Form 2 FORM_Telehealth Performance Measurement Report RESPONSE

0906-XXXX XX/XX/20XX

Form 1: Priorities

Did you provide services to patients in any of the following categories because of any Evidence Based Tele-behavioral Health Network Program (EB THNP) funding during this reporting period?
	Yes	No
Mental Health
Substance Abuse Treatment

Form 2: Originating and Distant Sites

Complete Form 1. Priorities before inputting data in this form. Only sites that are eligible for and receiving EB THNP funding should be included.

List of Selected Sites (Modify the List of Sites if Needed) and Settings (Modify the List of Settings if Needed)

Site Name	Street Address	City/Town	County	State	Zip Code	Originating or Distant Site (O/D)	Rural or Urban Site (R/U)	Setting
[grantee generated list]								[choose from menu]
[grantee generated list]								[choose from menu]

Number of Each Type of Site in this Reporting Period
Originating Sites	[#] auto-populate
Distant Sites	[#] auto-populate

Form 3: Specialties and Services, by Site

Complete Form 2. Originating and Distant Sites before inputting data in this form. Only sites and specialties that are eligible for and receiving EB THNP funding should be included.

List of Sites (Modify the List of Sites if Needed)/ List of Specialties (Modify the List of Specialties if Needed)

Originating Site	Specialty(s) actively available at this site through telehealth	Was specialty available in your community prior to this EB THNP funding?
[grantee generated site]	[choose from menu]	[yes/no radio button]
	[choose from menu]	[yes/no radio button]
[grantee generated site]	[choose from menu]	[yes/no radio button]
	[choose from menu]	[yes/no radio button]

Number of sites that have access to [specialty from configure report] services where access did not exist in your community prior to this EB THNP funding	[#] auto-populate
Number of sites that have access to [specialty from configure report] services where access did not exist in your community prior to this EB THNP funding	[#] auto-populate

Form 4: Volume of Services, by Site and Specialty

Complete Form 3. Specialties and Services, by Site before inputting data in this form.

Only unique patients seen and encounters occurring as the result of receiving EB THNP funding should be included.

Real-Time Encounters are encounters that are live, two-way interactions between a person and a provider using audiovisual telecommunications technology. Store-and-Forward Encounters, also called asynchronous, are the transmission of health information through digital images or pre-recorded videos through electronic communication to a practitioner who uses the information to make an evaluation.

Enter 0 if there is no data to report.

Originating Site	Setting	Specialty	Unique Patients	Number of Real-Time Encounters	Number of Store-and-Forward Encounters	Total Encounters
[grantee generated list]	[grantee generated list]	[grantee generated list]	[#]	[#]	[#]	[#]
[grantee generated list]	[grantee generated list]	[grantee generated list]	[#]	[#]	[#]	[#]

Total Number of Unique Patients Served because of EB THNP funding	[#] auto- populate
Total Number of Encounters because of EB THNP funding	[#] auto-populate

Form 5: Patient Travel Miles Saved

Complete Form 4: Volume of Services, by Site and Specialty before inputting data in this form.

Only sites and specialties that are eligible for and receiving EB THNP funding should be included.

For group sessions/clinics, each patient should be counted separately, as each would have had to travel for these sessions.

Originating Site	Specialty	Name of location where patient would have been referred in absence of telehealth	Distance Between Originating (patient) Site to the location where the patient would have been referred in the absence of telehealth (Miles)	Miles Roundtrip	Total Encounters	Miles Saved
[grantee generated list]	[grantee generated list]		[#]	[#]	[#]	[#]
[grantee generated list]	[grantee generated list]		[#]	[#]	[#]	[#]

Total Miles Saved

[#]

Form 6: Other Uses of the Telehealth Network

Complete Form 5. Patient Travel Miles Saved before inputting data in this form.

Provide required data in the tables below. Enter 0 if there is no data to report.

Enter ‘DK’ if ‘Total Number of People’ is unknown.

Categories	Number of Sessions
Administrative Meetings	[#]
Distance Learning	[#]
Other	[#]

Formal and Informal Education	Total Number of Sessions	Total Number of People
Formal Education (sessions are used to fulfill formal education, licensure or certification requirements)	[#]	[#]
Informal Education (sessions used to meet regulatory practice requirements, as well as supervision/advice requested by remote practitioners)	[#]	[#]

Form 7: Diabetes

Complete form 6: Other Uses of the Telehealth Network before inputting data in this form. Only patients seen and encounters occurring as a result of receiving EB THNP funding should be included. Provide required data in the tables below. Enter 0 if there is no data to report.

Number of unduplicated patients with diabetes served for at least three months during the reporting period	[grantee reported #]
Number of unduplicated patients with diabetes (who received services for at least three months during the reporting period) whose most recent Hemoglobin A1c (HbA1c) level is 7.0% or less.	[grantee reported #]
Number of unduplicated patients with diabetes (who received services for at least three months during the reporting period) whose most recent Hemoglobin A1c (HbA1c) level is between 7.1% and 9.0%.	[grantee reported #]
Number of unduplicated patients with diabetes (who received services for at least three months during the reporting period) whose most recent Hemoglobin A1c (HbA1c) level during the measurement year was greater than 9.0% (poor control), or if an HbA1c test was not done during the reporting period.	[grantee reported #]

Form 8: Mental Health

Complete form 7: Diabetes before inputting data in this form. Only patients seen and encounters occurring as a result of receiving EB THNP funding should be included. Provide required data in the tables below. Enter 0 if there is no data to report.

Number of sites that have access to mental health services where access did not exist prior to the EB THNP rant	[#]
Number of sites that have access to mental health services for pediatric and adolescent populations where access not exist prior to the EB THNP grant	[#]
Number of sites that have access to mental health services for adult populations where access did not exist prior to the EB THNP grant	[#]

Setup Forms:

Configure Sites:

Indicate the Sites in which you had activity during this reporting period. Only sites that are eligible for and receiving EB THNP funding should be included.

For the purposes of this grant program, rural is defined as all counties that are not designated as parts of metropolitan areas (MAs) by the Office of Management and Budget (OMB). In addition, we use Rural Urban Commuting Area Codes (RUCAs) to designate rural areas within MAs. This rural definition can be accessed at https://datawarehouse.hrsa.gov/tools/analyzers/geo/Rural.aspx. If the county is not entirely rural or urban, follow the link for “Check Rural Health Grants Eligibility by Address” to determine if a specific site qualifies as rural based on its specific census tract within an otherwise urban county.

Originating (or spoke) sites are the sites where a patient is located and receiving care. Distant (or hub) sites are the sites where the specialist is located and working.

When you are finished entering in data, click "Add" to add it to the table. Then click the "Save" button to move to

the next screen.

Site Name:
Street Address:
City/Town:
County:
State:
Zip Code:
Originating or Distant Site (O/D):
Rural or Urban Site (R/U):
HPSA:
MUA:
HCPN:
Primary Taxonomy:
NPI (Site):
EIN (if non-profit):
Site URL:

Select Specialty Areas

Indicate the Specialties for which you had activity during this reporting period. Only Specialties that are eligible for and receiving EB THNP funding should be included.

If you require a Specialty which is not available on this list, please contact the HRSA Project officer for your grant.

Select Settings

Indicate the Settings for which you had activity during this reporting period. Only Settings that are eligible for and receiving EB THNP funding should be included.

If you require a Settings which is not available on this list, please contact the HRSA Project officer for your grant.

Menu for Form 1 (Settings)

• School Based Health Center

• Community Health Center (including FQHCs)

• Health Care Provider in Private Practice

• Clinic (including RHC)

• Local Health Department

• Hospital (including CAH)

• Long Term Care Provider

• Home Health Service Provider

• Outpatient Mental Health Service Provider/Facility

• Local or Regional Emergency Health Care Provider

• Higher Education Institution

• School Based Health Center

• Oral Health Provider

• Other Publically Funded Health or Social Service Agency

• Other

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 5 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 14N136B, Rockville, Maryland, 20857.