1 Rural Maternity and Obstetrics Management Strategies Pro

OMB Number: XXXX-XXXX

Expiration Date: X/XX/XXXX

Federal Office of Rural Health Policy

Community-Based Division

Rural Maternity and Obstetrics Management Strategies (RMOMS) Program

Performance Improvement and Measurement System (PIMS) Measures

Public Burden Statement: The purpose of this program is to support networks that improve access to, and continuity of, maternal and obstetrics care in rural communities.The information gathered will be used in evaluating FORHP’s progress in achieving the above purpose and goals of the program. 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 information collection is XXXX-XXXX and it is valid until XX/XX/XXXX. This information collection is required to obtain or retain benefits (Section 330A(f) of the Public Health Service Act, 42 U.S.C. 254c f), as amended by section 201, P.L. 107-251 of the Health Care Safety Net Amendments of 2002). Public reporting burden for this collection of information is estimated to average 9 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 or paperwork@hrsa.gov. 

PIMS data are submitted to the EHBs. The EHB portal will open on September 1 immediately following the close of each reporting period and the PIMS measures are due on September 30.

Measures Overview

Pages 1-2 provide an overview of all data elements. To see more details of each data element, click on the links below to navigate to specific forms.

Form 1: Consortium/Network

1. Identify the types and number of organizations in the network for your project

2. Total number of NEW member organizations that joined the network during this reporting period

3. How many policies or procedures were created during this reporting period

4. How many policies or procedures were amended during this reporting period

5. How many policies or procedures were implemented during this reporting period

6. As a result of being part of the network, how many network member organizations were able to integrate joint policies, procedures and/or best practices within their respective organizations during this reporting period

7. Are all network sites contributing to direct service encounter data

8. Number of network sites contributing direct service encounter data

Form 2: Sustainability

9. Additional funding secured to assist in sustaining the network

10. How many of the network members have provided the following in-kind services

11. Sources of sustainability

12. Which of the following activities have you engaged in to enhance your sustained impact 

(Note: questions 13-15 only need to be answered in Year 4)

13. What is your Ratio for Economic Impact vs. HRSA Program Funding

14. Will the network sustain after this federal funding period

15. Will any of the network’s activities be sustained after this federal funding period

Form 3: Demographics

16. Number of counties served in project

17. Number of people in the target population

18. Number of unique individuals from your target population who received direct services during this reporting period

19. Number of unique women from your target population who received direct services during this reporting period

20. Number of people served by ethnicity

21. Number of people served by race

22. Number of people served by age group

Form 4: Project-Specific Domain

23. Health insurance status of women served during the reporting period in the continuum of care

24. Number of NICU stays for deliveries that occur within the network, including stays that are transferred outside of the network.

25. Number of live deliveries

26. Number of pregnancy-related deaths

27. Number of women who receive a prenatal visit

28. Number of women who receive a prenatal visit in the first trimester

29. Number of women who receive a postpartum visit

30. Number of women who receive case management contact

31. Number of network sites providing/using RMOMS relevant telehealth services

32. Number of women directly served by telehealth

33. Number of women receiving specialty care services via telehealth

34. Number of providers trained and/or supported through distance learning and/or telementoring

Form 1: 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 network for your project:
		Type of Member Organizations in the Consortium/Network	Year 1 Planning	Year 2 Implementation	Year 3 Implementation	Year 4 Implementation
1.a	Non-Profit Organization	Area Health Education Center
		Behavioral/Mental Health Organization
		Community College
		Community Health Center
		Emergency Medical Services Entity
		Faith-based Organization
		Federally Qualified Health Center (FQHC)
		FQHC Look-alike
		Free Clinic
		Health Department
		Hospital – Critical Access Hospital (CAH)
		Hospital – Small Rural (49 beds or less, non-CAH)
		Hospital – Rural (50 beds or more, non-CAH)
		Hospital – Urban
		Hospital – other
		Migrant Health Center
		Private Practice
		Rural Health Clinic
		School District
		State Medicaid Agency
		Social Services Organization
		University
		Other – Specify type
		TOTAL for non-profit organization	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)
1.b	For-Profit Organization	Hospital – Critical Access Hospital
		Hospital – Small Rural (49 beds or less, non-CAH
		Hospital – Rural (50 beds or more, non-CAH)
		Hospital – Urban
		Hospital – Other
		Private Practice
		Rural Health Clinic
		Other – Specify Type
		TOTAL for-profit organization	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)
2	Total number of NEW member organizations that joined the network during this reporting period. Please attach to this form a document listing current nework partners and noting any new or removed partners in the reporting period.		Number
3	How many policies or procedures were created during this reporting period?		Number
4	How many policies or procedures were amended during this reporting period?		Number
5	How many policies or procedures were implemented during this reporting period?		Number
6	As a result of being part of the network, how many network member organizations were able to integrate joint policies, procedures and/or best practices within their respective organizations during this reporting period?		Number
7	Are all network sites contributing to direct service encounter data? Please indicate whether all funded network partner sites are contributing to the direct service encounter values included for the purposes of this reporting.		Y/N
8	Number of network sites contributing direct service encounter data Please provide the total number of funded network partner sites contributing to the direct service encounter values included for the purposes of this reporting.		Number

Form 2: Sustainability

Table 2: Sustainability

Table Instructions: Please provide information about the contribution by network members and the network’s sustainability efforts.

		Year 1 Planning	Year 2 Implementation	Year 3 Implementation	Year 4 Implementation
9	Additional funding secured to assist in sustaining the network Please provide the amount of additional funding that has already been secured during this current reporting period to sustain the program.	Number
10	How many of the network members have provided the following in-kind services:
	Goods (i.e.: equipment, food)	Number
	Services (i.e.: education, screening)	Number
	Staff Support	Number
	Expertise (i.e.: legal, business, website/marketing development)	Number
	Other (please specify)	Number
11	Sources of Sustainability Select the type(s) of sources of funding for sustainability. Please check all that apply.	Selection list
	None
	Contractual services
	Fees charged to individuals for services
	Foundations
	Fundraising/monetary donations
	Grant – Federal
	Grant – other
	In-kind contributions (defined as donations of anything other than money, including goods or services/time.)
	Membership fees/dues
	Program revenue
	Reimbursement from third-party payers (e.g. private insurance, Medicaid, etc.)
	Other – specify type
12	Which of the following activities have you engaged in to enhance your sustained impact?  Sustained impacts are long term effects that may or may not be dependent on the continuation of a program. Check all that apply.	Selection list
	None
	Community Engagement Activities
	Local, State and Federal Policy Changes
	Media Campaigns
	Other – specify activity
Year 4 Sustainability Measures – To be collected during Year 4 reporting period only
13	What is your Ratio for Economic Impact vs. HRSA Program Funding? Use the HRSA’s Economic Impact Analysis Tool (http://www.raconline.org/econtool/) to identify your ratio.				Ratio
14	Will the network sustain after this federal funding period? Yes, the network and/or activities of the network are expected to operate after the period of performance. No, the network is not expected to continue after the period of performance.				Y/N
15	Will any of the network’s activities be sustained after this federal funding period? If yes, please select how the activities will be sustained.				Selection list
	Absorption of services or other means of in-kind support
	Fees
	Grant funding
	Reimbursement by third party payers
	Other: please describe

Form 3: Demographics

Access to Care

Definitions

Direct Services: A documented interaction between a patient/client and a clinical or non-clinical health professional. Examples of direct services include (but are not limited to) patient visits, counseling and education. This includes both face-to-face in-person encounters as well as non face-to-face encounters.

Note: Year 1 is the baseline year; you are to report on the services offered by network partners that meet the definition of direct services for your target population that were not supported by these award funds.
Years 2-4 are implementation years; only report direct services that are funded with HRSA grant dollars.

Table 3: Service Area
Table Instructions: Please provide information to the following based on available information.

Service Area		Year 1 Planning	Year 2 Implementation	Year 3 Implementation	Year 4 Implementation
16	Number of counties served in project This should be consistent with the figures reported in your grant application and should reflect your network’s service area.	Number
17	Number of people in the target population In the form comment box, please define your target population. This is the number of people targeted to receive services not the number of people who actually did receive direct services.	Number

Table 4: Patient Population
Table Instructions: Please provide information on the following based on your HRSA-funded network activities. Note that question 18 and 19 may be the same if your target population is exclusive to women of childbearing age.

	Numerator		Denominator		Percent of Targeted Patients Served
18	18.a) Number of unique individuals from your target population who received direct services during this reporting period. This is the unduplicated count of patients/clients from your target population that received direct services from your network. Depending on the target population definition, this could include families/children.	Number	18.b) Total number of unique individuals in your target population during this reporting period. This is the unduplicated count of patients/clients from your target population (it should match the number reported in question 17)	Number (auto-populated from question 17)	(Automatically calculated by system)
19	19.a) Number of unique women from your target population who received direct services during this reporting period. If your target population includes families/children, please report only the number of unique (i.e. the unduplicated count) women of childbearing age from your target population that received direct services from your network.	Number	19.b) Total number of unique individuals in your target population during this reporting period. This is the unduplicated count of patients/clients from your target population (it should match the number reported in question 17)	Number (auto-populated from question 17)	(Automatically calculated by system)

Table 5: Population Demographics

Definitions

Hispanic or Latino Ethnicity

• 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.

• 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.

• Unknown: Report on only individuals who did not provide information regarding their race or ethnicity.

Race

All people must be classified in one of the racial categories (including a category for persons who are “Unknown”). 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.

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

• 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

• Native Hawaiian or Other Pacific Islander: Persons having origins in any of the original peoples of Hawaii or 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
  
  

• American Indian/Alaska Native: 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: 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. “More than one race” must not be used as a default for Hispanics/Latinos who do not check a separate race.

Table Instructions: This table collects information about an aggregate count of the people served by race, ethnicity, and age. The total for each of the following questions should equal the total number of unique individuals from your network’s intervention patient population who received direct services during this reporting period reported previously.

In year 1, please report on these measures to the extent possible for the network. If data/information is not available, please enter N/A and/or utilize the form comment box for provision of any additional necessary information needed for interpreting values reported in this section.

In years 2-4, please do not leave any sections blank. There should not be a N/A (not applicable) response since the measures are applicable to all awardees. If the number for a particular category is zero (0), please put zero in the appropriate section (i.e., if the total number that is Hispanic or Latino is zero (0), enter zero in that section).

		Year 1 Planning	Year 2 Implementation	Year 3 Implementation	Year 4 Implementation
20	Number of people served by ethnicity
	Hispanic or Latino	Number
	Not Hispanic or Latino	Number
	Unknown	Number
	Total (equal to the total of the number of unique individuals who received direct services)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)
21	Number of people served by race
	American Indian or Alaska Native	Number
	Asian	Number
	Black or African American	Number
	Native Hawaiian or Other Pacific Islander	Number
	White	Number
	More than one race	Number
	Unknown	Number
	Total (equal to the total of the number of unique individuals who received direct services)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)
22	Number of people served by age group
	Children (0-12)	Number
	Adolescents (13-17)	Number
	Young Adults (18-35)	Number
	Adults (35 and over)	Number
	Unknown	Number
	Total (equal to the total of the number of unique individuals who received direct services)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)

Form 4: Project-Specific Domain

Table 6: Core Data Elements
Definitions

Telehealth Service
A telehealth service is defined as any care or consultation arranged by the RMOMS network that takes place via telehealth. Examples of telehealth services may include telehealth meetings with case managers, support service providers, primary care providers, or specialists.

Telehealth Specialty Care Service
Telehealth specialty care is defined as care or consultation with a clinical specialist that takes place via telehealth. Examples of specialty providers may include maternal-fetal medicine specialists, mental health specialists, non-primary-care specialists (e.g., cardiologists), or, in some cases, OB/GYNs, for non-routine care.

Table Instructions: This table collects information about core measures resulting from services provided by your network to unique individuals who received direct services funded by this grant during this reporting period.

In year 1, please report on these measures to the extent possible for the network. If data/information is not available, please enter N/A and/or utilize the form comment box for provision of any additional necessary information needed for interpreting values reported in this section.

In years 2-4, please do not leave any sections blank. There should not be a N/A (not applicable) response since the measures are applicable to all awardees (with the exception of question 26, which is optional). If the number for a particular category is zero (0), please put zero in the appropriate section.

Note: The number reported in PIMS measure 33 should be the same or less than the number reported in PIMS measure 32.

		Year 1 Planning	Year 2 Implementation	Year 3 Implementation	Year 4 Implementation
23	Health insurance status of women served during the reporting period in the continuum of care Report on the “final” health insurance status for each unique individual woman directly served for the reporting period. Please enter a number for each category below.
	Medicaid/CHIP	Number
	Private Insurance (i.e.: individual coverage, employer sponsored)	Number
	Other (i.e. VA, Tricare, or other military health care, Indian Health Service, etc.)	Number
	Uninsured	Number
	Unknown	Number
	Total (equal to the total of the number of unique individual women who received direct services)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)
24	Number of NICU stays for deliveries that occur within the network, including stays that are transferred outside of the network This is an unduplicated count of all babies delivered by network partners and transferred to a level three or four NICU (regardless of whether the NICU is a network partner).	Number
25	Number of live deliveries This is the total unduplicated count of live deliveries within the network.	Number
26	Number of maternal deaths This is unduplicated count of women served by network partners who die during pregnancy, childbirth, or within one year of giving birth.	Number
27	Number of women who receive a prenatal visit This is an unduplicated count of women who receive at least one prenatal visit by a network provider during the reporting period.	Number
28	Number of women who receive a prenatal visit in the first trimester In the baseline year, this measure is optional. If your network is able to report this number, please do.	Number
29	Number of women who receive a postpartum visit This is an unduplicated count of women who receive at least one postpartum visit by a network provider during the reporting period.	Number
30	Number of women who receive case management contact This is an unduplicated count of women who receive at least one case management contact by a network provider during the reporting period.	Number
31	Number of network sites providing/using RMOMS relevant telehealth services If telehealth services are no longer available at any of the network sites, please detail this in the form comment box.	Number
32	Number of women directly served by telehealth This is an unduplicated count of women who receive a telehealth service facilitated by the network during the reporting period (see definition in header).	Number
33	Number of women receiving specialty care services via telehealth This is an unduplicated count of women who receive a telehealth specialty care service facilitated by the network during the reporting period (see definition in header). Use the form comment box to list the types of clinical specialists that provided specialty care.	Number
34	Number of providers trained and/or supported through distance learning and/or telementoring Providers are inclusive of anyone on the care team. This is an unduplicated count of providers who were trained, educated or supported through telehealth during the reporting period.	Number

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