RFCC Clinical Intake Form (Non-Provider RFCC)

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Overview

General instructions
Clinical Care
Prof Ed & Training
Research
Education & Outreach
Leadership

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Sheet 1: General instructions

GENERAL INFORMATION

* The following tables should summarize activities conducted or offered only to RFCC women.

* Include information about RFCC, partner, and non-partner activities. A partner organization is considered an organization with whom you have an established agreement to provide services for a defined period of time. A non-partner typically provides services on a fee-for-service basis and agrees to provide one time only services.

* If needed, include any clarification at the bottom of each table in the "comment" row.

* Please be sure to complete all six tables included in this workbook. A tab for each of the tables is located at the bottom of the workbook. Click on each tab to view the pertinent table. (hint: when printing, select "entire workbook" to print all tables)

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Sheet 2: Clinical Care

RFCC NAME: ____________________________ REPORT DATE: _______________ QUARTER: ___________________

HEALTH CARE SERVICES

In the following table, women's health services are categorized into four (4) broad groupings: primary acute care, preventive care, specialty care and enabling services. For each women's health service listed, indicate the total number of encounters, as well as the number of referrals made for RFCC patients and family members (if applicable) to receive a listed service. For example, indicate the total number of physician primary acute care RFCC patient encounters during the Q1 reporting period in cell C10, and the total number of primary acute care patient referrals made by the RFCC or its affiliated health care entity to a physician provider during Q1 in cell M10. If a service is not listed, please include it in the "Other" row.

Report "Referrals" as the number of referrals issued. These columns should not summarize the number of patients who used their referrals (or estimate patient compliance).

Note: P = RFCC Patient, FM = RFCC Patient Family Member, Q1 = First Quarter, Q2 = Second Quarter, Q3 = Third Quarter, Q4 = Fourth Quarter, and YTD = Year to Date.

WOMEN'S HEALTH SERVICE OFFERED

PROVIDER PRACTICE SITE (RFCC or RFCC - AFFILIATED HEALTH CARE PROVIDER)

NUMBER OF RFCC PATIENT AND FAMILY MEMBER ENCOUNTERS IN 2006

NUMBER OF RFCC PATIENT AND FAMILY MEMBER REFERRALS MADE IN 2006

Q1

Q2

Q3

Q4

YTD

Q1

Q2

Q3

Q4

YTD

Primary Acute Care (includes any sick visit primary care services provided by physician and non-physician providers)

Physician Provider (specify specialty) ___________________________

Non-Physician Provider (specify type(s), i.e., Nurse Midwife, Nurse Practitioner) ___________________________

Preventive Care

Prenatal Services

Blood Pressure Screening

Vision Screening

Audiology Testing

Tuberculosis (PPD) Testing

Glucose Screening

Cholesterol Testing

Pap Smear (or similar test)

Mammography

Bone Density Testing

Colon Cancer Screening

Immunizations (including influenza vaccinations)

Smoking Cessastion Counseling

STD Education (includes HIV/AIDS)

Weight Reduction Programs

Nutrition counseling

Domestic Violence Counseling

Other (list): ________________

Other (list): ________________

Other (list): ________________

Specialty Care (includes any sub-specialty service provided at the RFCC or RFCC-affiliated health care provider)

Obstetrics (Labor and Delivery)

Gynecology

Psychiatry / Mental Health

Endocrinology (Diabetes, Hypothyroidism)

Cardiology (Hypertension, Heart Disease)

Infectious Disease (HIV/AIDS, TB)

Dentistry

Other (list): ________________

Other (list): ________________

Other (list): ________________

Enabling Service (indicate total number of RFCC patients and family members (if applicable) who used these services.

Transportation: Free passes or vouchers

Transportation: Pickup / Transport service

Language translation services (list language(s): ___________________)

Child Care Service

Home Care Visits

Medication Assistance Program

Other (list): ________________

Other (list): ________________

Comments:

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Sheet 3: Prof Ed & Training

RFCC NAME: ____________________________ REPORT DATE: _______________ QUARTER: ___________________
TRAINING OF LAY, ALLIED HEALTH AND HEALTH CARE PROVIDERS
Health care providers, include, but are not limited to, counselors or therapists, physicians, nurses, and allied health care providers.
Lay providers include, but are not limited to doulas and promotores.
Please list, by topic, each training activity that your RFCC participated in or coordinated during this quarter. Please indicate the type of health care provider (i.e. professional, lay, or allied health). Provide a description of health care provider that provides training to or on behalf of the RFCC and indicate if the provider is a partner organization (P). For each training activity, describe the goals and provide a description of the training and how it was developed. Indicate the date the training occurred and year the training was first offered to participants. Also include the number of training activities conducted during the last quarter and indicate the average number of training participants per activity.
*Be sure to include any activities conducted by your community partners for the RFCC program.*
TRAINING TOPIC	TYPE OF HEALTH CARE TRAINER	DESCRIPTION OF HEALTH CARE TRAINING PROVIDER (P = partner, NP = non-partner)	GOAL AND DESCRIPTION OF TRAINING (Include method of training used and a description of any partners' involved in the training effort.)	DATE OF TRAINING	YEAR TRAINING FIRST OFFERED	NUMBER OF TRAINING ACTIVITIES (this quarter)	NUMBER OF TRAINING PARTICIPANTS (this quarter)
Example: Doula Training	Certified Nurse Midwife	Partner	Goal: To provide comprehensive training that will enable students to achieve doula certification.	1/26/2006	2006	5	15
			Description: Curriculum developed by Doulas of North American (DONA) International. Courses are being taught by CNM from XYZ Hospital and local certified doula.
COMMENTS:

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Sheet 4: Research

RFCC NAME: ___________________________ REPORT DATE: _____________________ QUARTER: ____ ______________

RFCC COMMUNITY-BASED RESEARCH ACTIVITIES

In the table below, please list each community-based research activity your RFCC was involved in during the last quarter; include any activities conducted by your community partners for the RFCC program. List research activites by start date, with the most recent initiative first, and indicate what the project's status is (new or ongoing). For research activities being lead by organizations other than the RFCC, indicate the name of the organization leading the project. Provide a brief title for each research activity and an estimated length or duration (begin and end dates). Describe the study's purpose, identify primary outcome measures, and highlight the major demographic characteristics of the target population being studied. Indicate the number of study participants enrolled and provide an explanation for any significant changes in the number of enrollees in the comment section. List all collaborating organizations (in addition to RFCC entities) that are involved in the research activity. Provide a percent estimate of their involvement in the project, as well as any money or in-kind contributions made by the organizations (indicate what the contribution was). Lastly, summarize any interim findings to date for each research activity, as well as any major challenges encountered that may affect the completion of the research activity.

PROJECT STATUS (New or Ongoing) & START DATE

PROJECT LEADER (name of organization)

RESEARCH ACTIVITY / PROGRAM TITLE

EXPECTED DURATION OF RESEARCH ACTIVITY

PRIMARY GOAL(S) of RESEARCH ACTIVITY1

DEMOGRAPHIC CHARACTERISTICS OF TARGET RFCC POPULATION BEING STUDIED2

PRIMARY OUTCOME MEASURES

NUMBER OF ENROLLEES

COLLABORATING ORGANIZATIONS

INTERIM STUDY FINDINGS / MAJOR CHALLENGES ENCOUNTERED

NAME

PERCENT INVOLVEMENT

MONETARY FUNDING (dollar amount)

IN-KIND CONTRIBUTION(S) (type of contribution)

New (01/15/06)

RFCC XYZ

Example: Domestic Violence Reporting in Native American Women

(01/15/06 -06/30/06)

Goal: To identify barriers to domestic violence reporting in Native American women, and develop programs to address these barriers

Native American women

50

University of XYZ

70%

$50,000

none

INTERIM STUDY FINDINGS : Population lacks knowledge of available resorces MAJOR CHALLENGES ENCOUNTERED: Difficult retaining study participants. Large gaps in follow up data.

COMMENTS:

1Provide a brief description of the research activity, including its purpose and the outcome measures being investigated.

2Such as Elderly, Hispanics, etc.

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Sheet 5: Education & Outreach

RFCC NAME: ____________________________ REPORT DATE: _______________ QUARTER: ___________________
PUBLIC EDUCATION AND OUTREACH
Please list each educational activity and provide a brief description of each activity your RFCC participated in or coordinated during this quarter. For each activity, include the year your RFCC first offered or participated in the activity, list the organizations (in addition to the RFCC) that are involved in conducting, coordinating, or holding the education/outreach effort (indicate if the organization is a partner (P) or non-partner (NP)). Include the number of times the activity was conducted during this quarter. Estimate the total number of attendees, as well as total attendees by gender and percentage in each age group where possible (age groups: 0-17, 18-30, 31-45, 46-55, 56-70, and 70+). Also estimate, to the best of your ability, the percent of participation by race/national origin (C=Caucasian, non-Hispanic, AA=African American, non-Hispanic, A=Asian, P= Native Hawaiian or Other Pacific Islander, HC=Hispanic Caucasian, HA=Hispanic African American, O=Other (describe 'Other' in the comments section)). The Comments row (located at the bottom of this page) may include more specific information about the education or outreach event and/or the group targeted to receive the education. Also list the types of materials distributed during the activity.
*Be sure to include any activities conducted by your community partners for the RFCC program.*
ACTIVITY	DESCRIPTION	YEAR RFCC FIRST OFFERED ACTIVITY	PARTICIPATING ORGANIZATIONS (P = partner, NP = non-partner)	NUMBER OF ACTIVITIES (This Qtr)	NUMBER OF ATTENDEES (estimate)		AGE GROUPS						RACE/ NATIONAL ORIGIN								MATERIALS DISTRIBUTED
					Male	Female	0-17	18-29	30-44	45-54	55-69	70+	C	AA	A	P	H	HC	HA	O
Example: Health Fair	Focus on women’s preventive care	2005	Wellness Center (P)	1	3	62	0%	50%	25%	25%	0%	0%	95%	5%	0%	0%	0%	0%	0%	0%	Breast Cancer screening brochure
Example: Presentation	Healthy Living	2005	Hospital (NP)	1	17	20	0%	3%	55%	30%	10%	2%	0%	100%	0%	0%	0%	0%	0%	0%	Daybooks, pamphlets
COMMENTS:

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Sheet 6: Leadership

RFCC NAME: ____________________________ REPORT DATE: _______________ QUARTER: ___________________
LEADERSHIP DEVELOPMENT AND ADVOCACY TRAINING
For each leadership development activity listed in the far left column, please provide a description of the type(s) of activities conducted this quarter (include the goal of the activity). Include the year your RFCC first offered the activity, the number of participants by race/national origin (C=Caucasian, non-Hispanic, AA=African American, non-Hispanic, A=Asian, P= Native Hawaiian or Other Pacific Islander, HC=Hispanic Caucasian, HA=Hispanic African American, O=Other) and the audience type (such as high school students, expectant mothers, or senior citizens).
Please include only one activity per row. If your RFCC provides more than one program for any of the activities listed in the left hand column, then copy and paste the activity in a new row and complete the row per the above instructions. *Be sure to include any activities conducted by your community partners for the RFCC program.*
ACTIVITY	DESCRIPTION/ GOALS	YEAR RFCC FIRST OFFERED ACTIVITY	NUMBER OF ATTENDEES								AUDIENCE
			C	AA	A	P	H	HC	HA	O
Example: Women's Leadership Institute Training Session	Goal: To empower nurse practitioners to be leaders in rural areas by presenting the importance of their role in delivering services in underserved areas.	2005	0	5	0	5	0	0	0	0	Nurse practitioners
	Description: Training session for nurse practitioners on their role in the delivery of women's healthcare services in rural areas. Curriculum developed by XYZ organization.
Example: Mentoring and recruitment of women in health professions	Goal: To educate high school students on careers in healthcare.	2005	13	11	0	0	9	0	0	0	High school students
	Description: Two hour class that combined lecture and question and answer session on current issues and problems with women's healthcare in the community and various workforce positions that are needed.
COMMENTS: