient Mental Health Service Provider/Facility

  • Local or Regional Emergency Health Care Provider

  • Higher Education Institution

  • School Based Health Center

  • Oral Health Provider

  • Other Publically Funded Health or Social Service Agency

  • Other















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 5 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 14N136B, Rockville, Maryland, 20857.



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AuthorSarah Heppner
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File Created2021-01-22

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