1 Network Planning PIMS Document

Rural Health Network Development Planning Program Performance Improvement and Measurement System (PIMS)

Network Planning PIMS Document

OMB: 0915-0384

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OMB Number: 0915-0384

Expiration Date: XX/XX/XX

Rural Health Network Development Planning Program

Performance Improvement and Management System (PIMS) Measures


Public Burden Statement: 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 project is 0915-0384. 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 10C-031, Rockville, Maryland, 20857.

Table 1: Network Infrastructure

Table Instructions: Please provide information about the network members and network operations. 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.


1

Identify the types and number of organizations in the consortium or network for your project:




Type of Member Organizations in the Consortium/Network

Number


Non-Profit Organization

Area Health Education Center



Behavioral/Mental Health Organization



Community College



Community Health Center



Critical Access Hospital



Emergency Medical Services



Federally Qualified Health Center



Faith-based Organization



Free Clinic



Government



Health Department



Hospice



Hospital – Critical Access Hospital



Hospital- Other than a Critical Access Hospital



Law Enforcement



Migrant Health Center



Private Practice/Physician’s Clinic



Public Health



Rural Health Clinic



School District/System



Social Services Organization/Agency



University



Other – Specify type



TOTAL for non-profit organization

(Automatically calculated by system)


For-Profit Organization

Critical Access Hospital




Hospice



Private Practice



Rural Health Clinic



Other – Specify Type



TOTAL for-profit organization

(Automatically calculated by system)

2

Total number of NEW member organizations that joined the consortium/network during this project period (after the start date of the grant):

Number

3

Indicate the total number of full-member (all members that signed MOU, MOA, or letters of commitment) network meetings conducted during the reported budget year by meeting type:


Meeting Type

Number


Meeting conducted face-to-face



Meeting conducted via teleconference



Meeting conducted via webinar



Meetings conducted with combination of face-to-face and teleconference/webinar



Meeting conducted in a manner not listed above (please specify type)


4

From the beginning of this budget year, assess the following overall Network activities (check one answer for each type of network activity):


Type of Network Activity

Increased

No Change

Reduced


Financial Cost Savings





Access to Educational Opportunities





Access to Equipment





Access to Subject Matter Experts





Understanding of Community Health Needs





Staffing Capacity





Other (Please Specify):




5

What area(s) was the network focusing on for this project period? (Check all that apply)


Behavioral Health – Both Mental Illness and Substance Use



Cardiovascular disease



Care Coordination



Children/Adolescent Health



Chronic Disease – Asthma Specific



Chronic Disease –Chronic Obstructive Pulmonary Disease Specific



Chronic Disease – Diabetes Specific



Chronic Disease - Other



Elderly/Geriatric/Older Adult Health



Emergency Medical Services



Health Education



Health Information Technology



Hospital Closure/Alleviating Loss of Services



Mental Health/Mental Illness



Network Organization/Infrastructure Development



Obesity- Adult



Obesity – Child/Adolescent



Palliative Care



Population Health/Social Determinants of Health



Primary Care



Reimbursement for Health Services



School-based Health Services



Substance Use



Substance Use – Opioid Specific



Telehealth/Telemedicine



Workforce Development



Other – Specify type




Table 2: Network Collaboration

Table Instructions: Please provide information about collaboration and/or integration among the network members. Refer to the activities listed in the project work plan for this project period.

6

How many activities from the project work plan were initiated by at least two or more network members?


Number

7

How many activities from the project work plan were completed by at least two or more network members?


Number

8

Did the network develop the following (this does not include a needs assessment)?



Strategic Plan

(Y/N)


Business Plan

(Y/N)


Sustainability Plan

(Y/N)


Other (please specify)


9

What type of Network Planning activities were done during the project period (check all that apply):



Conduct community engagement activities



Conduct needs assessment



Develop incorporation document(s)



Develop network bylaws



Develop network charter



Develop network mission statement



Develop network partner Memorandum of Understanding (MOU) and/or Memorandum of Agreement (MOA)



Develop network governance structure



File/Submit incorporation document(s)



Other (please specify)




Table 3: Sustainability

Table instructions: Please provide information about the contribution by network members and the network’s sustainability efforts.

10

Annual Program award


Please provide the annual program award based on box 12a (Authorized Financial Assistance) of your Notice of Award


11

Additional funding secured to assist in sustaining the network

Please provide the amount of additional funding that has already been secured during this current project period to sustain the program or network, as a result of leveraging the grant.


12

Estimated amount of cost savings due to participation in the network during this current project period


13

Sources of Revenue (check all that apply)



Network revenue



In-kind contributions



Member fees



Fundraising



Providing contractual services



Other – specify type


14

How many of the network members have provided the following in-kind services:



Goods (ex: equipment, food)

Number


Services (ex: meeting space)

Number


Staff support

Number


Expertise (ex: legal, business, website/marketing development)

Number


Other (please specify)


15

How many network policies or procedures were created during this budget period:

Number

16

How many network policies or procedures were amended during this budget period:

Number

17

How many network policies or procedures were implemented during this budget period:

Number

18

As a result of being part of the network, how many network member organizations were able to integrate joint policies/procedures within their respective organizations during this budget period?

Number

19

Will the activities of the Network/Consortium continue to operate after the Federal grant funding period?

Y/N



Table 4: Network Assessment

Table instructions: Please provide information regarding the network’s assessment during this project period.

20

Does the network have a process or tool to assess effectiveness of network performance after the Federal grant funding period?

Y/N

21

If yes, how will the network performance assessed?

open-ended response

22

Does the network include a process or tool to assess effectiveness of network director (or the person tasked with leading the network)?

Y/N

23

If yes, how is the network director (or the person tasked with leading the network) assessed?

open-ended response

24

Did the network meet its program objectives outlined in the Network Planning grant work plan?

Y/N



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