Form D TRC Performance Indicator Data Collection Tool

OMB # 0915-0361

Expiration XX/XX/201X

TRC Performance Indicator Data Collection Tool

The Telehealth Resource Center (TRC) Performance Indicator Data Collection Tool is intended to collect data elements that are required for reporting to the Office for the Advancement of Telehealth (OAT) on TRC performance measures. The performance measures and associated data elements are designed to assess how the TRC program is meeting its goals to:

1. Expand the availability of telehealth services in underserved communities

2. Improve the quality, efficiency, and effectiveness of telehealth services

3. Promote knowledge exchange and dissemination about efficient and effective telehealth practices and technology

4. Establish sustainable technical assistance (TA) centers providing quality, unbiased TA for the development and expansion of effective and efficient telehealth services in underserved communities

OAT will require all TRC grantees to complete this tool every twelve months based on TRC activity for the preceding twelve-month reporting period. The TRC Performance Indicator Data Collection Tool collects telehealth service data at the telehealth program/network level, the originating site level, and also collects data on TRC activities, client service assessments and the impact of TRC activities. Please respond to all questions based on the current reporting period.

COMPLETE QUESTIONS 1-4

1: Service Utilization by State and Type of Organization Requesting Service

Service Utilization

• Total # of clients served

• Total # of repeat clients

• Direct

  • Total # of clients served via technical assistance (ie. consultation)

  • Total # of clients served via training

  • List each state in your region and total number of clients served in each

  • PIMS Form Example: State Acronym ____ Number of Clients Served via consultation____ via conference, meeting, or training ____

  • PIMS Form creates automated: Total Clients Served in TRC Region

  • PIMS Form creates automated: Total Clients Served in HRSA Region

• Indirect

  • Total # of clients served via education and outreach

Type of Organization Requesting Service

• Academic Institution/School

• Associations/Organizations (National, State or Regional)

  • Area Health Education Center (AHEC)

  • Rural Health Association

  • Other

• Clinic

  • Free Clinic ___

  • Federally Qualified Health Center (FQHC)

  • Rural Health Clinic (RHC)

  • Other

• Funders (Foundations/Health Plans)

• Hospital/Health System

  • Critical Access Hospital (CAH) (25 beds or less)

  • Small Rural Hospital (50 beds or less)

    • Medium Rural Hospital (50-99 beds)

    • Large Rural Hospital (100 or more beds)

    • Other

  • Health Resources and Services Administration (HRSA) Grant Funded Entity

  • Government Agency (Federal, State, Regional or Local)

    • Corrections

    • Health Department

    • Medicaid/Medicare

    • Mental Health

    • Public Health

    • Social Service

    • State Office of Rural Health (SORH)

    • VA

Tribal/IHS

• Other

• Legislator/Policy Maker /staffer(or office)

• Telehealth Resource Center

• Vendor

  • Clinical Service Provider ___

  • Technology

  • Telecommunications

  • Business solutions/consultants

  • Legal

  • Other

• Other (list other and provide total numbers)

2: TRC Technical Assistance Communication Method of Inquiry and Response

Method of Technical Assistance Inquiry

• Email

• Phone

• In-Person Contact at an event (ie. training, conference, meeting, other)

• TRC Website Form

• Referral from Another TRC

• Social Media (Twitter, Facebook, LinkedIn, etc.)

• TRC Initiated

• Other

Method Used to Respond to Inquiries

• Email

• Phone

• Videoconference

• In Person Visit

• Other

3: Topic of Inquiry

Category

• Financial (Reimbursement, Business Models, Grants)

• Policy/Legal

• Market Analysis

• About my TRC

• Broadband network infrastructure

• Readiness Assessment

• Distance Learning

  • Project ECHO

• Program Evaluation

• Strategic Planning

• Tools and Templates

• General Telehealth Information

• Clinical Service Program Development/Operations

  • Mental/Behavioral Health

• Equipment and Technology Assessment/Selection

• Other

4: Types of Services Provided by TRC

Training/Education and Outreach

• # of Conferences/Meetings ___

  • Total # of conferences/meetings hosted by TRC ____

  • Total # of participants ___

  • Total # of TRC presentations at conferences/meetings ____

• # of Trainings ___

  • Total # of trainings hosted by TRC ____

  • Total # of participants ___

• # of Webinars ___

  • Total # of webinars hosted by TRC ____

  • Total # of participants ___

  • Total # requested by HRSA

  • Total # requested by other Federal Agency ____

• # of Other ____

  • Describe other

Communications/Promotional Activities

• Exhibit booths at conferences

  • # of booths ___

  • # of contacts ___

  • # of hours managing exhibit ___

• General Media

  • # interviews ___ (decimal/fraction)

  • # articles ___ (decimal/fraction)

Tools/Materials/Resources

• Newsletter

  • # of newsletters ___

  • # of subscribers ___

• Website

  • # website visits ___

• Fact Sheets/One Pagers

  • # of fact sheets/one pagers ___

• Online Education

  • # Video Modules ___

    • # of views ____

  • # of Toolkits ____

    • # of views ____

  • # of Course Modules ____

    • # of people accessing ____

• Issue Briefs (# of issue briefs) ____ (decimal/fraction)

• Other (list type and #) ____