B U2W Flex Program Sample Data Collection

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Overview

Instructions
Quality Improvement
Financial & Operational
Population Health
EMS
CAH Designation

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Sheet 1: Instructions

Public Burden Statement: The purpose of this information collection is to obtain performance data for the following: monitoring, program planning, and performance reporting. In addition, these data will facilitate the ability to demonstrate alignment between HRSA’s Federal Office of Rural Health Policy and The Medicare Rural Hospital Flexibility 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 0915-0363 and it is valid until XX/XX/XXXX. The reporting burden for this collection of information is estimated to average 55 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 14NWH04, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

Instructions-You do not need to include this instruction page in your Grants.gov application package.

The workplan is a separate document from the text-based Project Narrative. It is a succinct overview of the program objectives, goals, activities, and projected outcomes in table format. The work plan is not a narrative. The work plan is organized by the Flex program areas and activity categories listed in the document Medicare Rural Hospital Flexibility Program Structure for FY 2024 - FY 2029. This is a work plan for FY24, or year 1, but it is intended to be a planning document for you to look forward to all 5 years, and document outcomes as such. FORHP does not expect you to have a completed plan for all 5 years. Only include the program areas and activity categories in the work plan that will be part of your state Flex Program. All other areas and activity categories should be removed from this work plan template prior to submission.

Note on color coding in the template: Quality Improvement = blue Financial and Operational = green Population Health = red EMS = orange CAH Designation=yellow

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Sheet 2: Quality Improvement

How many Critical Access Hospitals in your state are participating in any Flex-funded quality improvement initiatives (this can include networking meetings, discussing MBQIP data reports, receiving TA, or participating in a larger project)?	(Enter number here)
Estimate the dollar amount of your annual budget that is spent in quality improvement	(Enter dollar amount here)
Activities Description	Project Type	Expected Outputs	Actual Outputs (complete for progress reporting only)	Staff Responsible	Engagement Impact (complete for progress reporting only)	Short-term Expected Outcomes Effects occurring more immediately, typically within the first year	Intermediate Expected Outcomes Effects that occur in the first 1-2 years	Intermediate Expected Outcomes Effects that occur in the first 1-2 years	Long-term Expected Outcomes Effects that occur after 3 years	Long-term Expected Outcomes Effects that occur after 3 years
Program Area 1: Critical Access Hospital (CAH) Quality Improvement (a minimum of one activity is required)
Program Area Impact Goal:
Quality Improvement Needs Assessment (required)						Expected outcomes from your CAH Quality Assessment and Inventory
	Project Type Dropdown
Quality Improvement Education (information dissemination, meetings)
	Project Type Dropdown
Quality Improvement Education (information dissemination, meetings)
	Project Type Dropdown
Quality Measure Reporting Support						Short-term Outcome Description
	Project Type Dropdown					Goal: Overall Result:
Quality Improvement Project						Short-term Outcome Description	Intermediate Outcome Description	Intermediate Outcome Description	Long-term Outcome Description	Long-term Outcome Description
	Project Type Dropdown					Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:
Facility Tracking (complete for progress reporting only)		Outcome(s)	Baseline	Goal	Result	Notes:	Notes:	Notes:	Notes:	Notes:
Facility 1
Facility 2
Facility 3
Facility 4
Facility 5
Quality Improvement Project						Short-term Outcome Description	Intermediate Outcome Description	Intermediate Outcome Description	Long-term Outcome Description	Long-term Outcome Description
	Project Type Dropdown					Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:
Facility Tracking (complete for progress reporting only)		Outcome(s)	Baseline	Goal	Result	Notes:	Notes:	Notes:	Notes:	Notes:
Facility 1
Facility 2
Facility 3
Facility 4
Facility 5
Quality Improvement Project						Short-term Outcome Description	Intermediate Outcome Description	Intermediate Outcome Description	Long-term Outcome Description	Long-term Outcome Description
	Project Type Dropdown					Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:
Facility Tracking (complete for progress reporting only)		Outcome(s)	Baseline	Goal	Result	Notes:	Notes:	Notes:	Notes:	Notes:
Facility 1
Facility 2
Facility 3
Facility 4
Facility 5

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Sheet 3: Financial & Operational

How many Critical Access Hospitals in your state are participating in any Flex-funded financial or operational improvement initiatives (this can include networking meetings, discussing CAHMPAS data reports, receiving TA, or participating in a larger project)?	(Enter number here)
Estimate the dollar amount of your annual budget that is spent in financial and operational improvement	(Enter dollar amount here)
Activities Description	Project Type	Expected Outputs	Actual Outputs (complete for progress reporting only)	Staff Responsible	Engagement Impact (complete for progress reporting only)	Short-term Expected Outcomes Effects occurring more immediately, typically within the first year	Intermediate Expected Outcomes Effects that occur in the first 1-2 years	Intermediate Expected Outcomes Effects that occur in the first 1-2 years	Long-term Expected Outcomes Effects that occur after 3 years	Long-term Expected Outcomes Effects that occur after 3 years
Program Area 2: CAH Financial and Operational Improvement (a minimum of one activity is required)
Program Area Impact Goal:
Assessment (statewide or individual)
	Project Type Dropdown
Education (information dissemination, meetings)
	Project Type Dropdown
Education (information dissemination, meetings)
	Project Type Dropdown
CAH Financial and Operational Improvement Project						Short-term Outcome Description	Intermediate Outcome Description	Intermediate Outcome Description	Long-term Outcome Description	Long-term Outcome Description
	Project Type Dropdown					Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:
Facility Tracking (complete for progress reporting only)		Outcome(s)	Baseline	Goal	Result	Notes:	Notes:	Notes:	Notes:	Notes:
Facility 1
Facility 2
Facility 3
Facility 4
Facility 5
CAH Financial and Operational Improvement Project						Short-term Outcome Description	Intermediate Outcome Description	Intermediate Outcome Description	Long-term Outcome Description	Long-term Outcome Description
	Project Type Dropdown					Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:
Facility Tracking (complete for progress reporting only)		Outcome(s)	Baseline	Goal	Result	Notes:	Notes:	Notes:	Notes:	Notes:
Facility 1
Facility 2
Facility 3
Facility 4
Facility 5
CAH Financial and Operational Improvement Project						Short-term Outcome Description	Intermediate Outcome Description	Intermediate Outcome Description	Long-term Outcome Description	Long-term Outcome Description
	Project Type Dropdown					Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:
Facility Tracking (complete for progress reporting only)		Outcome(s)	Baseline	Goal	Result	Notes:	Notes:	Notes:	Notes:	Notes:
Facility 1
Facility 2
Facility 3
Facility 4
Facility 5

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Sheet 4: Population Health

How many Critical Access Hospitals in your state are participating in any Flex-funded population health improvement initiatives (this can include networking meetings, receiving TA, or participating in a larger project)?	(Enter number here)
Estimate the dollar amount of your annual budget that is spent in population health improvement	(Enter dollar amount here)
Activities Description	Project Type	Expected Outputs	Actual Outputs (complete for progress reporting only)	Staff Responsible	Engagement Impact (complete for progress reporting only)	Short-term Expected Outcomes Effects occurring more immediately, typically within the first year	Intermediate Expected Outcomes Effects that occur in the first 1-2 years	Intermediate Expected Outcomes Effects that occur in the first 1-2 years	Long-term Expected Outcomes Effects that occur after 3 years	Long-term Expected Outcomes Effects that occur after 3 years
Program Area 3: CAH Population Health (optional)
Program Area Impact Goal:
Needs Assessment (individual or statewide)
	Project Type Dropdown
Education (information dissemination, meetings)
	Project Type Dropdown
Education (information dissemination, meetings)
	Project Type Dropdown
Population Health Project						Short-term Outcome Description	Intermediate Outcome Description	Intermediate Outcome Description	Long-term Outcome Description	Long-term Outcome Description
	Chronic Care Management					Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:
Facility Tracking (complete for progress reporting only)		Outcome(s)	Baseline	Goal	Result	Notes:	Notes:	Notes:	Notes:	Notes:
Facility 1
Facility 2
Facility 3
Facility 4
Facility 5
Population Health Project						Short-term Outcome Description	Intermediate Outcome Description	Intermediate Outcome Description	Long-term Outcome Description	Long-term Outcome Description
	Project Type Dropdown					Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:
Facility Tracking (complete for progress reporting only)		Outcome(s)	Baseline	Goal	Result	Notes:	Notes:	Notes:	Notes:	Notes:
Facility 1
Facility 2
Facility 3
Facility 4
Facility 5

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Sheet 5: EMS

How many Critical Access Hospitals in your state are participating in any Flex-funded EMS improvement initiatives (this can include networking meetings, receiving TA, or participating in a larger project)?	(Enter number here)
Estimate the dollar amount of your annual budget that is spent in EMS improvement	(Enter dollar amount here)
Activities Description	Project Type	Expected Outputs	Actual Outputs (complete for progress reporting only)	Staff Responsible	Engagement Impact (complete for progress reporting only)	Short-term Expected Outcomes Effects occurring more immediately, typically within the first year	Intermediate Expected Outcomes Effects that occur in the first 1-2 years	Intermediate Expected Outcomes Effects that occur in the first 1-2 years	Long-term Expected Outcomes Effects that occur after 3 years	Long-term Expected Outcomes Effects that occur after 3 years
Program Area 4: Rural Emergency Medical Services (EMS) Improvement (optional)
Program Area Impact Goal:
Assessment (statewide or individual) and action planning
	Project Type Dropdown
Education (information dissemination, meetings)
	Project Type Dropdown
Education (information dissemination, meetings)
	Project Type Dropdown
Education (information dissemination, meetings)
	Project Type Dropdown
EMS Project						Short-term Outcome Description	Intermediate Outcome Description	Intermediate Outcome Description	Long-term Outcome Description	Long-term Outcome Description
	Project Type Dropdown					Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:
Facility Tracking (complete for progress reporting only)		Outcome(s)	Baseline	Goal	Result	Notes:	Notes:	Notes:	Notes:	Notes:
Facility 1
Facility 2
Facility 3
Facility 4
Facility 5
EMS Project						Short-term Outcome Description	Intermediate Outcome Description	Intermediate Outcome Description	Long-term Outcome Description	Long-term Outcome Description
	Project Type Dropdown					Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:
Facility Tracking (complete for progress reporting only)		Outcome(s)	Baseline	Goal	Result	Notes:	Notes:	Notes:	Notes:	Notes:
Facility 1
Facility 2
Facility 3
Facility 4
Facility 5
EMS Project						Short-term Outcome Description	Intermediate Outcome Description	Intermediate Outcome Description	Long-term Outcome Description	Long-term Outcome Description
	Project Type Dropdown					Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:	Goal: Overall Result:
Facility Tracking (complete for progress reporting only)		Outcome(s)	Baseline	Goal	Result	Notes:	Notes:	Notes:	Notes:	Notes:
Facility 1
Facility 2
Facility 3
Facility 4
Facility 5

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Sheet 6: CAH Designation

Estimate the dollar amount of your annual budget that is spent in CAH designation	(Enter dollar amount here)
Activities Description	Project Type	Expected Outputs	Actual Outputs (complete for progress reporting only)	Staff Responsible	Engagement Impact (complete for progress reporting only)
Program Area 5: CAH Designation (required if requested)
Program Area Impact Goal: Support rural hospitals who want to seek or maintain appropriate Medicare participation status to meet community needs
CAH Conversions and Transitions
	Project Type Dropdown