1_Redline (06.25) FORHP 0915-0292 Black Lung Clinics Program Measures (pro

0MB Number: 0906-0010
Expiration Date: 3/31/2027

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 netoorks
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 0MB control number. The
0MB control number for this information collection is 0906-0010 and it is valid until 3/31/2027. 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, induding 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 14N39, Rockville, Maryland,
20857 or paperwork@hrsa.gov. Please see https ://www.hrsa.gov/about/508-resources for the HRSA
digital accessibility statement.

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
Or2anizations
Area Health
Education Center
Accountable Care
Organization
Behavioral/Mental
Health Organization
Community College

Year I

Year II

Year III

Year IV

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Community Health
Center
Critical Access
Hosoital
Emergency Medical
Service
Federally Qualified
Health Center
Faith Based
Organizations
Free Clinic
Health Department
Home Health Care
Agency
Hosoice
Hosoital
Long Term Care
Facility
Migrant Health
Center
Private Practice
Primarv 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
Financial Cost Savings
Efficiencies

Yes

No

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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%
Year I

Type of Fundine:

Indirect Funding/Inkind Contributions
Reimbursement from
Third Party Payers
Fees for Services,
Value-Based Care,
Events, Consulting;
Products Sales
Membership Fees
Donations
Grants
Government Budgets
Other (Specify)

Year II

Year III

Year IV

%

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%)

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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? YIN
a. 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

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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 nonHispanic/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.

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Expiration Date: 3/31/2027

Year I
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:

Americanlndian 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)
Number of individuals served, by
AGE GROUP:

Children (0-12)
Adolescents (13-17)
Adults (18-64)
Elderly (65 and over)
Unknown

(Automatically
calculated by
system)

Year II

Year III

Year IV

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Expiration Date: 3/31/2027

Total (equal to the total of the
number of unique individuals
served)

9-14)

(Automatically
calculated by
system)

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 NIA (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 uni -=._- individuals served by all
activities, inclu_.. ,. .g 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 bud~et 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 budzet 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
Year I
area(s) provided by the network as a result of the RHND
grant funding
Health and Wellness:

Cardiovascular Disease
Chronic Obstructive Pulmonary Disease
Diabetes / Obesity Management

Year II

Year
III

Year IV

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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:

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Promoting Interoperability
Electronic Medical Records/Electronic Health Records
Health Information Exchange
Telehealth/Telemedicine
Patient/Disease Registry
Other, please specify.

openended
response

None- Explain

openended
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
r ortin eriod.
Year 1
Year4
Ratio
What is your ratio
for Economic
Impact vs. HRSA
Program Funding?
Yearly
What is your ratio
for Economic
Impact vs. HRSA
Program Funding?
Cumulative

Ratio

Section 3: Health Information Technology and Telehealth

16) Table Instructions: Please indicate if you used RHND grant funds to implement/install, use, or
expand use of Health Information Technology.
Yes
Implemented
Use
Expansion

No

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17) 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
aooly)
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

Yes

No

18) Does your network exchange clinical information electronically with other key providers/health
care settings such as hospitals, emergency rooms, or subspecialty clinicians?
19) 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?
20) 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)
If yes, then answer the following two questions:
1.

Who did you use telemedicine to communicate
with? (Select all that apply)

~earl

~ear II

Yearm

Year IV

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a. Patients at remote locations from your
organization (e.g., home telehealth, satellite
locations)
b. 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:
ii.

If you did not have telehealth services, please comment
why (select all that apply)
a. Have not considered/unfamiliar with telehealth
service options
b. Policy barriers (Select all that apply)
1) Lack of or limited reimbursement
Credentialing, licensing, or privileging
2) Privacy and security
3) Other (specify):
C. Inadequate broadband/ telecommunication service
(Select all that apply)
1) Cost of service
2) Lack of infrastructure
3) Other (specify):
d. Lack of funding for telehealth equipment
e. Lack of training for telehealth services
f. Not needed
g. Other - specify:

b

C

Number of consortium/network sites providing/using (Number)
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.
~umber of unique individuals who received direct
services by telehealth.
!Note: this is a unique count of patients who receive a
~elehealth consult facilitated by the organization and/or
inetwork/consortium during the budget period.

d ~umber of providers trained and/or supported
~hrough telehealth.

(Number)

(Number)

(Number)

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Note: This is an unduplicated count of providers who
twere trained, educated, or supported through
~elehealth/telemedicine during the budget period. For
example, Project ECHO.

Section 4: Direct Clinical Services (if applicable)
21) Number of unique individuals who received direct clinical services during this budget period
Year IV
Year I
Year II
Year III
Number of
uruque
individuals
who received
direct clinical
services during
this budget
period.
22) 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)

1

NQF 1789: Hospital-Wide All Cause Readmission
CMS138vll : Tobacco Use: Screening & Cessation
Intervention

2
3

CMS2v12: Screening for Depression

Numerator

Denominator

Percent

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NQF 0059/CMS122vll : Comprehensive Diabetes Care
4
NQF 0024/CMSlSSvll: Weight Assessment
5
NQF 0421/CMS69vll :Body Mass Index (BMI)
Screening and Follow-Up
6
CMS50v10: Closing the referral loop: receipt of
specialist report
7
NQF 0097: Medication Reconciliation Post-Discharge
8

9

NQF 0018/CMS 165v 11 : Controlling High Blood
Pressure

10

CMS 13 7v 11 :Initiation and Engagement of substance
Use Disorder Treatment

11

NQF0102:Chronic Obstructive Pulmonary Disease
(COPD)
NQF0419e/CMS68v 12:Medication Documentation

12
CMS347v6: Cardiovascular Disease
13

23) 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.