| 5a. DP18-1815 Category B: Resource Use and Cost Inventory Tool | |||
| Form Approved OMB No. 0920-xxxx Exp. Date XX/XX/20XX |
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| Introduction | |||
| Thank you for taking the time to participate in this Cost Study of the 1815 Category B strategies. Please follow the instructions provided in this Resource Use and Cost Inventory Tool to provide cost data related to the implementation of the 1815 Category B strategies. The data collected with this tool will be used to (1) estimate the overall costs of implementing each Category B strategy, (2) determine the level of variability in the cost of implementation from one state to another, and (3) identifying the factors driving cost and variability. Completion of this Resource Use and Cost Inventory Tool is voluntary. It is expected that it will take you approximately 2.5 hours to complete the tool, including time to retrieve information you may need to fill the form. You may save a partially completed tool and return to complete it at a different time. All information will be kept secure and any identifiable information will be removed when results are aggregated for analysis. The Deloitte National Evalaution Team is available to address any questions you may have and provide additional guidance to support completion of this this tool. You may email Gizelle Gopez, [email protected] with questions. |
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| 5a. DP18-1815 Category B: Resource Use and Cost Inventory Tool | ||||||
| Introduction to Cost Study | ||||||
| Thank you for taking the time to participate in the DP18-1815 Resource Use and Cost Inventory Tool. The Deloitte evaluation team is working with the CDC Division for Heart Disease and Stroke prevention to evaluation the DP18-1815 Cooperate Agreement -- Improving the Health of Americans through Prevention and Management of Diabetes and Heart Disease and Stroke, which we will refer to as 1815. As part of the larger national evaluation of 1815, we are conducting a cost study focused on the Heart Disease and Stroke, Category B strateges. The cost study is designed to calculate the overall costs of implementing each 1815 Category B strategy and will take approximately 2 hours to fill out. Your participation in this cost study is completely voluntary and it will not in any way impact the funding or technical assistance you receive from CDC. All information will be kept secure and any personally-identifiable information will be removed when results are aggregated for analysis. If you have any questions about the study or the tool, please contact Gizelle Gopez, [email protected]. Note: Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-20HP) |
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| Instructions | ||||||
| Each of the corresponding worksheets have their own specific instructions. Note that boxes shaded in yellow do not need to be filled out by the respondent as these cells will automatically populate as a result of the excel forumula within these cells. The information that will be asked of you to fill out the information will require some detail. Therefore, to fill out the corresponding spreadsheets, please have the following information readily available for the respective reporting period: 1) CDC budget 2) Workplans 3) APRs |
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| DP18-1815 Category B Strategies | ||||||
| Below are the Category B strategies which are referenced throughout the tool by strategy number and by shorthand description. You may refer back to this page for a full description of each of the strategies. | ||||||
| B1: Promote the adoption and use of electronic health records (EHR) and health information technology (HIT) to improve provider outcomes and patient health outcomes related to identification of individuals with undiagnosed hypertension and management of adults with hypertension. | ||||||
| B2: Promote the adoption of evidence-based quality measurement at the provider level (e.g., use dashboard measures) to monitor healthcare disparities and implement activities to eliminate healthcare disparities) | ||||||
| B3: Support engagement of non-physician team members (e.g., nurses, nurse practitioners, pharmacists, nutritionists, physical therapists, social workers) in hypertension and cholesterol management in clinical settings | ||||||
| B4: Promote the adoption of MTM between pharmacists and physicians for the purpose of managing high blood pressure, high blood cholesterol, and lifestyle modification | ||||||
| B5: Develop a statewide infrastructure to promote sustainability for CHWs to promote management of hypertension and high blood cholesterol | ||||||
| B6: Facilitate use of self-measured blood pressure monitoring (SMBP) with clinical support among adults with hypertension | ||||||
| B7: Implement systems to facilitate systematic referral of adults with hypertension and/or high blood cholesterol to community programs/resources | ||||||
| Please review all information completed with the individual to make sure it is accurate before departing | ||||||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | |||||
| Resource Totals | |||||
| Instructions: This page has been pre-populated. There is no need to fill out any of the information listed here. Items in yellow will automatically be populated due to the Excel formula within each cell. | |||||
| Form Approved OMB No. 0920-xxxx Exp. Date XX/XX/20XX |
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| State | |||||
| Reporting Period | |||||
| $- | |||||
| Total 1815 Category B Spending Amount | |||||
| Tabs | Cost Study Component | Total | |||
| 1 | Parameters | N/A | |||
| 2 | Personnel | $- | |||
| 3 | Consultants and Subcontractors | $- | |||
| 4 | Equipment, Supplies, Materials | $- | |||
| 5 | Travel | $- | |||
| 6 | Other Resources | N/A | |||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | |||||
| Parameters | |||||
| Instructions: Please select which of the strategies your health department is implementing (column D). For level of maturity (column E), please select the level of maturity which is defined as follows: Development: strategy is under the design phase (0% mature); Start-up: initiation of strategy for the first time under the 1815 NOFO (25% mature); Growth: strategy is gaining traction, increasing number of sites, participation from target audience (50% mature); Expansion: strategy has not only gained traction but has now expanded to desired size and reach (75% mature); Maintenance: continuation of strategy under 1815 perhaps under another NOFO or initiative, activities are established (100% mature). Items in yellow will automatically be populated due to the Excel formula within each cell. | |||||
| State | |||||
| Reporting Period | |||||
| Total 1815 Category B Funding Amount | |||||
| Is the SHD implementing this strategy? | (Yes/No) (Dropdown) |
Level of Maturity of Strategy (Dropdown) |
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| B.1 | Promote the adoption and use of electronic health records (EHR) and health information technology (HIT) to improve provider outcomes and patient health outcomes related to identification of individuals with undiagnosed hypertension and management of adults with hypertension | ||||
| B.2 | Promote the adoption of evidence-based quality measurement at the provider level (e.g. use dashboard measures) to monitor healthcare disparities and implement activities to eliminate healthcare disparities | ||||
| B.3 | Support engagement of non-physician team members (e.g., nurses, nurse practitioners, pharmacists, nutritionists, physical therapists, social workers) in hypertension and cholesterol management in clinical settings | ||||
| B.4 | Promote the adoption of MTM between pharmacists and physicians for the purpose of managing high blood pressure, high blood cholesterol, and lifestyle modification | ||||
| B.5 | Develop a statewide infrastructure to promote sustainability for CHWs to promote management of hypertension and high blood cholesterol | ||||
| B.6 | Facilitate use of self-measured blood pressure monitoring (SMBP) with clinical support among adults with hypertension | ||||
| B.7 | Implement systems to facilitate systematic referral of adults with hypertension and/or high blood cholesterol to community programs/resources | ||||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | |||||||||||||||||||
| Personnel Costs | |||||||||||||||||||
| Instructions: Please fill out the information below, listing the job titles for those working on the 1815 program (insert extra rows if there is not enough space, deleted extra rows if not needed). Please list the actual monthly salary of the specific individual that holds that current position. Please select the Category B strategies that the individual is working on. If staff do not have benefits (i.e. are temporary) please write 0 for their benefits. Items in yellow will automatically be populated due to the Excel formula within each cell. | |||||||||||||||||||
| State: | |||||||||||||||||||
| Reporting Period: | |||||||||||||||||||
| Total Personnel Costs: | $- | ||||||||||||||||||
| List names of all staff positions (insert extra rows if there is not enough space, delete extra rows if not needed) | |||||||||||||||||||
| Job Title (Write-In) |
Full-Time Employee (FTE) or Part-Time Employee (PTE) (Dropdown) |
Actual monthly salary for job title (Write-in) |
Average monthly benefits for job title (Write-in) |
Total Personnel Costs | Start date of job position (month and year) during 1815 reporting period (Write-in) | Is this a new position for 1815? (Yes/No) (Dropdown) |
# months worked on 1815 during reporting period (Dropdown) | # months position has been vacant in last 12 months (Dropdown) | Total # of hours per week allocated to working on 1815 (Write-In) | % time dedicated to 1815 (Write-In) |
Select which of the strategies each staff member and contractor is working on (Yes/No) (Dropdown) |
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| B.1 | B.2 | B.3 | B.4 | B.5 | B.6 | B.7 | |||||||||||||
| EHRs/HIT | Disparities | TBC | MTM | CHWs | SMBP | Referrals | |||||||||||||
| $- | |||||||||||||||||||
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| TOTAL | N/A | $- | $- | $- | N/A | N/A | N/A | N/A | N/A | N/A | |||||||||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | |||||||||||||||||
| Consultants, Contractors, Subcontractors, Grantees, and Other Partners | |||||||||||||||||
| Instructions: Please fill out the information below first filling out the name of the consultant/contractor/grantee/subcontractor/other partner within column B. After indentifying the individuals or firms who are being paid to implement 1815 program work, use the dropdown menu in each cell of column C to select whether the entities being paid to implement the work is a consultant/contractor/grantee/subcontractor/other partner. For columns D through G and I through K, please fill out the corresponding textboxes. For columns K-Q, please select the strategies the contractor has been paid to do. Insert extra rows if there is not enough space, delete extra rows if not needed. Items in yellow will automatically be populated due to the Excel formula within each cell. | |||||||||||||||||
| State: | |||||||||||||||||
| Reporting Period: | |||||||||||||||||
| Total Costs for Consultants, Contractors, Subcontractors, Grantees, and Other Partners: | $- | ||||||||||||||||
| List names of all staff positions (insert extra rows if there is not enough space, delete extra rows if not needed) | Select which of the strategies each staff member and contractor is working on (Yes/No) (Dropdown) |
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| Name of Consultant/Contractor/Grantee/Subcontractor/Other partner | Type of entity paid to implement activity (Dropdown) | Method of Selection for Contractor, Subcontractor, or Grantee (Sole Source/Competed) (Dropdown) |
Period of Performance (# days) |
Total Award Amount to sub (Write-In) |
Total amount spent by sub (Write-In) |
Total amount unspent | % allocated to Category B strategies (Write-In) |
# of strategies implemented (Dropdown) |
B.1 | B.2 | B.3 | B.4 | B.5 | B.6 | B.7 | ||
| EHRs/HIT | Disparities | TBC | MTM | CHWs | SMBP | Referrals | |||||||||||
| $0.00 | |||||||||||||||||
| $0.00 | |||||||||||||||||
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| TOTAL | N/A | N/A | N/A | $- | $- | $0.00 | |||||||||||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | ||||||||
| Office Equipment, Supplies, and Materials | ||||||||
| Instructions: Please fill out both tables below, General Equipment (Table 1) and Strategy-Specific Supplies/Materials (Table 2). For the General Equipment table, please fill out the equipment used for Category B. Same equipment have been inputted below for guidance. Please add additional office equipment to column B as needed. Office equipment is defined as a long-term assest such as computers, printers, copiers, etc. For the second table, Strategy-Specific Supplies/Materials are materials needed for activities related to the Category B strategies such as training rental costs, paper, folders, website maintenance costs, etc. Sample supplies have been inputted below for guidance. Please adjust the cells within table 2 as needed. Note that Table 1 and 2 are different materials and therefore different costs. Items in yellow will automatically be populated due to the Excel formula within each cell. | ||||||||
| State: | ||||||||
| Reporting Period: | ||||||||
| Total Costs for Equipment and Supplies: | $- | |||||||
| Table 1. Office Equipment | ||||||||
| Office equipment is defined as a long-term assest such as computers, printers, copiers, etc. The items below are examples of office equipment. Please update the chart below with the office equipment purchase for 1815. | ||||||||
| Office Equipment | Unit Cost (Write-In) |
Quantity (Write-In) |
Total costs | # of strategies implemented (Dropdown) |
Shared with Category A Strategies (Yes/No) (Dropdown) |
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| desktop computer | $- | |||||||
| laptop computer | $- | |||||||
| computer monitor | $- | |||||||
| software | $- | |||||||
| printer | $- | |||||||
| ink cartridge | $- | |||||||
| $- | ||||||||
| $- | ||||||||
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| $- | ||||||||
| TOTAL | N/A | N/A | $- | N/A | N/A | |||
| Table 2. Strategy Specific Supplies/Materials | ||||||||
| Please update the table below for strategy-specific supplies/materials that are needed for activities related to the Category B strategies such as training rental costs, paper, folders, website maintenance costs, etc. Sample supplies have been inputted below only as examples. Please adjust the cells within table 2 as needed. | ||||||||
| Strategy | Materials/Supplies | Unit Cost (Write-In) |
Quantity (Write-In) |
Total Costs | ||||
| Strategy B.1 | Printing costs | $- | ||||||
| Strategy B.1 | Training cost - venue rental | $- | ||||||
| Strategy B.1 | Website maintenance costs | $- | ||||||
| Strategy B.1 | $- | |||||||
| Strategy B.2 | Printing costs | $- | ||||||
| Strategy B.2 | Paper | $- | ||||||
| Strategy B.2 | $- | |||||||
| Strategy B.2 | $- | |||||||
| Strategy B.3 | Communication/informational materials about TBC | $- | ||||||
| Strategy B.3 | Printing costs | $- | ||||||
| Strategy B.3 | $- | |||||||
| Strategy B.3 | $- | |||||||
| Strategy B.4 | Communication/informational materials about MTM | $- | ||||||
| Strategy B.4 | Printing costs | $- | ||||||
| Strategy B.4 | $- | |||||||
| Strategy B.4 | $- | |||||||
| Strategy B.5 | Communication/informational materials about CHW | $- | ||||||
| Strategy B.5 | CHW training materials -printing cost | $- | ||||||
| Strategy B.5 | Training cost- venue rental | $- | ||||||
| Strategy B.5 | $- | |||||||
| Strategy B.6 | Communication/informational materials about SMBP | $- | ||||||
| Strategy B.6 | Printing costs | $- | ||||||
| Strategy B.6 | Self-monitoring equipment | $- | ||||||
| Strategy B.6 | $- | |||||||
| Strategy B.7 | $- | |||||||
| Strategy B.7 | $- | |||||||
| Strategy B.7 | $- | |||||||
| Strategy B.7 | $- | |||||||
| $- | ||||||||
| TOTAL | N/A | N/A | N/A | $- | ||||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | |||||||||||||||||||||||||||||||
| Travel Costs | |||||||||||||||||||||||||||||||
| Instructions: Please fill out the following table for 1815-related travel only. Travel for 1815 may include, but is not limited to: conferences where the attendee is attending/presenting for 1815; site visits; meetings with sites, partners, etc. For columns Y to AE please indicate whether the travel supported any of the Category B strategies. Items in yellow will automatically be populated due to the Excel formula within each cell. | |||||||||||||||||||||||||||||||
| State: | |||||||||||||||||||||||||||||||
| Reporting Period: | |||||||||||||||||||||||||||||||
| Total Travel Costs: | $0.00 | ||||||||||||||||||||||||||||||
| Conference | CarTravel | Air Travel | Lodging | Per Diem | Other Ground Transportaion | Other Travel Costs | Did travel support any of these strategies? (Yes/No) (Dropdown) |
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| Purpose of travel (Write-In) |
Does travel coincide with 1817 travel? (Yes/No) (Dropdown) |
In-state/ out of state travel? (Dropdown) |
State traveled to (if applicable) (Write-In) |
# of 1815-funded staff traveling (Dropdown) |
Conference Registration Fees (if applicable) (Write-In) |
Total Conference Registration Fees | If Driving - Total number of miles (Write-In) |
Cost per mile (Write-In) |
Number of people per car (Dropdown) |
Total ground travel | Cost of airfare (unit cost) (Write-In) |
Total Air Travel | Hotel cost per night (Write-In) |
Number of nights (Write-In) |
Total Lodging | Per Diem rate (Write-In) |
Number of days (Write-In) |
Total Per Diem | Unit cost (Write-In) |
Total cost |
Other travel costs (Write-In) |
Total other costs | TOTAL TRAVEL COSTS | B.1 | B.2 | B.3 | B.4 | B.5 | B.6 | B.7 | |
| EHRs/HIT | Disparities | TBC | MTM | CHWs | SMBP | Referrals | |||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||
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| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||
| TOTAL | N/A | N/A | N/A | N/A | $- | N/A | N/A | N/A | $- | N/A | $- | N/A | N/A | $- | N/A | N/A | $- | N/A | $- | N/A | $- | $- | |||||||||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | |||||||||||||
| Other Resources | |||||||||||||
| Instructions: For the other resources funding table, it is encouraged that principal investigators fill out this information in conjunction with other principal investigators in charge of other heart-disease prevention programs as in-kind funding may overlap with 1815 activities. Items in yellow will automatically be populated due to the Excel formula within each cell. | |||||||||||||
| State: | |||||||||||||
| Reporting Period: | |||||||||||||
| Total Additional Funding: | $- | ||||||||||||
| Does this funding source support the following strategies (Yes/No) (Dropdown) |
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| B.1 | B.2 | B.3 | B.4 | B.5 | B.6 | B.7 | |||||||
| List of Other Funding Source(s) (State budget, other CDC program, other Federal program, other funding) (Write-In) |
Total Amount ($) (Write-In) |
List Services/ Programs Supported (i.e. WISEWOMAN) (Write-In) |
EHRs/HIT | Disparities | TBC | MTM | CHWs | SMBP | Referrals | ||||
| TOTAL | $- | N/A | |||||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |