Form 1 RHND PIMS 3-25-21

OMB #: 0906-0010
Expires: XX/XX/20XX

Federal Office of Rural Health Policy
Community-Based Division
Rural Health Network Development Program (RHND)
Performance Improvement and Measurement Systems (PIMS) Database

MEASURES
Instructions:

Please review and respond to each question listed below. Provided answers should
only reflect information that has resulted from your network’s use of the Rural Health Network
Development (RHND) funding. Do not leave any question blank, if a question does not pertain to your
program, please reply with N/A. Unless otherwise noted, please answer each of the below questions
using data collected from the most recent grant funding year.
Section 1: Network /Collaboration
1) Table Instructions: Please identify the types and number of network members who are
participating in the RHND Grant. Network members are defined as members who have signed a
Memorandum of Understanding or Memorandum of Agreement or have a letter of commitment
to participate in the network. Network members do not include other partner organizations who
are playing a role in the grant but who are not member. If the organization type is not applicable,
please insert N/A. DO NOT leave any space blank under the current budget year for your grant. If
you mark “Other”, please specify the type of member organization in the comment section below.
Type of Member
Organizations
Area Health Education
Center
Accountable Care
Organization
Behavioral/Mental
Health Organization
Community College
Community Health
Center
Critical Access
Hospital
Emergency Medical
Service
Federally Qualified
Health Center
Faith Based
Organizations
Free Clinic
Health Department
Home Health Care
Agency
Hospice
Hospital

Year I

Year II

Year III

Long Term Care
Facility
Migrant Health Center
Private Practice
Primary Care
Private Practice
Specialty Care
Public or Private Payers
Rural Health Clinic
School District
Social Services
Organization
Tribal Organization
University
Other
Total

Automatically calculated
by system

Automatically calculated
by system

Automatically calculated
by system

2) Table Instructions: Assess the overall benefits realized by network members as a result of being
in the network during the current budget year. Select all that apply. Do not leave any space
blank; if one of the benefits does not apply, insert N/A. Definitions of each type of network
benefit can be found below in the RHND Program Reference Guide. Please provide any specific
network benefit examples you wish to share in the comment section below.
Note: Only assess the below benefits for the network funded by the RHND grant.
Type of Network
Year I
Year II
Year III
Benefit
Financial Cost Savings
Efficiencies
Quality Improvement
Access to Educational
Opportunities
Access to Equipment
Branding/Marketing
Development of
workforce that is
change ready and
adaptable
Knowledge Sharing
Understanding of
community health
needs
Opportunities for
Innovation
Policy Development
Other Capacity
Building: Please
specify
Other: Please specify

3) Table Instructions: Indicate the funding strategy that your network currently utilizes and the
percent of total network budget. If you select “Other”, please specify the funding type and percent
of your network budget. You may select as many funding strategies as apply. Do not leave any
space blank, if the network does not utilize a type of funding, respond N for No.
Type of Funding
Indirect Funding/In-kind
Contributions
Reimbursement from
Third Party Payers
Fees for Services, Events,
Consulting; Products
Sales
Membership Fees
Donations
Grants
Government Budgets
Other (Specify)

Year I
y/n and %

Year II

Year III

4) ONLY YEAR 3: What percent of the future cost of network operations do you project will be
covered by grant funds after the RHND grant is complete (June 30, 2023)?
All (100%)
Most (50-99%)
Some (Less than 50%)
None (0%)
5) ONLY YEAR 3: Please indicate the percent of programs created or enhanced through this grant
funding that will continue to sustain after the funding ends.
More (Expanded)
All (100%)
Most (50-99%)
Some (Less than 50%)
None (0%)
6) ONLY YEAR 3: Will the formal network continue after this grant funding? Y/N
a. Please explain the factors that will contribute to your formal network sustaining or ending
after this grant.
7) Table Instructions: Please review the following components of network sustainability and
indicate where your network falls on the scale. Definitions for the sustainability components can
be found below. If you mark “other”, please specify in the comment section below, otherwise,
please leave blank.
Sustainability Component
Strategic Vision

Never

Sometimes

Often

Always

Don’t
Know

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Collaboration
Leadership
Relevance and Practicality
Evaluation and ROI
Communication

Efficiency and Effectiveness
Capacity
Other: Please specify

Section 2: Demographics and Services
8) Table Instructions: This table collects information about an aggregate count of the people served
by race, ethnicity, and age. The total for each of the following questions should equal the total
of the number of unique individuals who received direct services. This number represents the
total number of people served by all of the activities outlined in your work plan and includes all
direct clinical (if applicable) and non-clinical people served by the program. Direct services are
defined as a documented interaction between a patient/client and a clinical or non-clinical health
professional that has been funded with this grant. Examples of direct services include but are not
limited to patient visits, counseling, and education. Please do not leave any sections blank. There
should not be a N/A (not applicable) response since the measures are applicable to all awardees.
If the number for a particular category is zero (0), please put zero in the appropriate section (e.g.,
if the total number that is Hispanic or Latino is zero (0), enter zero in that section). Response
totals reported for each measure in this section must equal the total number of individuals who
received direct services (Question 12). Please refer to the specific definitions for each field below
for additional measure guidance and instructions.
Hispanic or Latino Ethnicity






Hispanic/Latino: Report the number of persons of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin, broken down by their racial identification
and including those Hispanics/Latinos born in the United States. Do not count persons from
Portugal, Brazil, or Haiti whose ethnicity is not tied to the Spanish language.
Non-Hispanic/Latino: Report the number of all other people except those for whom there are
neither racial nor Hispanic/Latino ethnicity data. If a person has chosen a race (described below)
but has not made a selection for the Hispanic /non-Hispanic question, the patient is presumed to
be non-Hispanic/Latino.
Unknown: Report on only individuals who did not provide information regarding their race or
ethnicity.

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Race
All people must be classified in one of the racial categories (including a category for persons who are
“Unknown”). This includes individuals who also consider themselves Hispanic or Latino. People who
self-report race, but do not separately indicate if they are Hispanic or Latino, are presumed to be nonHispanic/Latino and are to be reported on the appropriate race line.
People sometimes categorized as “Asian/Other Pacific Islander” in other systems are divided into three
separate categories:







Asian: Persons having origins in any of the original peoples of the Far East, Southeast Asia, or
the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Indonesia, Thailand, or Vietnam
Native Hawaiian: Persons having origins in any of the original peoples of Hawaii
Other Pacific Islander: Persons having origins in any of the original peoples of Guam, Samoa,
Tonga, Palau, Truk, Yap, Saipan, Kosrae, Ebeye, Pohnpei or other Pacific Islands in Micronesia,
Melanesia, or Polynesia
American Indian/Alaska Native: Persons who trace their origins to any of the original peoples of
North and South America (including Central America) and who maintain Tribal affiliation or
community attachment.
More than one race: Use this line only if your system captures multiple races (but not a rac e and
an ethnicity) and the person has chosen two or more races. “More than one race” must not be
used as a default for Hispanics/Latinos who do not check a separate race.

Year I

Year II

(Automatically
calculated by
system)

(Automatically
calculated by
system)

Year III

Number of individuals served by
ETHNICITY:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Total (equal to the total of the number of
unique individuals served)

Number of individuals served by RACE:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander

(Automatically
calculated by
system)

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White
More than one race
Unknown
Total (equal to the total of the number of
unique individuals served)

(Automatically
calculated by
system)

(Automatically
calculated by
system)

(Automatically
calculated by
system)

Number of individuals served, by AGE
GROUP:
Children (0-12)
Adolescents (13-17)
Adults (18-64)
Elderly (65 and over)
Unknown
Total (equal to the total of the number of
unique individuals served)

9-13)

(Automatically
calculated by
system)

(Automatically
calculated by
system)

Table Instructions: Please fill out the following information about an aggregate number of
people served through your project funded by the RHND Program during this budget period.
Please provide numerical answers. If the total number is zero (0) please put zero in the
appropriate section. Do not leave any sections blank or provide N/A (not applicable). All
awardees must answer every question.
Year I

9

(Automatically
calculated by
system)

Total number of counties where the target population
resides.
Example: Your network has anticipated carrying out
activities in 4 counties in this budget period.
10 Total number of counties served in the project during this
budget period.
Example: Your network has carried out activities in 3
counties this budget period.
11 Number of people in the target population during this
budget period.
12 Number of unique individuals (i.e. unduplicated count)
who received direct services that were funded with this
grant.
13 Number of unique individuals served for by all activities,
including direct and indirect services.

Year II

Year
III

OMB #: 0906-0010
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14) Table Instructions: Please indicate the types and number of new, continued, and/or
expanded service areas provided by the network as a result of the RHND grant funding. Please
mark all that apply, do not leave any section blank. If an area is not applicable, insert N/A.
Type(s) of new, continued, and/or expanded service area(s)
provided by the network as a result of the RHND grant
funding
Health and Wellness:
Cardiovascular Disease
Chronic Obstructive Pulmonary Disease
Diabetes / Obesity Management
Elderly / Geriatric Care
Emergency Medical Service (EMS)
Health Education
Health Insurance Enrollment
Health Literacy/Translation Services
Health Promotion/Disease Prevention
Maternal and Child Health
Mental/Behavioral Health
Nutrition
Oral Health
Pharmacy
Primary Care
Specialty Care
Substance Abuse Treatment
Transportation
Workforce
Care Coordination:

Year I

Year II

Year III

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Care Coordination
Care Transitions
Case Management
Quality Improvement:
Accountable Care Organization
Medical Home or Patient Centered Medical Home
Health Information Technology:
Promoting Interoperability (previously known as attestation of
Meaningful Use Stage 1, 2 or 3)
Electronic Medical Records/Electronic Health Records
Health Information Exchange
Telehealth/Telemedicine
Patient/Disease Registry
Other, please specify.

openended
response

None- Explain

openended
response

14) What is your ratio for Economic Impact vs HRSA program funding?
Note: Please use the HRSA’s Economic Impact Analysis Tool to identify your ratio
https://www.ruralhealthinfo.org/econtool . Responses should reflect the ratio for the annual
economic impact for your grant’s budget year funded for your project’s annual and cumulative
reporting period.
Year 1
Year 2
Year 3
What is your ratio for
Ratio
Ratio
Ratio
Economic Impact vs.
HRSA Program
Funding? Yearly
What is your ratio for
Economic Impact vs.
HRSA Program
Funding? Cumulative

n/a

n/a

Ratio

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Section 3: Health Information Technology and Telehealth
15) Table Instructions: Please indicate if you used RHND grant funds to implement/install, use, or
expand use of Health Information Technology. If your program did not use HIT, please mark
“None” for the corresponding year.
Year I

Year II

Year III

Implemented
Use
Expansion
None

16) Table Instructions: This table collects information about Health Information Technology (HIT)
activities as part of the RHND Program. Coordinating care across network partners may often
involve navigating multiple Electronic Health Records (EHR) systems. If your program did not
use HIT, please mark “none” for the corresponding year, you do not need to indicate N/A for the
types of HIT activities. Please indicate N/A if the type of HIT is not applicable to your program
but your program did use some form of HIT program.

Types of HIT Implemented,
Year I
use, or expanded through this
program (please check all that
apply)
Computerized Order entry
Electronic medical
records/electronic health records
Health information exchange
Patient/disease registry
Clinical Decision Tools
Care Management Tools
Summary of Care Records
Other
None

Year II

Year III

17) Does your network exchange clinical information electronically with other key providers/health
care settings such as hospitals, emergency rooms, or subspecialty clinicians?
18) Does your consortium use health IT to coordinate or to provide enabling services such as
outreach, language translation, transportation, case management, or other similar services?
19) Table Instructions: Telehealth: This table collects information about telehealth activities as part
of the Rural Health Network Development Program.

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The term “telehealth” includes “telemedicine” services but encompasses a broader scope of remote
healthcare services. Telemedicine is specific to remote clinical services whereas telehealth may
include remote non-clinical services, such as provider training, administrative meetings, and
continuing medical education, in addition to clinical services.
a

Did your organization use telehealth to provide
remote clinical/non-clinical care services?
(Yes/No)
If yes, then answer the following two questions:

Year I

Year II

Year III

i.

Who did you use telemedicine to communicate
with? (Select all that apply)
a. Patients at remote locations from your
organization (e.g., home telehealth, satellite
locations)
b. Specialists outside your organization (e.g.,
specialists at referral centers)

ii.

What telehealth technologies did you use?
(Select all that apply)
a. Real-time telehealth (e.g., live videoconferencing)
b. Store-and-forward telehealth (e.g., secure email
with photos or videos of patient examinations)
c. Remote patient monitoring
d. Mobile Health (mHealth)
If no, then answer the following question:
If you did not have telehealth services, please comment
why (select all that apply)
a. Have not considered/unfamiliar with telehealth
service options
b. Policy barriers (Select all that apply)
1) Lack of or limited reimbursement
Credentialing, licensing, or privileging
2) Privacy and security
3) Other (specify):
c. Inadequate broadband/ telecommunication service
(Select all that apply)
1) Cost of service
2) Lack of infrastructure
3) Other (specify):
d. Lack of funding for telehealth equipment
e. Lack of training for telehealth services
f. Not needed
g. Other - specify:
b

Number of consortium/network sites providing/using (Number)
relevant telehealth services.

(Number)

(Number)

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Note: if telehealth services are no longer available at any
of the network sites please detail this in the form
comment box.
c Number of unique individuals who received direct
services by telehealth.
Note: this is a unique count of patients who receive a
telehealth consult facilitated by the organization and/or
network/consortium during the budget period.
d Number of providers trained and/or supported
through telehealth.
Note: providers are inclusive of anyone on the care
coordination team. This is an unduplicated count of
providers who were trained, educated or supported
through telehealth/telemedicine during the budget period.
For example, Project ECHO.

Section 4: Direct Clinical Services (if applicable)
20) Number of unique individuals who received direct clinical services during this budget period
Year I
Year II
Year III
Number of unique
individuals who
received direct clinical
services during this
budget period.
21) Table Instructions: Please use your electronic patient registry and/or electronic health records
system to extract the clinical data requested for patients served through the RHND program as
applicable.
Please refer to the specific definitions for each field below and consult each measure’s web link provided
for additional measure guidance and instructions. Please indicate if this measure is applicable to your
program or not. If it is applicable, provide the requested information. If it is not applicable to your
program, please mark the first column “No”. All responses reported should be reflective of grant project
target intervention patient population values only. The denominator should not be larger than the
total of the number of unique individuals served in Question 20.
Note: Please complete responses, as data/information is available to do so. If data/information is not
available, please utilize the form comment box for provision of any additional necessary information
needed for interpreting values reported in this section.
Is this
measure
applicable
to your

Numerator

Denominator

Percent

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program?
(Yes/No)
1

NQF 1789: Hospital-Wide All Cause Readmission
NQF 0028e/ CMS138v8: Tobacco Use: Screening &
Cessation Intervention

2
NQF 0418e/ CMS2v9: Screening for Clinical
Depression
3
NQF 0059/CMS122v6: Comprehensive Diabetes Care
4
NQF 0024/CMS155v6: Weight Assessment
5
NQF 0421/ CMS69v6:Body Mass Index (BMI)
Screening and Follow-Up
6
CMS50v8: Closing the referral loop: receipt of specialist
report
7
NQF 0097: Medication Reconciliation Post-Discharge
8

9

NQF 0018/CMS165v6: Controlling High Blood
Pressure
CMS137v8:Alcohol and other Drug Dependence

10
11

NQF0102:Chronic Obstructive Pulmonary Disease
(COPD)
NQF0419e/CMS68v9:Medication Documentation

12
CMS347v3: Cardiovascular Disease
13

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22) Please provide any additional NQF measures that your program is collecting. Indicate which
measures you are collecting and provide the clinical data collected for each measure.

Public Burden Statement: The purpose of this program is to support integrated rural health care networks that have combined the functions of
the entities participating in the network to address the health care needs of the targeted rural community. The information gathered will be used
in evaluating FORHP’s progress in achieving the above purpose and goals of the 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 0906-0010 and it is valid until XX/XX/202X. This information collection is required to obtain or
retain benefits (Section 330A(f) of the Public Health Service Act, 42 U.S.C. 254c f), as amended by section 201, P.L. 107-251 of the Health
Care Safety Net Amendments of 2002). Public reporting burden for this collection of information is estimated to average 6 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].