Form 1 PIMS Measures

OMB Number: 0915-0311 Expiration Date: XX/XX/20XX

Performance Measures

Telehealth Network Grant Program (TNGP)

Performance Improvement and Measurement System (PIMS)

Form 1: Priorities

Did you provide services to patients in any of the following categories because of any TNGP funding during this reporting period?
	Yes	No
Stroke
Mental Health/Behavioral Health
Substance Use Disorder

Form 2: Originating and Distant Sites

Complete Form 1. Priorities before inputting data in this form. Only sites that are

eligible for and receiving TNGP 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

Number of Each Type of Site in this Reporting Period
Originating Sites
Distant Sites

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 TNGP 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 TNGP funding?
		yes/no

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

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 TNGP 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 Encounter s	Number of Store-an- Forward Encounter s	Total Encounter s

Total Number of Unique Patients Served because of TNGP funding
Total Number of Encounters because of TNGP funding

Form 5: Patient Travel Miles and Time 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 TNGP funding should be included.

Miles and time from the patient’s location to where the patient could receive health services in the absence of telehealth.

Use Google maps or similar program to determine the shortest travel time by car one way. (If multiple routes are possible, choose shortest travel time not shortest travel miles. Round trip will be assumed to be twice one way travel.)

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

Miles from Originating (patient) site to location where patient would have been referred in the absence of telehealth

Estimated time for travel in previous column

Total Encounters

Miles Saved (Miles X Encounters X 2)

Time Saved (Time X Encounters X 2)

Total Miles Saved
Total Time Saved

Form 6: Other Uses of the Telehealth Network

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

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

Enter ‘UNK’ 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)

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 receiving TNGP 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
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.
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%.
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.

Setup Forms:

Configure Sites:

Indicate the Sites in which you had activity during this reporting period. Only sites that are eligible for and receiving TNGP 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 HRSA’s Rural Health Grants Eligibility Analyzer. 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.

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 TNGP funding should be included.

Select Settings

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

Public Burden Statement: The purpose of this collection is to use a performance measurement tool to collect data from grantees receiving funds under the Telehealth Network Grant Program. 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 information collection is 0915 -0311 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (Section 330I of the Public Health Service Act. The Health Care Safety Net Amendments of 2002 (Public Law 107-251) amended the Public Health Service Act by adding Section 330I)]. [If this information collection includes information protected by any form of confidentiality then explain this confidentiality and cite the authority.] Public reporting burden for this collection of information is estimated to average 1 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 or [email protected].

HRSA-20-036

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