Form 1 RHND PIMS

O MB Number: 0906-0010

Expiration Date: X/XX/XXXX

Federal Office of Rural Health Policy

Community-Based Division

Rural Health Network Development Program (RHND)

Performance Improvement and Measurement Systems (PIMS) Database

Public Burden Statement:  The purpose of this program is to support integrated rural health care networks that collaborate to achieve efficiencies; expand access to, coordinate, and improve the quality of basic health care services and associated health outcomes; and strengthen the rural health care system as a whole. 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 0906-0010 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. Public reporting burden for this collection of information is estimated to average 48.8 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. 

MEASURES

Instructions: Please review and respond to each question listed below. Provided answers should only reflect information that has resulted from your network’s use of the Rural Health Network Development (RHND) funding. Do not leave any question blank, if a question does not pertain to your program, please follow the question instructions. Unless otherwise noted, please answer each of the below questions using data collected from the most recent grant funding year.

Section 1: Network Collaboration

1. Table Instructions: Please identify the types and number of network participants who are participating in the RHND Grant. Network participants 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. Network participants do not include other organizations who are playing a role in the grant but have not signed a Memorandum of Understanding or Memorandum of Agreement or do not have a letter of commitment. If the organization type is not applicable, please insert 0. DO NOT leave any space blank under the current budget year for your grant. If you mark “Other”, please specify the type of member organization in the comment section below.

Type of Participant Organizations	Year I	Year II	Year III	Year IV
Area Health Education Center
Accountable Care Organization
Behavioral/Mental Health Organization
Community College
Community Health Center
Critical Access Hospital
Emergency Medical Service
Federally Qualified Health Center
Faith Based Organizations
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
Public or Private Payers
Rural Emergency Hospital
Rural Health Clinic
School District
Social Services Organization
Tribal Organization
University
Other
Total	Automatically calculated by system

2. Table Instructions: Assess the overall benefits realized by network members as a result of being in the network during the current budget year. Select ‘Yes’ for all that apply and ‘No’ for those that do not apply. Do not leave any space blank. Definitions of each type of network benefit can be found in the RHND Program Reference Guide. Please provide any specific network benefit examples you wish to share in the comment section below.

Note: Only assess the below benefits for the network funded by the RHND grant.

Type of Network Benefit	Yes	No
Financial Cost Savings
Efficiencies
Quality Improvement
Access to Educational Opportunities
Improved Care Transitions
Access to Equipment
Branding/Marketing
Development of workforce that is change ready and adaptable
Knowledge Sharing
Understanding of community health needs
Opportunities for Innovation
Policy Development
Other Capacity Building: Please specify
Other: Please specify

3. Table Instructions: Indicate the funding strategy that your network currently utilizes and the percent of total network budget. If you select “Other”, please specify the funding type and percent of your network budget. You may select as many funding strategies as apply. Do not leave any space blank, if the network does not utilize a type of funding, mark 0. The sum of all strategies should not exceed 100%

Type of Funding	Year I	Year II	Year III	Year IV
Indirect Funding/In-kind Contributions	%
Reimbursement from Third Party Payers
Fees for Services, Value-Based Care, Events, Consulting; Products Sales
Membership Fees
Donations
Grants
Government Budgets
Other (Specify)

4. ONLY YEAR 4: What percent of the future cost of network operations do you project will be covered by grant funds after the RHND grant is complete (June 30, 2027)?

All (100%)

Most (50-99%)

Some (Less than 50%)

None (0%)

5. ONLY YEAR 4: Please indicate the percent of programs created or enhanced through this grant funding that will continue to sustain after the funding ends.

More (Expanded)

All (100%)

Most (50-99%)

Some (Less than 50%)

None (0%)

6. ONLY YEAR 4: Will the formal network continue after this grant funding? Y/N

1. Please explain the factors that will contribute to your formal network sustaining or ending after this grant.

7. Table Instructions: Please review the following components of network sustainability and indicate where your network falls on the scale. Definitions for the sustainability components can be found in the RHND Program Reference Guide. If you mark “other”, please specify in the comment section below, otherwise, please leave blank.

Sustainability Component	Never	Sometimes	Often	Always	Don’t Know
Strategic Vision
Collaboration
Leadership
Relevance and Practicality
Evaluation and ROI
Communication
Efficiency and Effectiveness
Capacity
Other: Please specify

Section 2: Demographics and Services

8. 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 of the number of unique individuals who received direct services. This number represents the total number of people served by all of the activities outlined in your work plan and includes all direct clinical (if applicable) and non-clinical people served by the program. Direct services are defined as a documented interaction between a patient/client and a clinical or non-clinical health professional that has been funded with this grant. Examples of direct services include but are not limited to patient visits, counseling, and education. 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 (e.g., if the total number that is Hispanic or Latino is zero (0), enter zero in that section). Response totals reported for each measure in this section must equal the total number of individuals who received direct services (Question 12). Please refer to the specific definitions for each field below for additional measure guidance and instructions.

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 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 three 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: Persons having origins in any of the original peoples of Hawaii

• 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

• 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.

		Year I	Year II	Year III	Year IV
	Number of individuals served by ETHNICITY:
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown
	Total (equal to the total of the number of unique individuals served)	(Automatically calculated by system)
	Number of individuals served by RACE:
	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Other Pacific Islander
	White
	More than one race
	Unknown
	Total (equal to the total of the number of unique individuals served)	(Automatically calculated by system)
	Number of individuals served, by AGE GROUP:
	Children (0-12)
	Adolescents (13-17)
	Adults (18-64)
	Elderly (65 and over)
	Unknown
	Total (equal to the total of the number of unique individuals served)	(Automatically calculated by system)

9-14) Table Instructions: Please fill out the following information about an aggregate number of people served through your project funded by the RHND Program during this budget period. Please provide numerical answers. If the total number is zero (0) please put zero in the appropriate section. Do not leave any sections blank or provide N/A (not applicable). All awardees must answer every question.

		Year I	Year II	Year III	Year IV
9	Number of people in the target population during this budget period.
10	Number of unique individuals (i.e. unduplicated count) who received direct services that were funded with this grant.
11	Number of unique individuals served by all activities, including direct and indirect services that were funded with this grant.
12	Total number of counties where the target population resides. Example: Your network has anticipated carrying out activities in 4 counties in this budget period.
13	Total number of counties served in the project during this budget period. Example: Your network has carried out activities in 3 counties this budget period.
14	Identify the counties served in the project during this budget period.

15) Table Instructions: Please indicate the types and number of new, continued, and/or expanded service areas provided by the network as a result of the RHND grant funding. Please mark all that apply.

Type(s) of new, continued, and/or expanded service area(s) provided by the network as a result of the RHND grant funding	Year I	Year II	Year III	Year IV
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
Health Equity/Social Determinants of Health
Specialty Care
Substance Use Disorder 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:
Promoting Interoperability
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

15. What is your ratio for Economic Impact vs HRSA program funding?

Note: Please use the HRSA’s Economic Impact Analysis Tool to identify your ratio https://www.ruralhealthinfo.org/econtool . Responses should reflect the ratio for the annual economic impact for your grant’s budget year funded for your project’s annual and cumulative reporting period.

	Year 1	Year 2	Year 3	Year 4
What is your ratio for Economic Impact vs. HRSA Program Funding? Yearly	Ratio	Ratio	Ratio	Ratio
What is your ratio for Economic Impact vs. HRSA Program Funding? Cumulative	n/a	n/a	n/a	Ratio

Section 3: Health Information Technology and Telehealth

15. Table Instructions: Please indicate if you used RHND grant funds to implement/install, use, or expand use of Health Information Technology.

	Yes	No
Implemented
Use
Expansion

15. Table Instructions: This section collects information about Health Information Technology (HIT) activities as part of the RHND Program. If your program has used grant funds to implement/install, use, or expand use of Health Information Technology, please indicate below the types of HIT utilized or not utilized. If your program did not use any type of HIT, please mark “no” for the corresponding activity.

Types of HIT Implemented, use, or expanded through this program (please check all that apply)	Yes	No
Computerized Order entry
Electronic medical records/electronic health records
Health information exchange
Patient/disease registry
Clinical Decision Tools
Care Management Tools
Summary of Care Records
Other
None

15. Does your network exchange clinical information electronically with other key providers/health care settings such as hospitals, emergency rooms, or subspecialty clinicians?

15. Does your network use health IT to coordinate or to provide enabling services such as outreach, language translation, transportation, case management, or other similar services?

15. Table Instructions: Telehealth: This table collects information about telehealth activities as part of the Rural Health Network Development Program.

For purposes of these reporting measures, Telehealth is defined as: “the use of electronic information and telecommunication technologies to support remote clinical services and remote non-clinical services.” Please see the PIMS Reference guide for further guidance.

a	Did your organization use telehealth to provide remote clinical/non-clinical care services? (Yes/No)	Year I	Year II	Year III	Year IV
	If yes, then answer the following two questions:
	Who did you use telemedicine to communicate with? (Select all that apply) Patients at remote locations from your organization (e.g., home telehealth, satellite locations) Specialists outside your organization (e.g., specialists at referral centers)
	What telehealth technologies did you use? (Select all that apply) a. Real-time telehealth (e.g., live videoconferencing) b. Store-and-forward telehealth (e.g., secure email with photos or videos of patient examinations) c. Remote patient monitoring d. Mobile Health (mHealth)
	If no, then answer the following question:
	If you did not have telehealth services, please comment why (select all that apply) Have not considered/unfamiliar with telehealth service options Policy barriers (Select all that apply) Lack of or limited reimbursement Credentialing, licensing, or privileging Privacy and security Other (specify): Inadequate broadband/ telecommunication service (Select all that apply) Cost of service Lack of infrastructure Other (specify): Lack of funding for telehealth equipment Lack of training for telehealth services Not needed Other – specify:
b	Number of consortium/network sites providing/using relevant telehealth services. Note: if telehealth services are no longer available at any of the network sites, please detail this in the form comment box.	(Number)	(Number)	(Number)	(Number)
c	Number of unique individuals who received direct services by telehealth. Note: this is a unique count of patients who receive a telehealth consult facilitated by the organization and/or network/consortium during the budget period.
d	Number of providers trained and/or supported through telehealth. Note: This is an unduplicated count of providers who were trained, educated, or supported through telehealth/telemedicine during the budget period. For example, Project ECHO.

Section 4: Direct Clinical Services (if applicable)

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

	Year I	Year II	Year III	Year IV
Number of unique individuals who received direct clinical services during this budget period.

15. Table Instructions: Please use your electronic patient registry and/or electronic health records system to extract the clinical data requested for patients served through the RHND program as applicable.

Please refer to the specific definitions for each field below and consult each measure’s web link provided for additional measure guidance and instructions. Please indicate if this measure is applicable to your program or not. If it is applicable, provide the requested information. If it is not applicable to your program, please mark the first column “No”. All responses reported should be reflective of grant project target intervention patient population values only. The denominator should not be larger than the total of the number of unique individuals served in Question 20.

Note: Please complete responses, as data/information is available to do so. If data/information is not available, please utilize the form comment box for provision of any additional necessary information needed for interpreting values reported in this section.

		Is this measure applicable to your program? (Yes/No)	Numerator	Denominator	Percent
1	NQF 1789: Hospital-Wide All Cause Readmission
2	CMS138v11: Tobacco Use: Screening & Cessation Intervention
3	CMS2v12: Screening for Depression
4	NQF 0059/CMS122v11: Comprehensive Diabetes Care
5	NQF 0024/CMS155v11: Weight Assessment
6	NQF 0421/CMS69v11:Body Mass Index (BMI) Screening and Follow-Up
7	CMS50v10: Closing the referral loop: receipt of specialist report
8	NQF 0097: Medication Reconciliation Post-Discharge
9	NQF 0018/CMS165v11: Controlling High Blood Pressure
10	CMS137v11:Initiation and Engagement of substance Use Disorder Treatment
11	NQF0102:Chronic Obstructive Pulmonary Disease (COPD)
12	NQF0419e/CMS68v12:Medication Documentation
13	CMS347v6: Cardiovascular Disease

15. Please provide any additional NQF measures that your program is collecting. Indicate which measures you are collecting and provide the clinical data collected for each measure.