Form 29 FY2020 Ending the HIV Epidemic Primary Care HIV Preventi

The Health Center Program Application Forms

FY2020 Ending the HIV Epidemic Primary Care HIV Prevention PCHP Progress Reporting

FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting

OMB: 0915-0285

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FY2020 Ending the HIV Epidemic – Primary Care HIV Prevention (PCHP)

Progress Reporting


OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

  1. PCHP Staffing Positions by Major Service Category

Enter the number of FTEs hired or contracted by your health center to support the expansion of HIV prevention services from 3/1/2020 to the end of the current reporting period. Report only the FTE increases supported by PCHP funds. For example, if you hired a 1.0 FTE PrEP navigator and increased a 0.5 FTE internist to full time using PCHP funds, you would report 1.0 FTE under Case Managers and 0.5 FTE under Internists.

Enabling Services

Hired

Contracted

Case Managers (e.g., PrEP navigators)



Patient/Community Education Specialists



Patient Advocates



Outreach Workers



Transportation Staff



Eligibility Assistance Workers



Interpretation Staff



Community Health Workers



Other Enabling Services



Physicians

Hired

Contracted

Family Physicians



General Practitioners



Internists



Obstetricians/Gynecologists



Pediatricians



Licensed Medical Residents



Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives

Hired

Contracted

Nurse Practitioners



Physician Assistants



Certified Nurse Midwives



Medical

Hired

Contracted

Nurses



Other Medical Personnel

(e.g. Medical Assistants, Nurse Aides)



Laboratory Personnel



Mental Health

Hired

Contracted

Psychiatrists



Physicians (other than psychiatrists)



Nurse Practitioners



Physician Assistants



Certified Nurse Midwives



Nurses - psychiatric, mental health



Nurse Counselors



Licensed Clinical Psychologists



Licensed Clinical Social Workers



Family Therapists



Unlicensed Mental Health Providers, including trainees and certified staff



Other Licensed Mental Health Providers



Other Mental Health Staff



Substance Use Disorder



Psychiatrists



Physicians (other than psychiatrists)



Nurse Practitioners



Physician Assistants



Certified Nurse Midwives



Nurse Counselors



Licensed Clinical Psychologists



Licensed Clinical Social Workers



Family Therapists



Alcohol and Drug Abuse Counselors



Other Licensed Substance Use Disorder Providers



Professional Services

Hired

Contracted

Other Professional Health Services Staff (e.g., physical therapists, occupational therapists, acupuncturists)



Pharmacy

Hired

Contracted

Pharmacy Personnel



Other Programs and Services

Hired

Contracted

Quality Improvement Staff



Information Technology Staff



Patient Services Support Staff



Other Programs and Services Staff (e.g., staff who support outreach, care coordination, transportation)



SUBTOTAL



TOTAL (Hired and Contracted)


  1. HIV Prevention Services

Enter patients and visits from 3/1/2018 to the end of the current reporting period. Report all patients and visits, regardless of funding source (do not limit responses to activities supported by PCHP funding).

2a.

Number of health center visits during which an HIV test was performed



2b.

Number of patients tested for HIV



2c.

Percentage of patients with a documented HIV test performed between the ages of 15 and 65 years



2d.

Number of patients at risk for HIV who were prescribed PrEP



2e.

Percentage of patients newly diagnosed with HIV who were seen for follow-up treatment within 30 days of HIV diagnosis



2f.

Personnel FTE added to support HIV prevention services



2g.

Number of patients newly diagnosed with HIV



3.    Issues and Barriers

What new or ongoing issues/barriers have you encountered in implementing the activities supported with the PCHP supplemental funding over the past four months?










Required field; Minimum 500 characters up to 2500 characters (1 page)

4.    Successes and Lessons Learned

What new or ongoing success and/or lessons learned have you experienced in implementing the activities supported with the PCHP supplemental funding over the past four months?










Required field; Minimum 500 characters up to 2500 characters (1 page)


Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1 hour 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 or [email protected].


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