Appendix A Program Data Collection Tool

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Overview

Targets and Milestones
Participating Providers
Training Sessions
Incentive Payments

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Sheet 1: Targets and Milestones

QPR Appendix A: Section 2.1 -- Program Targets and Milestones Record the program operational targets in accordance with planned operations. The targets focus primarily on recruitment, timeliness and coordination of services, and worker participant outcomes. In each QPR, submit targets for the next quarter. For example, in the QPR for Quarter 3 in FY 2019, submit targets for Q4 in FY 2019.
Data Element Number	Data Element Category	Measure Description	Data Type	QPR Q3: FY2019 Target for Q4: FY2019	QPR Q4: FY2019 Target for Q1: FY2020	QPR Q1: FY2020 Target for Q2: FY2020
TAR01	Target number of worker participants	Record the target number of worker participants enrolled in the treatment group at end of the current quarter.	Count
TAR02	Target number of participating RETAIN service providers	Record the target number of RETAIN service providers enrolled at end of the current quarter. A RETAIN service provider is “participating” in RETAIN if they has signed an agreement to provide RETAIN services to worker participants.	Count
TAR03	Target number of participating RETAIN service providers that have received any training	Record the target number of RETAIN service providers that have received any training as part of the RETAIN program.	Count
TAR04	Target days for RTW Coordinator initial communication with worker participant	Record the target (maximum) number of days from worker participant enrollment to RTW Coordinator initial communication with worker participant.	Days
TAR05	Target days for RTW Coordinator initial communication with worker participant’s employer	Record the target (maximum) number of days from worker participant enrollment to RTW Coordinator initial communication with participant’s employer.	Days
TAR06	Target days for RTW Coordinator initial communication with worker participant’s healthcare provider	Record the target (maximum) number of days from worker participant enrollment to RTW Coordinator initial communication with healthcare provider.	Days
TAR07	Target days for RTW Plan Development	Record the target (maximum) number of days from worker participant enrollment until a RTW Plan is finalized.	Days
TAR08	Target days between referral to employment-related services and when services begin	Record the target (maximum) number of days between the date a worker participant is referred to employment-related services and the date the worker participant begins the services.	Days
TAR09	Target number of instances of communication between RTW Coordinator and worker participant	Record the target (minimum) number of instances of communication between the RTW Coordinator and worker participant.	Count
TAR10	Target number of instances of communication between RTW Coordinator and healthcare provider	Record the target (minimum) number of instances of communication between the RTW Coordinator and healthcare provider.	Count
TAR11	Target number of instances of communication between RTW Coordinator and the worker participant’s employer	Record the target (minimum) number of instances of communication between the RTW Coordinator and the worker participant’s employer.	Count
TAR12	Target number of instances of communication between RTW Coordinator and workforce professional	Record the target (minimum) number of instances of communication between the RTW Coordinator and a workforce professional involved in the worker participant’s treatment.	Count
TAR13	Target percentage of worker participants returning to work within 6 weeks	Record the target (minimum) percentage of worker participants that will return to work within 6 weeks of enrolling in RETAIN.	Percent
TAR14	Target percentage of worker participants returning to work within 12 weeks	Record the target (minimum) percentage of worker participants that will return to work within 12 weeks of enrolling in RETAIN.	Percent
TAR15	Target percentage of worker participants returning to work within 24 weeks	Record the target (minimum) percentage of worker participants that will return to work within 24 weeks of enrolling in RETAIN.	Percent

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Sheet 2: Participating Providers

QPR Appendix A: Section 2.2 -- RETAIN Service Provider Participation and Training This section asks for information on the number and type of service providers that are participating in RETAIN, and the number of service providers that have received any training as part of the RETAIN program. For the RTW Coordinators, provide the number working for RETAIN and the number that received any RETAIN training in Full-Time Equivalents (FTEs). For example, a RTW Coordinator working full-time should be counted as 1, but a RTW Coordinator working half-time in RETAIN should be counted as 0.5. For service providers other than RTW Coordinators, if feasible, count them in FTEs based on the proportion of time involved with RETAIN. For example, if a provider spends half their time at a hospital involved with RETAIN and half at another hospital not participating in RETAIN, then the provider would be counted as 0.5 FTEs for the number providing RETAIN services and 0.5 FTEs for the number that received any training as part of the RETAIN program. If this is not feasible, then simply count each service provider (other than RTW Coordinators) as 1 FTE. Please mention in your QPR narrative which method was used.
Data Element Number	Provider Type	Number Providing RETAIN Services		Number That Completed Training
PRV00	There are 11 potential types of providers listed below and an additional category for "Other." List any additional provider types under the "Other" row and include text that describes the provider type. EXAMPLE: To include a "Neurologist" that is not included below, list it below the "Other" row. You may add as many additional provider types as necessary. Additionally, you may add more details to any of the provider types listed. For example, to identify the Physician Assistant type.	For each provider type, record the number who have signed a contract to provide RETAIN services.		For each provider type, record the number that have completed RETAIN training.
Data Element Number	Provider Type	Quarter 3: FY 2019		Quarter 4: FY 2019		Quarter 1: FY 2020		Quarter 2: FY 2020
		Number Providing RETAIN Services	Number Completed Training	Number Providing RETAIN Services	Number Completed Training	Number Providing RETAIN Services	Number Completed Training	Number Providing RETAIN Services	Number Completed Training
PRV01	RTW Coordinators (Health System) (FTEs)
PRV02	RTW Coordinators (Workforce Development System) (FTEs)
PRV03	Primary Care Physicians
PRV04	Occupational Medicine Physicians
PRV05	Physical Medicine and Rehabilitation Specialists
PRV06	Orthopedic Surgeons
PRV07	Neurosurgeons
PRV08	Physical Therapists
PRV09	Chiropractors
PRV10	Registered Nurses
PRV11	Nurse/Nurse Practitioners
PRV12	Physician/Physician Assistants
PRV13	Mental Health Professionals
PRV14	Other Physicians or Clinicians -- please specify
PRV15	Workforce Development Professionals
PRV16	Vocational Rehabilitation Counselors
PRV17	Other Workforce Professionals -- please specify

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Sheet 3: Training Sessions

QPR Appendix A: Section 2.3 -- RETAIN Service Provider Training Descriptions Record information for each specific training session held for RETAIN service providers. Record the title of the training session, a brief description of the training session, the date of the training, the training delivery method, the duration of training (in hours), and the number of trainees/participants that attended. Record each training session as a separate entry below. For instance, if the same training course was delivered twice to two different sets of trainees, enter the session twice.
Data Element Number	Training Session Title	Training Session Description	Date of Training	Training Delivery Method	Duration (hours) of Training per Session	Number of Trainees/Participants per Session
TRNXX	Record the Training Session Title.	Record a brief text description of the training session.	Date (MM/DD/YYYY)	Record whether the training session was: 1. Classroom, training, or conference room setting 2. Live virtual training (e.g. Skype, live webcast) 3. Self-directed online resource (may include an interactive online module or a training housed online but conducted via paper) 4. On-the-job Training 5. Other method not included above	Hours	Count
TRN00 EXAMPLE	Identifying and Overcoming Barriers to Return to Work	This session focused on how to identify barriers to RTW faced by workers depending on their job requirements and their particular injury/illness and how to best work with other providers and the employer to identify ways to overcome those barriers.	3/11/2019	1	3	16
Data Element Number	Training Session Title	Training Session Description	Date of Training	Training Delivery Method	Duration (hours) of Training per Session	Number of Trainees/Participants per Session
TRN01
TRN02
TRN03
**ADD AS NEEDED

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Sheet 4: Incentive Payments

QPR Appendix A: Section 2.4 -- Incentives to Adopt Occupational Health Best-Practices Record information for each specific type of incentive payment that is offered to RETAIN stakeholders. This may include incentives to healthcare providers, employers, and/or workers. Do NOT include incentives to worker participants for filling out surveys. Include a brief description of the incentive, who the incentive targets, its value, and the number of times the specific incentive payment was made. NOTE: Total incentive payments may not exceed 10 percent of any annual RETAIN budget.
Data Element Number	Activity Being Incentivized	Incentive Target	Monetary Incentive Value	Non-Monetary Incentive Value	Number of Times Incentive "Payment" was made
INCXX	Include a brief description of the incentive.	Identify whether the incentive is paid to healthcare providers, employers, workers, or any other group you identify.	Record the monetary value of the incentive (if there is a monetary incentive value). If there is no monetary incentive value, leave this blank.	If there is no monetary incentive value, please describe the incentive (for example, 2 CME credits). If there is no non-monetary incentive value, leave this blank.	Record the number of times an incentive payment was made.
Data Element Number	Activity Being Incentivized	Incentive Target	Monetary Incentive Value	Non-Monetary Incentive Value	Number of Times Incentive Payment was Made
					Quarter 3: FY2019	Quarter 4: FY2019	Quarter 1: FY2020	Quarter 2: FY2020
INC00 EXAMPLE	Finalize RTW Plan	Healthcare provider	$50		7	21	17	33
INC01
INC02