Form 1 Rural Health Care Outreach

OMB No. 0915-0319

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 0915-0319. Public reporting burden for this collection of information is estimated to be 3.25 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 Care Services Outreach Grant Program

Table 1: ACCESS TO CARE

Instructions:

Information collected in this table provides an aggregate count of the number of people served through program. Please refer to the detailed definitions and guidelines in answering the following measures. Please indicate a numerical figure or DK for do not know, if applicable.

 

Number of counties served

• Denotes the total number of counties served through the program. Please include entire, as well as partial counties served through the grant program. If your program is serving only a fraction of a county, please count that as one (1) county.

Number of people in target population

• Denotes the number of people in your target population (not necessarily the number of people who availed your services). For example, if a grantee organization’s target population is females in county A, then the grantee organization reports the number of females that resides in county A.

Number of Direct Unduplicated Encounters

• Denotes the number of unique individuals in the target population who have received documented services provided directly to the patient (patient visits, health screenings etc.)

• Denotes the number of people served in your target population

Number of Indirect Encounters

• Denotes the number of people reached through mass communication methods, such as mailings, posters, flyers, brochures, etc.

Number of Direct Duplicated Encounters

• Denotes the total number of activities done through the program.

 Type(s) of services provided through program funding

• Please check the box that applies to your program

1	Number of counties served	Number
2	Number of people in target population	Number
3	Number of direct unduplicated encounters	Number
4	Number of direct duplicated encounters	Number
5	Number of indirect encounters	Number
6	Type(s) of services provided through grant funding (Check all that apply)	Selection list
	Cardiovascular Disease (CVD)
	Case Management
	Diabetes / Obesity Management
	Elderly/Geriatric Care
	Emergency Medical Services (EMS)
	Health Education
	Health Literacy/translation services
	Health Promotion/Disease Prevention
	Maternal and Child Health/Women’s Health
	Mental/Behavioral Health
	Nutrition
	Oral health
	Pharmacy
	Primary Care
	Substance abuse treatment
	Telehealth/telemedicine
	Transportation
	Workforce
	Other	Grantee will specify

Table 2: POPULATION DEMOGRAPHICS

Instructions:

Please provide the total number of people served by race, ethnicity, and age. The total for each of the following questions should equal to the total number of direct unduplicated encounters provided in the previous section (Access to Care section). Please indicate a numerical figure. There should not be a N/A (not applicable) response since all measures are applicable.

Number of people served by ethnicity (Hispanic or Latino/Not Hispanic or Latino)

• Hispanic or Latino origin includes Mexican, Mexican American, Chicano, Puerto Rican, Cuban and other Hispanic, Latino or Spanish origin (i.e. Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard etc.)

7	Number of people served by ethnicity:	Number
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown
8	Number of people served by race:	Number
	American Indian/Alaska Native
	Asian
	Black or African American
	Native Hawaiian/Other Pacific Islander
	White
	More than one race
	Unknown
9	Number of people served by age group	Number
	Children (0-12)
	Adolescents (13-17)
	Adults (18-64)
	Elderly (65 and over)
	Unknown

Table 3: UNINSURED

Instructions:

Please respond to the following questions based on these guidelines:

Number of uninsured people receiving preventive and /or primary care

• Uninsured is defined as those without health insurance and those who have coverage under the Indian Health Service only

• The response should be based of the total number of direct unduplicated encounters provided on ‘Access to Care’ section

Number of total people enrolled in public assistance (i.e. Medicare, Medicaid, SCHIP or any State-sponsored insurance)

• Denotes the number of people who are uninsured but are enrolled in any of these public assistance insurance programs

Number of people who use private third-party payments to pay for the services received

• Denotes number of people who use private third-party payers such as employer-sponsored or private non-group insurance to pay for health services

Number of people who pay out-of-pocket for the services received

• Denotes the number of people who are uninsured, not enrolled in any public assistance (i.e. Medicare, Medicaid, SCHIP or State-sponsored insurance), not enrolled in private third party insurance (i.e. employer-sponsored insurance or private non-group insurance) and does not receive health services free of charge

Please indicate a numerical figure or DK for do not know, if applicable. If your grant program was not funded to provide these services, please type N/A for not applicable.

10	Number of uninsured people receiving preventive and/or primary care.	Number
11	Number of total people enrolled in public assistance, i.e., Medicare, Medicaid, SCHIP or any State-sponsored insurance	Number
12	Number of people who use private third-party payments to pay for the services received	Number
	Number of people who pay out-of-pocket for the services received	Number
13	Number of people who receive health services free of charge	Number

Table 4: STAFFING

Instructions:

Please provide the number of clinical and non-clinical staff recruited on the program and the number of staff that are shared between two or more Network partners. Please indicate a numerical figure. There should not be a N/A (not applicable) response since all questions are applicable.

14	Number of new clinical staff recruited to work on the program:	Number
	Dental Hygienist
	Dentist
	Health Educator / Promotoras
	Licensed Clinical Social Worker
	Nurse
	Pharmacist
	Physician Assistant
	Physician, General
	Physician, Specialty
	Psychologist
	Technicians (medical, pharmacy, laboratory, etc)
	Therapist  (Behavioral, PT, OT, Speech, etc)
	Other – Specify Type(s)
	None	Selection list
15	Number of new non-clinical staff recruited to work on the program for each type:	Number
	HIT/CIO
	Case Manager
	Medical Biller / Coder
	Translator
	Enrollment Specialist
	Other – Specify Type:
16	Number of staff positions shared between two or more Network partners	Number

Table 5: WORKFORCE/ RECRUITMENT & RETENTION

Traineeships:

If your grant funds support traineeships, please provide the number of new and existing trainees by type (student or resident).

Trainees are considered “New” if:

1. They have never engaged in a training/rotation within a rural community as a part of their certificate/degree/residency program and/or

2. They do not self identify as “having lived”/ “living”/ “claiming residence” within a rural area.

Trainees are considered “Existing” if:

1. They have had prior exposure to rural areas by either engaging in a training/rotation within a rural area as a part of their certificate/degree/residency program prior to the respective budget year and/or

2. They self identify as “having lived”/ “living”/ “claiming residence” within a rural area.

(Please refer to the Definition of Key Rural Health Community-Based Grant Programs to view the detailed definition for “New Trainees” and “Existing Trainees”.)

Please provide the number of trainees by type that complete the trainings/rotations; this figure should not exceed the total number of all trainees recruited by type. Please also provide the number of trainees by type that plan to practice in a rural area after completing their trainings/rotations. If appropriate, of those trainees that completed their trainings/rotations, please specify the number that return to formally practice in rural areas; for this measure, please indicate a numerical figure or type DK for do not know. For example, if there are zero (0) students that completed their trainings/rotations and returned to formally practice in a rural area, please put zero in the appropriate section. Do not leave any sections blank. There should not be a N/A (not applicable) response since all measures are applicable.

For your program, please provide the types of trainee primary care focus areas and disciplines; please check all that apply. Please keep in mind that psychiatrists, like other physicans, are either allopathic (MD) or osteopathic (DO) physicians. Also, please specify the types of Mid-Levels, Nurses, and Allied Health Professionals as appropriate. For example, Physician Assistants, Nurse Practitioners, Certified Nurse Mid-Wives, and Certified Registered Nurse Anesthesiologists are considered Mid-Level providers. Allied health professionals, to name a few, include dental hygienists, diagnostic medical sonographers, dietitians, medical technologists, occupational therapists, physical therapists, pharmacists, radiographers, respiratory therapists, community health workers, and speech language pathologists. If the targeted trainee does not fall under the categories listed, please refer to the detailed definition for Allied Health Professionals and specify the discipline(s) in the Allied Health Professionals category.

Please provide the number of trainings/rotations provided during the respective budget period as well as the number of training sites by type where the trainings/rotations were conducted. Please indicate a numerical figure. If the total number of trainings/rotations is zero (0), please put zero in the appropriate section. Do not leave any sections blank.

Definition of Key Terms for the Workforce/Recruitment and Retention section:

Allied Health Professionals: Allied health care practitioners/workers with formal education and clinical training who are credentialed through certification, registration and/or licensure. Allied Health professionals are involved with the delivery of health or related services pertaining to the identification, evaluation and prevention of diseases and disorders; dietary and nutrition services; rehabilitation and health systems management, among others.

Existing Trainee: A health professions student or resident that has prior exposure to rural areas. This prior exposure may stem from either previously engaging in a training or rotation within a rural area as a part of their certificate/degree/residency program and/or self identifying as “having lived”/ “living”/ “claiming residence” within a rural area.

New Trainee: A health professions student or resident that has never engaged in a training or rotation within a rural community as a part of their certificate/degree/residency program and/or does not self identify as “having lived”/ “living”/ “claiming residence” within a rural area.

8	Number of New Students/Residents Recruited to Work on the Program:	Number
	New Students
	Existing Students
	All Students	Number (automatically calculated by the system)
	New Residents
	Existing Residents
	All Residents	Number (automatically calculated by the system
	Of the total number of students recruited, how many completed the training/rotation
	Of the total number of students that complete the training/rotation, how many plan to practice in a rural area
	Percentage of students trained that plan to practice in a rural area	Percent (automatically calculated by the system)
	Of the total number of students that complete the training/rotation, how many returned to formally practice in rural areas	Number/DK
	Percentage of students trained that return to formally practice in rural areas	Percent (automatically calculated by the system)
	Of the total number of residents recruited, how many completed the training/rotation
	Of the total number of residents that complete the training/rotation, how many plan to practice in a rural area
	Percentage of residents trained that plan to practice in a rural area	Percent (automatically calculated by the system)
	Of the total number of residents that complete the training/rotation, how many returned to formally practice in rural areas	Number/DK
	Percentage of residents trained that return to formally practice in rural areas	Percent (automatically calculated by the system)
9	Trainee Primary Care Focus Area(s): (Please check all that apply)	Selection list
	Medical
	Mental/Behavioral Health
	Oral Health
10	Trainee Discipline Type(s): (Please check all that apply)	Selection list
	Allied Health Professional– Please specify type(s)
	Dentist
	Mid-Level Provider – Please specify type(s)
	Nurse – Please specify type(s)
	Physician (DO)
	Physician (MD)
11	Number of New Trainings/Rotations:	Number
	Number of New Trainings/Rotations provided
12	Number of Training Site(s) by Type:	Number
	Critical Access Hospital
	Other Rural Hospital
	Clinic
	Rural Health Clinic
	Community Health Center
	Federally Qualified Health Center (FQHC)
	Health Department
	Indian Health Service (IHS) or Tribal Health Sites
	Migrant Health Center (MHC)
	Other Community Based Site – Please specify type(s)

Table 6: NETWORK

Instructions:

Please identify the types of formal member organizations in the consortium or network by non-profit and for-profit status for your program. Please indicate a number for each category. Please provide the total number of member organizations in the consortium or network. Then, out of the total number of organizations in consortium/network, please provide the total number of new member organizations acquired within the budget year.  Please refer to the detailed definitions for consortium/networks, as defined in the program guidance.

22	Type(s) of member organizations in the consortium / network (Check all that apply)	Number
Non-profit Organization	Area Health Education Center (AHEC)
	Community College
	Community Health Center
	Critical Access Hospital
	Faith-Based Organization
	Health Department
	Hospital
	Migrant Health Center
	Private Practice
	Rural Health Clinic
	School District
	Social Services Organization
	University
	Other
	TOTAL for Non-Profit Organization	Number (automatically calculated by the system)
For-profit Organization	Community College
	Community Health Center
	Critical Access Hospital
	Faith-Based Organization
	Health Department
	Hospital
	Migrant Health Center
	Private Practice
	Rural Health Clinic
	School District
	Social Services Organization
	University
	Other
	TOTAL for For-Profit Organization	Number (automatically calculated by the system)
23	Total Number of Member Organizations in the Consortium/Network	Number
24	Total Number of New Members in the Consortium/Network	Number

Table 7: SUSTAINABILITY

Instructions:

• Please provide the annual program award based on box 12a of your Notice of Grant Award (NGA).

• Please provide the amount of annual revenue made through the services offered through the program. If the total amount of annual revenue made is zero (0), please put zero in the appropriate section. Do not leave any sections blank.

• Please provide the amount of additional funding secured to sustain the program. If the total amount of additional funding secured is zero (0), please put zero in the appropriate section. Do not leave any sections blank.

• Please provide the estimated amount of savings incurred due to participation in a network/consortium. If the total amount of savings incurred is zero (0), please put zero in the appropriate section. Do not leave any sections blank.

• Select the type(s) of sources of funding for sustainability. Please check all that apply.

• Please indicate if you have a sustainability plan and select your sustainability activities. Please check all that apply.

• Please indicate if you used HRSA’s Economic Impact Analysis Tool (website TBD). If so, please provide the ratio for Economic Impact vs. HRSA Program Funding.

For programs that are in Year 3 of grant funding, please indicate the following:

• Please indicate if your current network/consortium will sustain after the grant period is over

• Please indicate if any of your program’s activities will sustain after the grant period.

25	Annual program award	Dollar amount
26	Annual program revenue	Dollar amount
27	Additional funding secured to assist in sustaining the program	Dollar amount
28	Estimated amount of cost savings due to participation in network/consortium	Dollar amount
29	Sources of Sustainability	Selection list
	Program Revenue
	In-kind Contributions
	Member fees
	Fundraising
	Contractual Services
	Other grants
	Other – specify type
	None
30	Has a sustainability plan been developed using sources of funding besides grants?	Y/N
31	Sustainability Activities: (check all that apply)	Selection list
	Local, State and Federal Policy changes
	Media Campaigns
	Consolidation of activities, services and purchases
	Communication Plan Development
	Economic Impact Analysis
	Return on Investment Analysis
	Marketing Plan Development
	Community Engagement Activities
	Business Plan Development
	SWOT Analysis
	Other – Specify activity
32	Did you use the HRSA Economic Impact Analysis tool	Y/N
33	If yes, what was ratio for Economic Impact vs. HRSA Program Funding	Number
34	Will the network/consortium sustain after the grant period is over	Y/N
35	Will the program’s activities be sustained after the grant period	Y/N

Table 8: HEALTH INFORMATION TECHNOLOGY

Instructions:

Please select all types of technology implemented, expanded or strengthened through this program. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

36	Type(s) of technology implemented, expanded or strengthened through this program: (Check all that apply)	Selection list
	Computerized laboratory functions
	Computerized pharmacy functions
	Electronic clinical applications
	Electronic medical records
	Health Information Exchange
	Patient/Disease Registry
	Telehealth/Telemedicine
	None
	Other

Table 9: QUALITY IMPROVEMENT

Instructions:

Report the number of quality improvement clinical guidelines/benchmarks adopted and the number of network members using shared standardized benchmarks. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

37	Number of quality improvement clinical guidelines / benchmarks adopted by network/consortium	Number
38	Number of network/consortium members using shared standardized quality improvement benchmarks	Number

Table 10: PHARMACY

Instructions:

Report the overall annual dollars saved by joint purchasing of drugs through your network/consortium. Report the number of people receiving prescription drug assistance and the annual average amount of dollars saved per patient through prescription drug assistance. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

39	Average amount of dollars saved per patient through joint purchasing of drugs annually	Dollar amount
40	Number of people receiving prescription drug assistance annually	Number
41	Average amount of dollars saved per patient through prescription drug assistance annually	Dollar amount

Table 11: HEALTH PROMOTION/DISEASE MANAGEMENT

Instructions:

Number of health promotion/disease management activities offered to the public through this program

• Report the number of health promotion/disease management activities offered to the public through this program. Some examples include: health screenings, health education, immunizations, etc.

Number of people referred to health care provider/s

• Report the number of people that were referred to a health care provider. The response to this question should be based on the number reported in the previous question (Number of health promotion/disease management activities offered to the public through this program). Therefore, the number reported here should not be more than the number reported in the previous question.

Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

42	Number of health promotion/disease management activities offered to the public through this program.	Number
43	Number of people referred to health care provider/s	Number

Table 12: MENTAL/BEHAVIORAL HEALTH

Instructions:

Report the number of people receiving mental and/or behavioral health services through your program and the number of network members integrating primary and mental health services. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

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

Table 13: ORAL HEALTH

Instructions:

Report the number of people receiving dental/oral health services in target area. Please select the appropriate types of services and provide the number of network/consortium members integrating oral health services. Please check all that apply. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

46	Number of people receiving dental / oral health services in target area.	Number
47	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
48	Number of network members integrating primary and dental / oral health services.	Number

Table 14: CLINICAL MEASURES

Instructions:

Please refer to the specific instructions for each field below. Please indicate a numerical figure or N/A for not applicable if your grant program did not fund this.

Measure 1:

Numerator: Patients from the denominator that have the most recent blood pressure less than 140/190 mm Hg, within the last 12 months.

Denominator:  All patients 18-85 years of age seen at least once during the last 12 months with a diagnosis of hypertension within 6 months after measurement start date.

Measure 2

Numerator: Number of adult patients in the target population that have been screened for depression.  
Denominator: All patients ≥ 18 years of age in the target population.

Measure 3:

Numerator: Number of patients 18-75 years of age whose most recent hemoglobin A1c level during the measurement year is less than 8.0%

Denominator: Number of patients 18-75 years of age during measurement year with a diagnosis of type 1 or type 2 diabetes.  

Measure 4:  

Numerator: Number of patients 18-75 years of age with diabetes (type 1 or type 2) who had blood pressure less than 140/90 mm/Hg

Denominator: All patients 18-75 years of age during measurement year with a diagnosis of type 1 or 2 diabetes.  

Measure 5:

Numerator: Patients in the denominator with Body Mass Index (BMI) percentile documentation, counseling for nutrition, counseling for physical activity during the measurement year

Denominator: All patients 2-17 years of age

Measure 6:

Numerator: Patients in denominator with (1) Body Mass Index (BMI) charted and (2) follow-up plan documented if patient is overweight and underweight

Denominator: All patients age 18 years or older

Measure 7:

Numerator: Number of children who have received four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); two H influenza type B (HiB); three hepatitis B (HepB); one chickenpox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.  The measure calculates a rate for each vaccine and nine separate combination rates.
Denominator: Number of children who turn two years of age during the measurement year.   

Measure 8:

Numerator: Number of adolescents who have received a second MMR, completion of three hepatitis B (HepB) and Varicella (VZV).
Denominator: Number of adolescents who are 13 years of age during measurement year.      

		Numerator	Denominator	Percent
1	Percentage of adult patients, 18 -85 years of age, who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year	Number	Number	Automatically calculated by system
2	Percent of adult patients in the target population who have been screened for depression	Number	Number	Automatically calculated by system
3	Percent of adult patients, 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c less than 8.0%	Number	Number	Automatically calculated by system
4	Percent of patients 18-75 years of age with diabetes (type 1 or type 2) who had blood pressure less than 140/90 mm/Hg	Number	Number	Automatically calculated by system
5	Percent of patients 2-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or OB/GYN and who had evidence of Body Mass Index (BMI) percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year	Number	Number	Automatically calculated by system
6	Percent of patients aged 18 years and older with a calculated Body Mass Index (BMI) in the past six months or during the current visit documented in the medical record and if the most recent BMI is outside parameters, a follow-up is documented	Number	Number	Automatically calculated by system
7	Percent of children by 2 years of age with appropriate immunizations (please see types of immunizations as listed in the instructions)	Number	Number	Automatically calculated by system
8	Percent of adolescents 13 years of age with appropriate immunizations documented according to age group	Number	Number	Automatically calculated by system

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