Form 1 INSTRUMENT - RHND - 2017 PIMS

Federal Office of Rural Health Policy: Rural Health Network Development

Community-Based Division Grant Programs

Performance Improvement and Measurement System (PIMS) Database

SECTION I: NETWORK

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
	Area Health Education Center
	Behavioral/Mental Health Organization
	Community College
	Community Health Center
	Critical Access Hospital
	Emergency Medical Service
	Faith-based Organization
	Federally Qualified Health Center
	Free Clinic
	Health Department
	Home Health Care Agency
	Hospice
	Hospital
	Long Term Care Facility
	Migrant Health Center
	Private Practice Primary Care
	Private Practice Specialty Care
	Rural Health Clinic
	School District
	Social Services Organization
	Tribal Organization
	University
	Other – Member Organization
	Total

Table 2: Network Benefits

Table Instructions: Please select the benefits realized by network members as a result of being in the network.

Please refer to the following definitions of “network benefits”:

Financial Cost Savings: A reduction in historical or projected cost that may occur from a change to plans regarding frequency, volume, or policy that reduce the expense associated with a business activity. Examples may include: reduced operational costs, cost sharing, and reduced cost of services.

Efficiencies: A streamlined process or procedure that produces the least amount of waste of time and effort; competency in performance.

Quality Improvement: A systematic, formal approach to the analysis of practice performance and effort to improve performance.

Access to Educational Opportunities: Educational experience where new knowledge is acquired. Examples may include: webinars, conferences, workshops.

Access to Equipment: Newly acquired ability to utilize equipment. Examples may include: access to shared software, in kind use of equipment,

Branding/Marketing: To make the products and services provided by the network recognized and known by community members, network members, and other stakeholders.

Development of Workforce that is Change Ready and Adaptable: Creation of a workforce that is able to react and comply with changes in the provision of services; including rules, regulations, processes and services.

Knowledge Sharing: Dissemination of knowledge or expertise across staff members, such as through meetings, educational opportunities or access to subject matter experts.

Understanding of Community Health Needs: Ability to assess the health needs of the targeted community, through the use of data, surveys, focus groups, and other methods that provide insight into the unique health needs of the community.

Opportunities for Innovation: Ability to create innovative products and services, resulting from supportive management, understanding of needs of the network members and the community, efficiencies, adequate revenue streams, expertise, or other factors that promote and facilitate innovation.

2	During the current budget year, assess the following overall benefits realized by the network members as a result of being in the network (check the benefit(s) that apply):
	Type of Network Benefit	Select if Applicable
	Financial Cost Savings
	Efficiencies
	Quality Improvement
	Access to Educational Opportunities
	Access to Equipment
	Branding/Marketing
	Development of Workforce That is Change Ready and Adaptable
	Knowledge Sharing
	Understanding of Community Health Needs
	Opportunities for Innovation
	Other network benefit(s) (Please Specify):

Table 3: Network and Program Sustainability

Table Instructions: Please provide network and program sustainability information.

3	Will the network continue to collaborate after this grant funding?	Yes/No
4	Will the programs created through this grant funding continue to sustain after this grant funding?	All (100%) Most (50-99%) Some (less than 50%) None (0%)

Table 4: Indicators of Network and Program Sustainability

Table Instructions: Please select the following indicators of sustainability experienced by the network as a result of this grant funding, as applicable.

5	Sustainability Indicator	Select if Applicable
	Ability of the network to adapt to regional or national healthcare trends
	Collaboration across traditional and non-traditional healthcare members within the network
	Incorporation of the health needs of the community into the network’s decision making strategies
	Creation of diverse products and services that meet the needs of the target population and network members
	Creation of diverse revenue streams that include member dues, fee for services and product sales
	Utilization of an evaluation plan to assess progress towards program goals and objectives
	Absorption of the services provided from this grant funding into the routine operations of network members, without requiring additional funding support
	Other

Table 5: Impact

Table Instructions: Information collected in this table provides an aggregate count of the number of people targeted within the service area, which may or may not be the total population residing within the service area. Please indicate a numerical figure or DK for do not know, if applicable

Number of people in target population

• Denotes the number of people your program is trying to serve (not necessarily the number of people who availed themselves of your services). For example, if the network focuses its mission on serving a particular population such as migrant and seasonal farm workers, then the migrant and seasonal farm workers may be a subset of the total population within the service area.

6	Number of people in target population	Number
7	Number of people in the target population who received or participated in a new or expanded program/area of service this year as a result of network activities funded by the Rural Health Network Development Program	Number
8	Number of new programs/areas of service implemented or enhanced by the network this year - as a result of grant funding from the Rural Health Network Development Program

9	Type(s) of new and/or expanded service area(s) provided by the network as a result of the Rural Health Network Development grant funding	Please check  Please check any boxes below that apply to any new and/or expanded services provided as a result of Network Development grant funding. NOTE: Please check at least one box.
	Health and Wellness:
	Cardiovascular Disease
	Chronic Obstructive Pulmonary Disease
	Diabetes / Obesity Management
	Elderly / Geriatric Care
	Emergency Medical Service (EMS)
	Health Education
	Health Insurance Enrollment
	Health Literacy/Translation Services
	Health Promotion/Disease Prevention
	Maternal and Child Health
	Mental/Behavioral Health
	Nutrition
	Oral Health
	Pharmacy
	Primary Care
	Specialty Care
	Substance Abuse Treatment
	Transportation
	Workforce
	Care Coordination:
	Care Coordination
	Care Transitions
	Case Management
	Quality Improvement:
	Accountable Care Organization
	Medical Home or Patient Centered Medical Home
	Health Information Technology:
	Attestation of Meaningful Use Stage 1, 2 or 3
	Electronic Medical Records/Electronic Health Records
	Health Information Exchange
	Telehealth/Telemedicine
	Patient/Disease Registry
	Other, please specify.	open-ended response
	None- Explain	open-ended response

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What is your ratio for Economic Impact vs. HRSA Program Funding? Use the HRSA’s Economic Impact Analysis Tool (https://www.ruralhealthinfo.org/econtool) to identify your ratio.

Ratio

Section II: Demographics – All program activities

Table 6: Demographics- Number of People Served by the Program

Table Instructions: This table collects information about an aggregate count of the people served by race, ethnicity, age and insurance status. The total for each of the following questions should equal the total of the number of unique individuals who received only direct services reported in the previous section. Please do not leave any sections blank. There should not be a N/A (not applicable) response since the measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section (e.g., if the total number that is Hispanic or Latino is zero (0), enter zero in that section). 

Note: It is expected that each grantee organization will collect baseline data, and then again report at the end of the budget period. 

Hispanic or Latino Ethnicity

• Column A (Hispanic/Latino): Report the number of persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, broken down by their racial identification and including those Hispanics/Latinos born in the United States. Do not count persons from Portugal, Brazil, or Haiti whose ethnicity is not tied to the Spanish language.

• Column B (Non-Hispanic/Latino): Report the number of all other people except those for whom there are neither racial nor Hispanic/Latino ethnicity data. If a person has chosen a race (described below) but has not made a selection for the Hispanic /non-Hispanic question, the patient is presumed to be non-Hispanic/Latino.

• Column C (Unreported/Refused to Report): Only one cell is available in this column. Report on Line 7, Column C only those patients who left the entire race and Hispanic/Latino ethnicity part of the intake form blank.

People who self-report as Hispanic/Latino but do not separately select a race must be reported on Line 7, Column A as Hispanic/Latino whose race is unreported or refused to report. Health centers may not default these people to “White,” “Native American,” “more than one race,” or any other category.

Race

All people must be classified in one of the racial categories (including a category for persons who are “Unreported/Refused to Report”). This includes individuals who also consider themselves to be Hispanic or Latino. People who self-report race, but do not separately indicate if they are Hispanic or Latino, are presumed to be non-Hispanic/Latino and are to be reported on the appropriate race line in Column B.

People sometimes categorized as “Asian/Other Pacific Islander” in other systems are divided into three separate categories:

• Line 1, Asian: Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Indonesia, Thailand, or Vietnam

• Line 2a, Native Hawaiian: Persons having origins in any of the original peoples of Hawaii

• Line 2b, Other Pacific Islander: Persons having origins in any of the original peoples of Guam, Samoa, Tonga, Palau, Truk, Yap, Saipan, Kosrae, Ebeye, Pohnpei or other Pacific Islands in Micronesia, Melanesia, or Polynesia

• Line 2, Total Native Hawaiian/Other Pacific Islander: Must equal lines 2a+2b

American Indian/Alaska Native (Line 4): Persons who trace their origins to any of the original peoples of North and South America (including Central America) and who maintain Tribal affiliation or community attachment.

More than one race (Line 6): “More than one race” should not appear as a selection option on your intake form. Use this line only if your system captures multiple races (but not a race and an ethnicity) and the person has chosen two or more races. This is usually done with an intake form that lists the races and tells the person to “check one or more” or “check all that apply.” “More than one race” must not be used as a default for Hispanics/Latinos who do not check a separate race. They are to be reported on Line 7 (Unreported/Refused to Report), as noted above.

11	Line	Number of People Served By Race	Hispanic/Latino (a)	Non-Hispanic/Latino (b)	Unreported/ Refused to Report Ethnicity (c)	Total (d) (Sum Columns a+b+c)
	1	Asian
	2a.	Native Hawaiian
	2b.	Other Pacific Islander
	2.	Total Native Hawaiian/Other Pacific Islander (Sum lines
	3.	Black/African American
	4.	American Indian/ Alaska Native
	5.	White
	6.	More than one race
	7.	Unreported/Refused to report race
	8.	Total of individuals served (Sum Line 1+2+3 to 7)				Equal to the total number of unique individuals who receive direct services

SECTION III: HEALTH INFORMATION TECHNOLOGY

Table 7: Summary of Care Record

Table Instructions: If your RHND grant program is an EHR/HIT or Care Coordination program and any member of your network has achieved Meaningful Use Stage II or Stage III, please indicate “yes/no” to the following questions.

	Summary of Care Record	Yes/No
12	Is your program using a certified EHR technology (CEHRT) to create a summary of care record?
13	If yes, does your program submit this summary to a receiving provider for more than 10 percent of transitions of care referrals?
14	What percentage of care transitions between organizations receive an electronic care summary (if available)?	open-ended response

SECTION IV: TELEHEALTH

Table 8: Patient Travel Miles Saved

Table Instructions: Telehealth is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance. If your RHND grant program utilizes telehealth please fill out the following table.

In the table, enter the names of each consultant site (hub site) in column 1 and each originating site (patient data site) in column 2. For many programs, the telehealth provider site will be serving all your remote sites. We ask that you still list the telehealth provider (hub) site in column 1.

Estimate the distance between the two (in miles) and enter this number into column 3. This information can be obtained by using Google maps (https://www.google.com/maps) or other mapping resources.

Enter the number of patient care sessions between the two locations in column 5. For group sessions/clinics, each patient should be counted separately, as each would have had to travel for these sessions. For simplicity reasons (and to avoid collecting information from each patient) the distance a patient travels from their home to the remote site is intentionally omitted. Home patients should be excluded from this entire reporting sheet. Patients being stabilized prior to transport should be excluded as well, as their travel is not averted, only delayed.

Columns 4 and 6 will fill in automatically. You do not need to enter anything into these cells.

Definitions:

Consultant Site/Hub site: Site at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications system.

Originating Site/Patient Data Site: Site at which the patient is located or where patient data is collected at the time the service is provided via telecommunications system.

Patient-Care Sessions: Include therapy and counseling (including nutritional, group, etc.) but NOT didactic education, community meetings or administrative sessions.

1	2	3	4	5	6
Consultant Site	Patient/Patient-data Site	Distance Between (miles)	Miles Roundtrip ('column 3' X 2)	# Patient Care Sessions	Miles Saved ('column 4' X 'column 5')
			0		0
			0		0
			0		0
			0		0
			0		0
		Total:	0	0	0

SECTION: V DIRECT CLINICAL SERVICES (IF APPLICABLE)

Table 9: Number of People Receiving Direct Clinical Services (If applicable)

Table Instructions: Please provide information on the number of unique (i.e. unduplicated count) patients/clients that received direct clinical services from your organization.

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Number of unique individuals who received direct clinical services during this budget period

Number:

SECTION VI: CLINICAL MEASURES

Table 10: Clinical Measures

Table Instructions: Please use your health information technology system to extract the clinical data monitored through this grant program. Please only report on data that is aligned with the activities funded through this grant program. Please refer to the specific definitions for each measure.

Detailed descriptions of NQF measures can be found at: http://www.qualityforum.org/Home.aspx

Hospital Readmission:

Measure 1: NQF 1789: Hospital-Wide All Cause Readmission

Measure Description:

Numerator: Number of readmission for patients 18 years or older as an inpatient admission to any acute care facility which occurs within 30 days of the discharge date of an eligible index admission

Denominator: Number of admissions to acute care facilities for patients aged 18 years or older

Behavioral/Mental Health:

Measure 2: NQF 0028: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention

Measure Description: Percentage of patients aged 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received cessation counseling intervention if identified as a tobacco user

Numerator: Patients who were screened for tobacco use* at least once during the 24 month measurement period AND who received tobacco cessation counseling intervention** if identified as a tobacco user
*Includes use of any type of tobacco
** Cessation counseling intervention includes brief counseling (3 minutes or less), and/or pharmacotherapy.Numerator Details: ${NumeratorDetails}

Denominator: All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period

Measure 3: NQF 0418: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Measure Description: Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented

Numerator: Patients screened for clinical depression using an age appropriate standardized tool AND follow-up plan is documented

Denominator: All patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool

Diabetes:

Measure 4: NQF 0059: Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%):

Measure Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.

Numerator: Patients whose HbA1c level is >9.0% during the budget period.

Denominator: Patients 18-75 years of age by the end of the budget period who had a diagnosis of diabetes (type 1 or type 2) during the budget period.

Obesity:

Measure 5: NQF 0024: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

Measure Description: Percentage of patients 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of the following during the measurement year:

- Body mass index (BMI) percentile documentation*

- Counseling for nutrition

- Counseling for physical activity

*Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value.

Numerator: Body mass index (BMI) percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.

Denominator: Patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or OB-GYN during the measurement year.

Measure 6: NQF 0421: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

Measure Description: Percentage of patients aged 18 years and older with a documented BMI during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter. (Normal Parameters: Age 65 years and older BMI > or = 23 and < 30; Age 18 – 64 years BMI > or = 18.5 and < 25)

Numerator: Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, follow-up is documented during the encounter or during the previous six months of the encounter with the BMI outside of normal parameters

Denominator: All patients aged 18 years and older

Oral Health:

Measure 7: NQF 2508: Prevention: Dental Sealants for 6-9 Year-Old Children at Elevated Caries Risk

Measure Description: Percentage of enrolled children in the age category of 6-9 years at “elevated” risk (i.e., “moderate” or “high”) who received a sealant on a permanent first molar tooth within the reporting year.

Numerator: Unduplicated number of enrolled children age 6-9 years at “elevated” risk (i.e., “moderate” or “high”) who received a sealant on a permanent first molar tooth as a dental service

Denominator: Unduplicated number of enrolled children age 6-9 years who are at “elevated” risk (i.e., “moderate” or “high”)

Measure 8: CMS74v7: Primary Caries Prevention Intervention as Offered by Primary Care Providers, Including Dentists

Measure Description: Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period

Numerator: Children who receive a fluoride varnish application

Denominator: Children, age 0-20 years, with a visit during the measurement period

Care Coordination:

Measure 9: CMS50v6: Closing the referral loop: receipt of specialist report

Measure Description: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

Numerator: Number of patients with a referral, for which the referring provider received a report from the provider to whom the patient was referred

Denominator: Number of patients, regardless of age, who were referred by one provider to another provider, and who had a visit during the measurement period

Measure 10: NQF 0097: Medication Reconciliation Post-Discharge

Measure Description: The percentage of discharges for patients 18 years of age and older for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record by a prescribing practitioner, clinical pharmacist or registered nurse.

Numerator: Medication reconciliation conducted by a prescribing practitioner, clinical pharmacists or registered nurse on or within 30 days of discharge

Denominator: All discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care.

		Numerator	Denominator	Percent
17	Provide data on the NQFs monitored by and related to this grant program.
	Hospital Readmission
	Measure 1: NQF 1789: Hospital-Wide All Cause Readmission
	Behavioral/Mental Health
	Measure 2: NQF 0028: Preventive Care & Screening: Tobacco Use
	Measure 3: NQF 0418: Screening for clinical depression
	Diabetes
	Measure 4: NQF 0059: Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)
	Obesity
	Measure 5: NQF 0024: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
	Measure 6: NQF 0421: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
	Oral Health
	Measure 7: NQF 2508: Prevention: Dental Sealants for 6-9 Year-Old Children at Elevated Caries Risk
	Measure 8: CMS74v7: Primary Caries Prevention Intervention as Offered by Primary Care Providers, Including Dentists
	Care Coordination
	Measure 9: CMS50v6: Closing the referral loop: receipt of specialist report
	Measure 10: NQF 0097: Medication Reconciliation

Is your program addressing an NQF not provided in the table above

Yes

No

If your program IS addressing an NQF measure NOT provided in the table above, please provide the NQF number(s), numerator, denominator and percent in the table below.

		Numerator	Denominator	Percent
	NQF:
	NQF:

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 0906-XXXX.  Public reporting burden for this collection of information is estimated to average 6 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, Room14N-39, Rockville, Maryland, 20857.

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