Form rh2

OMB No. 0915-xxxx

Expiration Date:

Office of Rural Health Policy: Rural Health

Community-Based Grant Programs

Performance Improvement and Measurement System (PIMS) Database

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 valid OMB control number. The OMB control number for this project is 0915-xxxx. Public reporting burden for this collection of information is estimated to be 4 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 10-33, Rockville, Maryland, 20857.

Rural Health Network Development Program

Table 1: ACCESS TO CARE

1	Total number of people (unduplicated encounters) served.	Number
2	Total number of encounters.	Number
3	Number of people in the target population.	Number
4	Number of people in the target population with access to new/expanded programs/services.	Number
5	Number of new and/or expanded services provided.	Number
6	Type(s) of new and/or expanded services provided. (Check all that apply)	Number
	Primary Care
	Mental / Behavioral Health
	Oral Health
	Telehealth / Telemedicine
	Health Literacy / translation services
	Pharmacy
	Case Management
	Diabetes / Obesity Management
	Substance Abuse Treatment
	Health Promotion / Disease Prevention
	Health Education
	Transportation
	Nutrition
	Other

Table Instructions: Access to Care

Information collected in this table provides an aggregate count of the number of people served (unduplicated encounters) and the total number of encounters the program is providing. Please refer to the detailed definitions for encounters.

Provide the total number of people served (unduplicated encounters); the total number of encounters, and the total number of people in the target population as defined by your project and the number of people in the target population that has access to new or expanded services and/or programs. Please provide the total number of new and/or expanded services provided and then select the type(s) of services. Please check all that apply.

If your grant project was not funded to specifically provide these services, please do not select them, even is your organization offers those services.

Table 2: POPULATION DEMOGRAPHICS

7	Number of people served by ethnicity:	Number
	Hispanic or Latino
	Not Hispanic or Latino
8	Number of people served by race:	Number
	Black or African American
	Asian
	American Indian or Alaska Native
	Native Hawaiian or Other Pacific Islander
	White
	More than one race
	Unknown
9	Number of people served by age group that received services:	Number
	Children (0-12)
	Teens (13-17)
	Adults (18-64)
	Elderly (64 and over)

Table Instructions: Population Demographics

Please provide the total number of people served by race, ethnicity, and age. If your grant project was not funded to provide direct services, please type N/A for not applicable.

Rural Health Network Development Program

Table 3: NETWORK

10	Number of member organizations in the consortium / network.	Number
11	Type(s) of member organizations in the consortium / network. (Check all that apply)	Selection list
	Hospital
	Critical Access Hospital
	Rural Health Clinic
	Free Clinic
	Private Practice
	Community Health Center
	Migrant Health Center
	Health Department
	AHEC
	University
	School District
	Social Services Organization
	Non-profit organization
	Faith-based organization
	For-profit business
	Other

Table Instructions: Networks

Please provide the number of organizations in the consortium or network for your project and the type(s) of member organizations; check all that apply. Please refer to the detailed definitions for consortium/networks, as defined in program guidance.

Table 4: UNDER & UNINSURED

12	Number of under/uninsured people receiving preventive and/or primary care.	Number
13	Number of under/uninsured who now have a medical home.	Number
14	Number of total people enrolled for public assistance, i.e., Medicare, Medicaid, and SCHIP.	Number
15	Number of people who pay out-of-pocket for all or part of the services received.	Number
16	Number of people who use third-party payments to pay for all or part of the services received.	Number
17	Number of people who receive charity care.	Number

Table Instructions: Underinsured & Uninsured

This table indicates the number of underinsured and uninsured users receiving preventative and primary care in the program. For your project, please provide the total number of under/uninsured people receiving preventive and/or primary care, who now have a medical home, are enrolled in public assistance, pay out-of-pocket, use third-party payments or receive charity care. If your grant project was not funded to provide direct services, please type N/A for not applicable. Please refer to the detailed definitions for underinsured and medical homes.

Table 5: WORKFORCE/ RECRUITMENT & RETENTION

18	Type(s) of new Clinical staff recruited to work on the project:	Selection list
	General Physician
	Specialty Physician
	Physician Assistant
	Dentist
	Dental Hygienist
	Psychologist
	Pharmacist
	Nurse
	Health Educator / Promotoras
	Licensed Clinical Social Worker
	Therapist (Behavioral, PT, OT, Speech, etc)
	Technicians (medical, pharmacy, laboratory, etc)
	Other
	None
19	Type(s) of new Non-Clinical staff recruited to work on the project:	Selection list
	HIT/CIO
	Case Manager
	Medical Biller / Coder
	Translator
	Enrollment Specialist
	Other
	None
20	Number of staff positions shared between two or more Network partners.	Number
21	Number of people trained.	Number

Table Instructions: Workforce/ Recruitment and Retention

Please provide the number of clinical and non-clinical staff recruited and trained on the project and the number of staff that are shared between two or more Network partners. If your grant project funds did not contribute to recruitment or retention of these staff, please type N/A for not applicable.

Table 6: SUSTAINABILITY

22	Annual project revenue made through the new or expanded services offered through the project.	Dollar Amount
23	Additional amount of funding secured to assist in sustaining the project.	Dollar Amount
24	Estimated amount of cost-savings due to participation in the network.	Dollar Amount
25	Has a sustainability plan been developed using sources of funding besides grants?	Y/N
26	Type(s) of sources of funding for sustainability: (Check all that apply)	Selection list
	Program revenue
	In-kind
	Member fees
	Other grants
	Other
	None

Table Instructions: Sustainability:

Please provide the amount of annual revenue the project has made through new and expanded services, the amount of additional funding secured to sustain the project and any estimated cost-savings the project has had as a result of your participation in the network. Please identify if a sustainability plan has been developed using funding sources other than grants and then select the type(s) of sources for that funding. Please check all that apply. If your grant project has not received any additional funding, please type N/A for not applicable.

Table 7: HEALTH INFORMATION TECHNOLOGY

27	Type(s) of technology implemented, expanded or strengthened through this project: (Check all that apply)	Selection list
	Telehealth
	Telemedicine
	Electronic medical records
	Electronic clinical applications
	Computerized pharmacy functions
	Computerized laboratory functions
	Other
	None

Table Instructions: Health Information Technology (HIT)

Please select the types of technology implemented, expanded or strengthened through this project. If your grant project did not fund this, please select none.

Table 8: MENTAL/BEHAVIORAL HEALTH

28	Number of people receiving mental and/or behavioral health services in target area.	Number
29	Number of network members integrating primary and mental health services.	Number

Table Instructions: Mental/Behavioral Health

Report the number of people receiving mental and/or behavioral health services in target area and the number of network members integrating primary and mental health services. If your grant project did not fund these services, please type N/A for not applicable.

Table 9: ORAL HEALTH

30	Number of people receiving dental / oral health services in target area.	Number
31	Type(s) of dental / oral health services provided. (Check all that apply)	Selection list
	Screenings / Exams
	Sealants
	Varnish
	Oral Prophylaxis
	Restorative
	Extractions
	Other
	Not Applicable
32	Number of network members integrating primary and dental / oral health services.	Number

Table Instructions: Oral Health

Report the number of people receiving dental/oral health services in target area, select the appropriate types of services and provide the number of network members integrating oral health services. Please check all that apply. If your grant project did not funded these services, please type N/A for not applicable.

Table 10: QUALITY

33	Number of clinical guidelines / benchmarks adopted	Number
34	Number of network members using shared standardized benchmarks	Number

Table Instructions: Quality

Report the number of clinical guidelines/benchmarks adopted and the number of network members using shared standardized benchmarks. If your grant project did not fund this, please type N/A for not applicable.

Table 11: PHARMACY

35	Annual number of people receiving prescription drug assistance	Number
36	Annual dollars saved by joint purchasing of drugs of the project members.	Dollar Amount
37	Annual average amount of dollars saved per patient through joint purchasing of drugs.	Dollar Amount

Table Instructions: Pharmacy

Report the number of people receiving prescription drug assistance, the overall annual dollars saved by joint purchasing of drugs of the project members, and the annual average amount of dollars saved per patient through joint purchasing of drugs. If your grant project did not fund these services, please type N/A for not applicable.

Table 12: HEALTH PROMOTION/DISEASE MANAGEMENT

38	Number of health promotion/disease management activities offered to the public through this project.	Number
39	Number of health screenings conducted.	Number

Table Instructions: Health Promotion and Disease Management

Report the number of health promotion/disease management activities offered to the public through this project and the number of health screenings conducted. If your grant project did not fund these services, please type N/A for not applicable.

Definition of Key Terms for Rural Health Community-Based Grant Programs

Charity Care: any services provided free of cost or reimbursement

Consortium/Network: Comprised of at least 3 separately owned organizations that are working together towards the project’s goals and objectives. Specifically respond only for the formal member organizations, for the purposes of your grant project.

Medical Home: provides patients with continuous access to services.

Target Population: The population identified by the grant project to receive services.

Total Encounters: The number of documented services provided to all individuals.

Total Non Duplicated Encounters: The number of unique individual users who have received documented services.

Underinsured: A person who has health insurance but face significant cost sharing or limits on benefits that may affect its usefulness in accessing or paying for needed health services and/or who may lack continuous access to health insurance coverage.