Form BLCP 2008 2009 BLCP 2008 2009 BLCP 2008 2009

OMB No. 0915-0292

Expiration Date:

Black Lung Clinic Program Report

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 0915-0292. Public reporting burden for this collection of information is estimated to average 20 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 the burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33 Rockville, Maryland, 20857.

Program Background

The BLCP was authorized by the Federal Mine Safety and Health Act of 1977, as amended by the Black Lung Benefits Reform Act of 1977 (Pub. L. 95-239), in order to provide treatment and rehabilitation for individuals who currently or formerly worked within a coal or other mining industry and, as a result, were exposed to coal dust. It provides the authority for competitive grants to States, private, or public entities to provide the services listed below in Section A (Program Expectations and Requirements) to the population described above. Program expectations include: (1) outreach, (2) primary care (including screening, diagnosis and treatment), (3) patient and family education and counseling (including anti-smoking education), (4) patient care and coordination (including individual patient care plans for all patients and referrals as indicated), and (5) pulmonary rehabilitation. Services may be provided either directly or through formal arrangements with appropriate health care providers. The implementing regulations for the BLCP may be found at 42 CFR Part 55a.

The BLCP database is maintained on the HRSA Electronic Handbook (EHB) website. For assistance with any technical questions, please call the EHB Helpdesk.

The database was developed so the same program can be used each year, with the ability to create an annual summary report of the Calendar Year for the ORHP.

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http://www.grants.gov/CustomerSupport

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Database Tables and Instructions

Complete the following tables for the 2008 and 2009 calendar year reporting period.

Table 1: Age Groups

Age	Number of Total users	Number of Coal Miners
Under 40
40-59
60-75
Over 75

This table tracks the program users by age group. Report the number of total users and number of coal miners by the age categories provided in the table.

Table 2: Gender

Gender	Number of Total Users	Number of Coal Miners
Male
Female

This table captures the gender of the project users. Report the number of total users and number of coal miners by gender.

Table 3: Ethnicity

Ethnicity	Number of Total Users	Number of Coal Miners
Hispanic/Latino

Ethnicity of users is reported in Table 3. Report the number of total users that are Hispanic/Latino and the total number of miners that are Hispanic/Latino.

Table 4: Race

Race	Number of Total Users	Number of Coal Miners
African American or Black
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaska Native
White
More than one race
Unknown

Information on Race of users is reported in Table 4. Use the categories provided to report race for total users and total miners.

Table 5: Medical User Diagnostic Mix

Primary Pulmonary Diagnosis	Number of Medical Users in Current Year
Black Lung (Includes patients with obstructive and restrictive impairments caused by coal mine dust exposure)
Mining Related Lung Disease (related to mining other than coal)
Other Occupational Lung Disease (disease not related to mining, i.e. asbestosis, occupational asthma, hypersensitivity pneumonitis, etc)
Non-Occupational Lung Disease (disease such as COPD from tobacco, non-occupational asthma, TB, etc)
At Risk

Table Instructions: Medical User Diagnostic Mix

This table counts the number of users based on their primary pulmonary diagnosis. Each user is counted only once. Please refer to the detailed definitions for medical user.

The Black Lung category includes anyone with obstructive and restrictive impairments, with a history of coal mine dust exposure. This category also includes any railroaders or power plant workers that present with black lung as a result of their exposure to coal dust.

The category for Mining Related Lung Disease includes miners in industries other than coal.

Other Occupational Lung Disease includes those individuals whose occupational lung disease is not related to coal or other mining industries.

At risk includes individuals who do not have a diagnosed pulmonary disease, but are at risk of developing one due to occupational exposure, including mining.

Table 6: Medical User Occupation Mix

Occupation	Number of Medical Users
Active Miner
Former/Retired Miner
Other Occupationally Related
Other

Table Instructions: Medical User Occupation Mix

Each user is counted only once. Please refer to the detailed definitions of a medical user.

Active Miner includes anyone who is currently employed or working in the coal mining industry.

Former/Retired Miner includes anyone who has worked in the coal mining industry at any point in his/her life.

Other Occupationally Related includes anyone whose none-coal mine employment contributed to their pulmonary disease or who is at risk for pulmonary disease due to occupational exposure that is not related to coal mine dust.

Other includes those individuals who do not have occupation related lung disease and are not at risk for occupational lung disease.

Table 7: Level of Disability

	Level I	Level II	Level III	Level IV	Level V
Black Lung
Occupational Lung Disease
Non Occupational Lung Disease
At Risk

Table Instructions: Level of Disability

This table tracks the disability level by disability type for program users. This tests the forced expiratory volume (FEV) for pulmonary function. This table does not have to include all medical users at the clinic, just those that have been leveled.

The following definitions should aid in populating the correct information in this table:

Disability Level I – FEV1 80% or greater

Disability Level II – FEV1 60-80% or greater

Disability Level III – FEV1 less than 60% but usually greater than 40%

Disability Level IV – FEV1 40% or less of predicted

Disability Level V – Homebound

At Risk –Does not meet any level requirements, but is at risk for developing Black Lung disease

Table 8: Encounters

Encounter type	Number of Encounters Total	Number of Encounters to Miners	Number of Encounters to Users with Black Lung
Medical Encounter
Non-Medical Encounter
Benefits Counseling

Table Instructions: Encounters

Please refer to the detailed definitions for the medical encounter.

For this table you will count the total number of encounters and the number of encounters to coal miners. The total count will include the coal miner encounters.

Medical Encounters to Users with Black Lung disease is a performance measure. This tracks all medical encounters provided to patients with a diagnosis of black lung. The program does not need to collect disease specific information about non-medical encounters and benefits counseling encounters, but Black Lung Medical Encounters was selected as an OMB PART performance measure and is best fit to be included in this table.

Benefits Counseling encounters can take place face-to-face or over the phone. A benefits encounter is one in which a benefits counselor provides the client with appropriate information regarding legal, social, and medical assistance programs. A benefits counselor assists in filling out application documents, explaining the process, and advising patients where they can obtain legal representation specifically for Federal Black Lung Claims.

Table 9: Project Revenues

Project Revenues
For Period Beginning:			And Ending:
Federal Black Lung Grant		3rd Party-Medicare		3rd Party-UMW Benefits
State Funding		3rd Party-Medicaid		3rd Party-Other Insurance
3rd Party-Dept of Labor				Patient Revenues
		Total Revenue:

Table Instructions: Project Revenues

Input the amount of funding associated with the Black Lung Clinics Program Activities. This includes the federal grant award amount and all other Federal, State, patient and third party sources.

Table 10: Pulmonary Rehabilitation

Total Miners Completed Pulmonary Rehabilitation:
Total Miners that Show Improvement:
Total Miners Referred to Pulmonary Rehabilitation:

Total Users Completed Pulmonary Rehabilitation:
Total Users that Show Improvement:
Total Users Referred to Pulmonary Rehabilitation:

Table Instructions: Pulmonary Function

This table calculates data for the long term performance measure that will calculate the percentage of coal miners that show improvement after completion of a pulmonary rehabilitation program. The table includes the total number of users that complete pulmonary rehabilitation programs as well as the number of users that receive a referral.

Functional improvement will be measured using the 6 minute walk pre/post test, applying uniform standards of measurement established by the American Thoracic Society (ATS).

For the purposes of this measure the patient will take the test prior to starting the pulmonary rehabilitation program and again after the completion of the program. An improvement in the post-test indicates an improved functional capacity in the patient, an indication of improved quality of life.

Data on this measure can be collected through directly provided rehabilitation or through partner organizations.

The table counts the total number of active and former coal miners that completed pulmonary rehabilitation. These are coal miners that attended all the required sessions of the pulmonary rehabilitation program.

The total miners that show improvement are the ones whose 6 minute walk post test indicates improvement over their pre test results.

The total number referred counts all patients who were referred for pulmonary rehabilitation whether or not they actually attended or completed the program.

The table also includes total user counts for pulmonary rehabilitation. This table will include the coal miners and all other users referred for pulmonary rehabilitation.

Table 11a:

Outreach/education activities

Outreach/Education Activities	Report Total Number
Telephone encounters
Patient Follow-up (mailings/phone calls)
Immunizations

Table 11b:

Outreach/education activities: presentations

Outreach Presentations	Number of Presentations	Number of Participants
Presentations: community meetings, health fairs, educations classes, etc.

Report the number of sessions and the number of encounters of outreach and education activities in Table 11a and 11b. In Table 11b, report the total number of outreach presentations and the total number of participants overall.

Table 12: Procedures/Services

Procedure/Service	Number Provided
CLINICAL EXAMS:
Initial Health Assessment (history & physical)
DOL Exams
Follow-up exam
PULMONARY FUNCTION/RX:
Simple Spirometry Test
Spirometry Pre & Post Bronchodilator
Diffusion Capacity
Lung Volume
Arterial blood gas (resting)
Arterial blood gas (exercise)
Bronchoprovocation Challenge
Pulse Oximetry (Resting)
6 minute walk test
Full exercise physiology with metabolics
IMAGING:
Chest x-ray
B-reading
REHAB:
Phase II Pulmonary Rehabilitation – Outpatient Pulmonary Rehab (patient sessions)
Phase III Pulmonary Rehabilitation –Maintenance (patient sessions)
AUDIOMETRY/HEARING:
Audiometry
HEALTH MAINTENANCE:
Influenza Vaccine
Pneumovax Vaccine

Table Instructions: Procedure/Service

This table provides information about the scope of services provided by each grantee. The activities are key components to the program expectations for the BLCP program. Please input the number of procedures or services provided next to each line.

Table 13: Benefits Counseling Activities

Federal DOL Claim Applications filed
Interrogatories
Depositions
Modifications
Hearings
Federal DOL Interim Awards
Federal DOL ALJ Awards
Federal DOL Denials
Federal DOL Appeals
Federal DOL Claims Withdrawn

Table Instructions: Benefits Counseling Activities

Please complete the table for all the benefits counseling activities that your clinic is involved. If your clinic is not involved in a particular activity, complete the table with a zero.

Federal DOL Claim Applications Filed: The number of applications, including all required forms, filled out and submitted to the Federal Department of Labor.

Interrogatories: The number of completed questionnaires from the responsible coal operator.

Depositions: The number of depositions attended by physician or lay advocate.

Modifications: The number of modifications requested.

Hearings: The number of hearings attended by lay advocates.

Federal DOL Interim Awards: The number of awards at the district director level.

Federal DOL ALJ Awards: The number of awards at the Administrative Law Judge level.

Federal DOL Denials: The number of Administrative Law Judge denials.

Federal DOL Appeals: The number of appeals to the Benefits Review Board.

Federal DOL Claims Withdrawn: The number of Federal Department of Labor claims withdrawn.

Detailed Definitions for Medical User and Encounters

Definition of a Medical User: Users are individuals who have at least one encounter during the year, as defined below. All individuals who make at lease one encounter during the year are within the scope of activities supported by the Black Lung Clinics grant. For each Grant Report, users include individuals who make at least one encounter during the year within the scope of project activities supported by the specific BLCP grant. Medical Users never include individuals who only have encounters such as outreach, community education services, and other types of community-based services not documented on an individual basis. Also, persons who only receive services from large scale efforts such as a mass immunization program, screening programs, and health fairs are not users.

Definitions of Medical Encounter: Encounters are defined to include a documented, face-to-face contact between a user and a provider who exercises independent judgment in the provision of services to the individual. To be included as an encounter, services rendered must be documented. To meet the criterion for “documentation,” the service (and associated patient information) must be recorded in written form. The patient record does not have to be a full and complete health record in order to meet this criterion if a patient receives only minimal services and is not likely to return to the health center. For example, if an individual receives services on an emergency basis and these services are documented, the encounter criteria are met even though a complete health record is not created.

Mass screenings at health fairs or mass immunizations do not result in encounters.

An encounter may take place in the health center or at any other location in which project-supported activities are carried out. Examples of other locations include mobile vans, hospitals, patient’ homes, schools, and extended care facilities. A provider may not generate more than one inpatient encounter per patient per day.

A patient may only have one medical encounter per day. However, a patient could have a medical encounter, a non-medical encounter, a benefits counseling encounter and an outreach encounter in the same day.

The encounter criteria are not met in the following circumstances: (1) When a provider participates in a community meeting or group session that is not designed to provide health services. Examples of such activities include information sessions for prospective users, health presentations to community groups and information presentations about available health services at the center. (2) When the only health services provided is part of a large-scale effort, such as a mass immunization program, screening program, or community-wide service program (e.g., health fair). (3) When a provider is primarily conducting outreach and/or group education sessions, not providing direct services.

Encounter Definitions Specific to BLCP Activities

Non Medical Encounters:

Casefinding

Non medical Outreach (including health fairs, blood pressure checks)

Immunization Campaigns

Education:

General health education

Smoking cessation information when it doesn’t involve an individualized treatment plan,

Anatomy and physiology as they pertain to pneumoconiosis and other disease processes

Any activities that you provide that are not listed under medical encounters should be counted as non medical encounters

Medical Encounters:

Screenings:

Medical Outreach (for example PFTs)

Medical History

Occupational History

Physical Exam

Pulmonary function test

Spirometry

Lung volume

Diffusion capacity

Flow-Volume loop

Nebulizer treatment

Audiometry/Hearing test

EKG/Holter Monitor

Other general preventive screenings for hypertension, diabetes, prostate, colon, etc.

Diagnostic Tests:

Advanced Pulm testing

Resting and exercise arterial blood gases

Metabolic cart

Computerized tomography

Bronchoscopy

Ventilation/Perfusion Lung Scanning

Pulmonary Angiography

Thoracentesis

Pleural biopsy

Chest Radiography

Treatment:

Development of treatment plan

Chest physiotherapy (chest percussion, postural drainage)

Pulmonary Rehabilitation

Strength and weight training

Pulmonary stress test

Pulse oximetry

Training on:

Medication (aerosolized medication)

Efficient breathing techniques including pursed lip breathing

Energy conservation, weight control and physical conditioning

Bronchial hygiene (chest percussion, postural breathing, etc)

Exercise Therapy

Relaxation Techniques

Smoking Cessation (if involves individualized treatment and plan)

Use and maintenance of home breathing equipment including home oxygen therapy and home nebulizers

Warning symptoms of disease exacerbations and where and when to report for medical intervention

How to reduce and avoid environmental irritants

.

Medical User:

A user is counted as any individual who has received at least one medical encounter during the course of the calendar year.

Provider Type:

Physician

Nurse

PA

NP

Patient care coordinator (usually professional nurse)

Respiratory therapist

X-ray technician

Lab Tech

11 of 11 BLCP Database Manual 8/31/2007