100-3 Hrsa 100-3_fy13

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Overview

Cover Page
HRSA 100-3-A DIFF POP TYPES TRN
HRSA 100-3-B DIFF POPS TRN CONT
HRSA 100-3-C CHANGES IN CURRIC
HRSA 100-3-D CHNG IN TRNG QUAL
HRSA 100-3-E CHNG IN NO. OF RES
HRSA 100-3-F PRAC LOC GRAD RES
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...

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Sheet 1: Cover Page

Department of Health and Human Services						OMB No. 0915-0313
Health Resources and Services Administration						Expiration Date: 11/30/2013
	CHILDREN’S HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM ANNUAL REPORT FORM HRSA 100-3
	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 0915-0313. Public reporting burden for the applicant for this collection of informtain is estimated to average 39.4 hours per response, including the time for reviewing instrucitons, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggetions for redcing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14-33, Rockville, Maryland, 20857.

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Sheet 2: HRSA 100-3-A DIFF POP TYPES TRN

Department of Health and Human Services		OMB No. 0915-0313
Health Resources and Services Administration		Expiration Date: 11/30/2013
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-3-A: Training in the Health Care Needs of Different Populations
Residency Program Name:
Medicare Provider Number:
Date of Report:	12/31/12
Types of Training
For each of the following types of training, use the drop down boxes to indicate whether the training is required, elective, or not currently used in your program and, if currently used, whether the training applies to those who are underserved due to financial, sociocultural, geographic or medical reasons or combinations of these reasons. If not currently used, select none of the above or N/A for underserved population. Please complete both columns. There should be no columns left blank. See detailed guidance for complete instructions.
Type of Training	Required/Elective/Not Currently Used	Underserved Population
Didactic Approaches
Formal courses
Lectures
Workshops
Standardized patients
Case-based experiential learning (e.g., morning report, noon case presentation, morbidity & mortality)
Grand Rounds
Medical simulations
Clinical Experiences
Bedside Training
Patient Rounds
Identify/mobilize medical home
Coordination of health care and community resources
Coordination of mental health care services
Interdisciplinary patient care conferences
Assist families with transition of children into child care and educational settings
Pediatric Palliative Care/ Pediatric Hospice
Transition to adult care
Community-based Experiences
Community health center
Public health department
Drug rehabilitation program
Homeless shelter
Day care settings, including Head Start
Home visits to patients
Mobile health van
School health
Juvenile detention facilities
Migrant Health Center
Indian Health Center Sites
National Health Service Corps sites
Area Health Education Center (AHEC) sites
Rural health centers
Cultural immersion experiences
Other, specify
Research
Other Training
Advocacy Training
Language Training
Cultural Efficacy Training

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Sheet 3: HRSA 100-3-B DIFF POPS TRN CONT

Department of Health and Human Services			OMB No. 0915-0313
Health Resources and Services Administration			Expiration Date: 11/30/2013
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-3-B: Training Related to Underserved Populations: Training Content and Types of Training
Residency Program Name:	#N/A
Medicare Provider Number:	00-0000
Date of Report:	12/31/12
For each of the following topic areas, please use the check boxes to indicate the types of training used to address the topic in the training program in the most recent academic year (2011-2012). Check all that apply. For example, if your program offers a lecture on homelessness as well as a community rotation in a homeless shelter, check both didactic and clinical experiences. There must be at least one check in each row. See detailed guidance for complete instructions.
	Didactic	Clinical Experiences/ Patient Care	Research	Not Currently in the Curriculum
Underserved for Financial Reasons
Poverty, including causes, consequences, & implications for child health
Uninsured and Underinsured
Medicaid and SCHIP and related programs such as EPSDT
Public sources of care (e.g., community health centers, public health departments)
Other social services, such as WIC
Homelessness
Migrant worker families and children
Community-based medicine
Advocacy Training
Substance Abuse
Domestic violence/child abuse
Underserved for Socio-cultural Reasons
Foreign language instruction
Issues related to use of interpreter services (both professional and ad hoc)
Cultural beliefs and attitudes
Availability of community based programs such as cultural centers
Immigration/Deportation issues
Underserved for Geographic Reasons
Telemedicine
Transportation and travel barriers
Availability of allied health providers (PT/OT/Speech Pathology, etc.)
Public sources of care in rural areas
Underserved for Medical Reasons
Medical Home
Care coordination with other health care providers
Interfacing with community organizations (such as schools and day cares)
Palliative care for terminally ill children / Pediatric hospice
Individualized education plans (IEPs)
Americans with Disabilities Act
Dental Care
Oral health screening
Counseling for oral hygiene, diet (e.g., baby bottle use), and fluoride use
Fluoride guidelines
Referral for dental care
Access to dental health services
Availability of public sources of dental services

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Sheet 4: HRSA 100-3-C CHANGES IN CURRIC

Department of Health and Human Services				OMB No. 0915-0313
Health Resources and Services Administration				Expiration Date: 11/30/2013
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-3-C: Residency Training Topics, Changes in Residency Training
Training Experiences and Resulting Benefits
Residency Program Name:			#N/A
Medicare provider number:			00-0000
Date of Report:			12/31/12
Please indicate whether each topic listed in this worksheet was part of the program's training/curriculum in the most recent academic year (2011-2012) and, if so, whether the topic was newly offered since the previous year (2010-2011) or expanded or improved since the previous academic year . Also, please briefly describe resulting benefits from any change(s) in the space provided following each broad subheading. If you wish to provide greater detail about the benefits resulting from changes in the curricula, you may do so by adding a sheet to the Excel workbook or attaching a separate document.
[Benefits may include, for example, increases in medical knowledge; improvements in clinical competence; increased awareness of psychosocial and behavioral aspects of health and illness; increased awareness of the availability of community resources; increased ability to function as a medical home provider; improvements in patient care and outcomes and promotion of leadership skills.]
If no changes have occurred, you need not complete the rationale and "benefits" sections. See detailed guidance for complete instructions.
				If Yes	If Yes
TRAINING TOPIC		No, Not Part of Training in Most Recent Academic Year (2011-2012)	Yes, Part of Training in Most Recent Academic Year (2011-2012)	Is this Newly Offered since the Previous Academic Year? (2010-2011)?	Has this Training Expanded or Improved since previous year (2010-2011)?
Didactic Training
Basic Science
Genomics/Proteomics
Neuroscience
Developmental biology
Translational Research
Effects of physical environment (toxins, etc)
Effects of social environment (crime, etc)
Tailoring therapy to the individual
Health Promotion
Promoting positive health behaviors
Health promotion/ Illness Prevention
Screening/referral for maternal depression
Screening/referral for parental substance abuse
Screening/referral for domestic violence
Tobacco prevention and control
Obesity-directed care
Anticipatory guidance
Other Topics in Didactic Training
Family-centered pediatrics
Interdisciplinary care
Medical Home model
Cultural competency
Competency-based training
Physician-patient communication
Patient advocacy
Leadership training (conflict resolution, self-awareness, vision-entrepreneurship, etc)
Interpretation of research
Care of domestically adopted children
Care of internationally adopted children
Dental Care
Oral health screening
Counseling for oral hygiene, diet (e.g., baby bottle use), and fluoride use
Fluoride guidelines
Referral for dental care
Access to dental health services
Availability of public sources of dental services
Community Health System Topics
Substance abuse treatment system
Domestic violence resources
Mental/behavioral health care system
Social service system
Public education
Welfare system
Foster care system
Migrant health system
Indian health service
Community-level advocacy
Legislative/ policy advocacy
Clinical Training
Community Based Pediatric Rotations/Clinical Experiences
Local and state health departments
Community health centers
Schools
Day care
Juvenile detention facilities
Home care services
Advocacy (communicating with elected officials, providing legislative testimony, etc.)
Private practice
Child protective teams
Head Start
Homeless Shelters
Mobile health van
Other Clinical Experiences/Rotations
Scholarly activities (performing basic, clinical, translational, or health services research)
Use of transformative learning techniques, e.g., role plays, reflective exercises
Resident project
Changes in Training Evaluation
Observed structured clinical examination (OSCE)
360 evaluations
Standardized patients
Record reviews
Chart-stimulated recall
Checklists of observed behaviors
Global ratings
Procedure logs
Case logs
Patient surveys
Reflective exercises

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Sheet 5: HRSA 100-3-D CHNG IN TRNG QUAL

Department of Health and Human Services					OMB No. 0915-0313
Health Resources and Services Administration					Expiration Date: 11/30/2013
Children's Hospitals Medical Education Payment Program
HRSA 100-3-D: Training Related to Measurement and Improvement in Quality, Changes in Training and Resulting Benefits of Change
Residency Program Name:			#N/A
Medicare Provider Number:			00-0000
Date of Report:			12/31/12
Please indicate whether each topic listed in this worksheet was part of the program's training/curriculum in the most recent academic year (2011-2012) and, if so, whether the topic was newly offered since the previous year or expanded or improved since the previous academic year (2010-2011). There must be at least one check mark in each row. Also, please briefly describe the reasons for and resulting benefits from any change(s) in the space provided following each broad subheading. If you wish to provide greater detail about the benefits resulting from changes in the curricula, you may do so by adding a sheet to the Excel workbook or attaching a separate document.
[Benefits may include, for example, increases in medical knowledge; improvements in clinical competence; increased awareness of psychosocial and behavioral aspects of health and illness; increased awareness of the availability of community resources; increased ability to function as a medical home provider; improvements in patient care and outcomes and promotion of leadership skills.]
If no changes have occurred, you need not complete the rationale and "benefits" section. See detailed guidance for complete instructions.
TRAINING TOPIC				If Yes	If Yes
		No, Not Part of Training in Most Recent Academic Year (2011-2012)	Yes, Part of Training in Most Recent Academic Year (2011-2012)	Is this Training Newly Offered since the Previous Academic Year (2010-2011)?	Has this Training been Expanded or Improved since the Previous Academic Year (2010-2011)?
Health Care Quality
Quality characteristics
Evidence-based medicine
Ambulatory care sensitive conditions
Volume-outcomes
Small area variation
Health care disparities
Systematic literature reviews/meta-analysis
Practice guidelines
Quality Measurement
Benchmarking
Consumer Assessments of Health Plans (CAHPS)
Health Plan Employer Data and Information Set (HEDIS)
Agency for Health Care Research and Quality (AHRQ) Pediatric Quality Indicators
AHRQ Clinical Performance Measures for Ambulatory Care
Structure/Process/Outcomes Measures
Performance measurement and indicators
Severity/risk adjustment
Sentinel event
Interdisciplinary care
Quality Improvement
Physician reminder systems (e.g., prompts in paper charts or computer-based reminders)
Facilitated relay of clinical data to providers (e.g., use of faxes to send information between PCP and specialists)
Audit and feedback approaches (e.g., performance review, report cards, benchmarking)
Physician education (e.g., conferences, etc.)
Patient education (e.g., pamphlets, classes, self-care instruction, etc.)
Promotion of disease self management (e.g., workshops, monitoring devices, etc)
Patient reminder systems (e.g., telephone or postcard reminder systems)
Organizational changes (e.g., total quality management, continuous quality improvement, etc.)
Financial incentives (e.g., pay for performance)
Use of practice guidelines

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Sheet 6: HRSA 100-3-E CHNG IN NO. OF RES

Department of Health And Human Services			OMB No. 0915-0313
Health Resources and Services Administration			Expiration Date: 11/30/2013
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-3-E: Changes in the Numbers of Residents and Faculty Members and Resulting Benefits
Residency Program Name:		#N/A
Medicare Provider Number:		00-0000
Date of Report:		12/31/12
For your training program answer the following questions. See detailed guidance for complete instructions.
In which year was this training program first offered?
In the following table, please indicate the total number of trainees (which is the sum of the number of residents documented in the last column(s) of 100-1-C plus 100-1-D of each specified program) and faculty involved in your program in the previous academic year (2010-2011) and in the most recent year of funding (2011-2012):
Previous Academic Year (2010-2011)		Most Recent Year (2011-2012)
Number of Residents	Number of Faculty	Number of Residents	Number of Faculty
How have the changes in the number of residents and/or the number of faculty in your program yielded benefits to your residents, institution, or patients?
[Benefits may include, for example, increases in medical knowledge; improvements in clinical competence; increased awareness of psychosocial and behavioral aspects of health and illness; increased awareness of the availability of community resources; increased ability to function as a medical home provider; improvements in patient care and outcomes and promotion of leadership skills.] Please respond in the space below.

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Sheet 7: HRSA 100-3-F PRAC LOC GRAD RES

Department of Health and Human Services				OMB No. 0915-0313
Health Resources and Services Administration				Expiration Date: 11/30/2013
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-3-F: Practice Locations of Residents Completing Training
Residency Program Name:				#N/A
Medicare Provider Number:				00-0000
Date of Report:				12/31/12
Public Law 109-307 requires that you report for each resident (who was in a hospital-sponsored program or who spent 75% of his/her training time in your hospital in the last academic year) who completed training in the academic year (2011-2012), his or her first place of employment lasting at least 6 months: city, state, zip code, and type of employment for their current position. Do not include names or SSN's--just resident # 1; resident #2, etc., as indicated in the table. If no residents completed training in the academic year (2011-2012) indicate by selecting the "No" response in the question immediately following these instructions. See detailed guidance for complete instructions.
Did one or more resident(s) complete training in the academic year (2011-2012)?
Resident No.	City	State	Zip Code	Type of Employment
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45

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Sheet 8: .

		None
Required		Less than 25%
Elective		26-50%
Not Currently Used		51-75%
		76% or more
		Not Applicable
The annual number of trainees increased
The annual number of trainees decreased
The annual number of trainees stayed the same
The number of faculty increased
The number of faculty decreased
The number of faculty stayed the same
N/A
Private Practice
Non-academic medical center
Non-academic medical center - Hospitalist
Non-academic medical center - Outpatient clinic
Academic medical center - Additional training (fellowships, etc.)
Academic medical center - Hospitalist
Academic medical center - Staff Physician
Academic medical center - Faculty Physician
Academic medical center - Other academia
Public setting - Community/rural/migrant health center
Public setting - Health department
Government - Federal (CDC, FDA, NCHS, etc)
Government - State government
Government - National Health Service Corps
Government - Military
Private industry - Pharmaceuticals/Biotechnology/Software
Other
Not currently employed
Financial
Sociocultural
Geographic
Medical
2 or 3 Populations
All of the above
None of the above or N/A

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Sheet 9: ...

No	No	Yes
1	Adolescent Medicine Pediatrics	No
2	Allergy Immunology
3	Anesthesiology
4	Child Abuse Pediatrics
5	Child and Adolescent Psychiatry
6	Child Neurology
7	Colon & Rectal Surgery
8	Dermatology
9	Developmental Behavioral Pediatrics
10	Emergency Medicine
11	Emergency Medicine (Pediatric)a
12	Family Medicine
13	Hospice and Palliative Medicine
14	Internal Medicine /Pediatrics
15	Medical Genetics
16	Medical Toxicology
17	Neonatal-Perinatal Medicine
18	Neurodevelopmental Disabilities
19	Neurological Surgery
20	Neurology
21	Nuclear Medicine
22	Obstetrics and Gynecology
23	Ophthalmology
24	Orthopedic Surgery
25	Otolaryngology
26	Pathology
27	Pediatric Anesthesiology
28	Pediatric Cardiology
29	Pediatric Cardiothoracic Surgery
30	Pediatric Critical Care Medicine
31	Pediatric Dermatology
32	Pediatric Emergency Medicine
33	Pediatric Endocrinology
34	Pediatric Gastroenterology
35	Pediatric Hematology/Oncology
36	Pediatric Infectious Disease
37	Pediatric Nephrology
38	Pediatric Neurosurgery
39	Pediatric Ophthalmology
40	Pediatric Orthopedics
41	Pediatric Otolaryngology
42	Pediatric Pathology
43	Pediatric Pulmonology
44	Pediatric Radiology
45	Pediatric Rehabilitation Medicine
46	Pediatric Rheumatology
47	Pediatric Sleep Medicine
48	Pediatric Sports Medicine
49	Pediatric Surgery
50	Pediatric Transplant Hepatology
51	Pediatric Urology
52	Pediatrics
53	Pediatrics/Dermatology
54	Pediatrics/Emergency Medicine
55	Pediatrics/Medical Genetics
56	Pediatrics/Physical Medicine and Rehab
57	Pediatrics/Psychiatry/Child & Adolescent Psych
58	Physical Medicine & Rehabilitation
59	Plastic Surgery
60	Preventive Medicine
61	Psychiatry
62	Radiology
63	Surgery
64	Thoracic Surgery
65	Urology
66	Other: ABA Alternative Pathway (Anesthesia)
67	Other: Addiction Psychiatry
68	Other: Adolescent Bariatric Surgery
69	Other: Adolescent Medicine
70	Other: Adult Transplant Hepatology
71	Other: Adult Cardiothoracic Anesthesiology
72	Other: Adult Congenital Heart Disease
73	Other: Advanced General Dentistry
74	Other: Advanced Pediatric Hematology/ Oncology Neurooncology
75	Other: Advanced Pediatric Hematology/ Oncology Stem Cell Transplantation
76	Other: Anesthesia/Pain Medicine
77	Other: Anesthesiology/ Critical Care Medicine
78	Other: Body MRI
79	Other: Bone & Marrow Transplantation
80	Other: Cardio DS
81	Other: Cardiology
82	Other: Child Psychology
83	Other: Clinical Cardiac Electrophysiology
84	Other: Clinical Cardiac Electrophysiology (Adult)
85	Other: Clinical Immunodeficiency
86	Other: Clinical Neurophysiology
87	Other: Clinical Pharmacology and Toxicology
88	Other: Congenital Cardiac Surgery
89	Other: Craniofacial Surgery
90	Other: Critical Care Anesthesiology
91	Other: Critical Care Medicine
92	Other: Dentistry
93	Other: Dermapathology
94	Other: Emergency Medicine/ Family Medicine
95	Other: Endocrinology, Diabetes and Metabolism
96	Other: Endodontics
97	Other: Endovascular Surgical Neuroradiology
98	Other: Epilepsy
99	Other: Family Medicine/ Psychiatry
100	Other: Family Medicine/ Sports Medicine
101	Other: Female Pelvic Medicine and Reconstructive Surgery
102	Other: Fetal Cardiology
103	Other: Fetal Surgery
104	Other: Foot and Ankle Orthopedics
105	Other: Gastroenterology
106	Other: General and Community Medicine
107	Other: General Internship (DO)
108	Other: General Pediatrics
109	Other: GI Motility
110	Other: Gynecological Oncology
111	Other: Headache
112	Other: Hematology
113	Other: Hematology/ Oncology
114	Other: Hematopathology
115	Other: Hospice and Palliative Medicine
116	Other: Hospitalist
117	Other: Infectious Disease
118	Other: Internal Medicine
119	Other: Internal Medicine/ Emergency Medicine
120	Other: Internal Medicine/ Hematology/ Oncology Fellowship
121	Other: Internal Medicine/ Infectious Disease
122	Other: International Pediatric Neurosurgery
123	Other: Interventional Cardiology
124	Other: Interventional Radiology
125	Other: Lung Transplant
126	Other: Maternal Fetal Medicine
127	Other: Medical Biochemical Genetics
128	Other: Medical Genetics, Molecular Genetic Pathology
129	Other: Medical Microbiology
130	Other: Molecular Genetic Medicine
131	Other: Movement Disorders
132	Other: Musculoskeletal Oncology
133	Other: Musculoskeletal Radiolology
134	Other: Neonatology
135	Other: Nephrology
136	Other: Neuromuscular Medicine
137	Other: Neuropathology
138	Other: Neuroradiology
139	Other: Nuclear Radiology
140	Other: Oral and Maxillofacial Surgery
141	Other: Oral Surgery
142	Other: Orthopaedic Sports Medicine
143	Other: Orthopedic Hand Surgery
144	Other: Orthopedic Surgery of the Spine
145	Other: Osteopathy
146	Other: Pain Medicine
147	Other: Palliative Care
148	Other: Pathology, Anatomic and Clinical, Dermatopathology
149	Other: Pathology, Anatomic and Clinical, General
150	Other: Pathology, Anatomic and Clinical, Hematology
151	Other: Pathology, Blood Banking/ Transfusion Medicine
152	Other: Pathology/ Medical Microbiology
153	Other: Pediatric Allergy and Immunology
154	Other: Pediatric and Adolescent Gynecology
155	Other: Pediatric Cardiac Imaging
156	Other: Pediatric Clinical Cardiac Electrophysiology
157	Other: Pediatric Clinical Pharmacology
158	Other: Pediatric Colorectal Surgery
159	Other: Pediatric Dentistry
160	Other: Pediatric Diagnotic Radiology
161	Other: Pediatric Environmental Health
162	Other: Pediatric Epilepsy
163	Other: Pediatric Heart Failure Transplant
164	Other: Pediatric Hospital Medicine
165	Other: Pediatric International Surgery
166	Other: Pediatric Inteventional Cardiac Catherization
167	Other: Pediatric Neurocritical Care
168	Other: Pediatric Neuromuscular
169	Other: Pediatric Neuroradiology
170	Other: Pediatric Nutrition
171	Other: Pediatric Optometry
172	Other: Pediatric Orthodontics
173	Other: Pediatric Physical Medicine and Rehabilitation
174	Other: Pediatric Plastic Surgery
175	Other: Pediatric Preventive Cardiology
176	Other: Pediatric Surgical Critical Care
177	Other: Pediatric Transplantation Surgery
178	Other: Pediatric Trauma Surgery
179	Other: Pedodontics
180	Other: Plastic Hand Surgery
181	Other: Plastic Surgery - Integrated
182	Other: Podiatric Medicine and Surgery
183	Other: Preliminary Medicine
184	Other: Preliminary Surgery
185	Other: Preventative Medicine-Medical Toxicology
186	Other: Procedural Dermatology, General
187	Other: Psychosomatic Medicine
188	Other: Pulmonary Disease
189	Other: Pulmonary Medicine/ Critical Care Medicine
190	Other: Pulmonology
191	Other: Quality Scholars in Transforming Health Care
192	Other: Radiation Oncology
193	Other: Reproductive Endocrinology
194	Other: Rheumatology
195	Other: Sleep Medicine
196	Other: Spinal Cord
197	Other: Spinal Cord Injury Medicine
198	Other: Sports Medicine
199	Other: Surgical Critical Care
200	Other: Surgical Scholar
201	Other: Traditional Rotating Internships (Osteopathic)
202	Other: Transitional Year
203	Other: Transplant Medicine
204	Other: Transplant Surgery
205	Other: Vascular and Interventional Radiology
206	Other: Vascular Anomalies Surgery
207	Other: Vascular Neurology
208	Other: Vascular Surgery