| 5b. DP18-1815 Heart Disease Prevention and Management: Resource Use and Cost Inventory Tool | |||
| Form Approved OMB No. 0920-xxxx Exp. Date XX/XX/20XX |
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| Introduction | |||
| The CDC Division for Heart Disease and Stroke Prevention (DHDSP) has contracted Deloitte Consulting to support a national-level evaluation of the 1815 Cooperative Agreement the Division has with state health departments (SHDs). As part of that larger evaluation, the Deloitte National Evaluation Team is conducting a cost study to better understand the costs of implementing CDC-recommended strategies for strengthening prevention and management of cardiovascular disease within health organizations. Specifically, the Cost Study will seek to (1) estimate the overall costs of implementing each heart disease prevention or management strategy funded by the 1815 cooperative agreement, (2) determine the level of variability in the cost of implementation across different types of health organizations, and (3) identify the factors driving cost and variability. Your organization was selected for participation in this cost study based on your close collaboration with the state health department on implementing the CDC-funded strategies and interventions. Please follow the instructions provided in this Resource Use and Cost Inventory Tool to provide cost data related to the implementation key CDC-funded and SHD-supported heart disease prevention and management strategies within your organization. Completion of this Resource Use and Cost Inventory Tool is voluntary. It is expected that it will take you approximately 2 hours to complete the tool, including time to retrieve information you may need to fill the form. You may save a partially completed tool and return to complete it at a different time. All information will be kept secure and any identifiable information will be removed when results are aggregated for analysis. The Deloitte National Evalaution Team is available to address any questions you may have and provide additional guidance to support completion of this this tool. You may email Gizelle Gopez, ggopez@deloitte.com, with questions. |
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| 5b. DP18-1815 Category B: Resource Use and Cost Inventory Tool | ||||||
| Introduction to Cost Study | ||||||
| Thank you for taking the time to participate in the DP18-1815 Resource Use and Cost Inventory Tool. The Deloitte evaluation team is working with the CDC Division for Heart Disease and Stroke prevention to evaluation the DP18-1815 Cooperate Agreement -- Improving the Health of Americans through Prevention and Management of Diabetes and Heart Disease and Stroke, which we will refer to as 1815. As part of the larger national evaluation of 1815, we are conducting a cost study focused on the Heart Disease and Stroke, Category B strateges. The cost study is designed to calculate the overall costs of implementing each 1815 Category B strategy and will take approximately 2.5 hours to fill out. Your participation in this cost study is completely voluntary and it will not in any way impact the funding or technical assistance you receive from CDC. All information will be kept secure and any personally-identifiable information will be removed when results are aggregated for analysis. If you have any questions about the study or the tool, please contact Gizelle Gopez, ggopez@deloitte.com. Note: Public reporting burden of this collection of information is estimated to average 2.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-20HP) |
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| Instructions | ||||||
| Each of the corresponding worksheets have their own specific instructions. Note that boxes shaded in yellow do not need to be filled out by the respondent as these cells will automatically populate as a result of the excel forumula within these cells. The information that will be asked of you to fill out the information will require some detail. Therefore, to fill out the corresponding spreadsheets, please have the following information readily available for the respective reporting period: 1) Heart Disease Budget 2) Workplans |
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| DP18-1815 Category B Strategies | ||||||
| Below are the Category B strategies which are referenced throughout the tool by strategy number and by shorthand description. You may refer back to this page for a full description of each of the strategies. | ||||||
| B1: Supporting adoption and use of electronic health records (EHR) and health information technology (HIT) to improve provider outcomes and patient health outcomes related to identification of individuals with undiagnosed hypertension and management of adults with hypertension | ||||||
| B2: Supporting adoption of evidence-based quality measurement | ||||||
| B3: Supporting engagement of non-physician team members in hypertension and cholesterol management | ||||||
| B4: Promoting adoption of MTM between pharmacists and physicians for the purpose of managing high blood pressure, high blood cholesterol, and lifestyle modification | ||||||
| B5: Facilitating the sustainability for CHWs to promote management of hypertension and high blood cholesterol | ||||||
| B6: Facilitating use of self-measured blood pressure monitoring (SMBP) with clinical support among adults with hypertension | ||||||
| B7: Facilitating systematic referral of adults with hypertension and/or high blood cholesterol to community programs/resources | ||||||
| Please review all information completed with the individual to make sure it is accurate before departing | ||||||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | ||||
| Resource Totals | ||||
| Instructions: This page has been pre-populated. There is no need to fill out any of the information listed here. Items in yellow will automatically be populated due to the Excel formula within each cell. | ||||
| Form Approved OMB No. 0920-xxxx Exp. Date XX/XX/20XX |
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| State | ||||
| Reporting Period | ||||
| $- | ||||
| Cardiovascular Disease Spending Amount | ||||
| Tabs | Cost Study Component | Total | ||
| 1 | Parameters | N/A | ||
| 2 | Personnel | $- | ||
| 3 | Equipment, Supplies, Materials | $- | ||
| 4 | Travel | $- | ||
| 5 | Other Resources | $- | ||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | |||||
| Parameters | |||||
| Instructions: This section will be pre-populated by the Deloitte National Evaluation Team. No information by the health organization will need to be filled out on this page. | |||||
| State | |||||
| Health/Community Organization Name | |||||
| Total Cardiovascular Disease Funding Amount from SHD | |||||
| Table to be completed by the Deloitte National Evaluation Team | |||||
| Is the SHD implementing this strategy? | (Yes/No) (Dropdown) |
Level of Maturity of Strategy (Dropdown) |
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| B.1 | Promote the adoption and use of electronic health records (EHR) and health information technology (HIT) to improve provider outcomes and patient health outcomes related to identification of individuals with undiagnosed hypertension and management of adults with hypertension | ||||
| B.2 | Promote the adoption of evidence-based quality measurement at the provider level (e.g. use dashboard measures) to monitor healthcare disparities and implement activities to eliminate healthcare disparities | ||||
| B.3 | Support engagement of non-physician team members (e.g., nurses, nurse practitioners, pharmacists, nutritionists, physical therapists, social workers) in hypertension and cholesterol management in clinical settings | ||||
| B.4 | Promote the adoption of MTM between pharmacists and physicians for the purpose of managing high blood pressure, high blood cholesterol, and lifestyle modification | ||||
| B.5 | Develop a statewide infrastructure to promote sustainability for CHWs to promote management of hypertension and high blood cholesterol | ||||
| B.6 | Facilitate use of self-measured blood pressure monitoring (SMBP) with clinical support among adults with hypertension | ||||
| B.7 | Implement systems to facilitate systematic referral of adults with hypertension and/or high blood cholesterol to community programs/resources | ||||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | |||||||||||||||||||
| Personnel Costs | |||||||||||||||||||
| Instructions: Please fill out the information below, listing the job titles for those working on the 1815 program (insert extra rows if there is not enough space, deleted extra rows if not needed). Please list the actual monthly salary of the specific individual that holds that current position. Please select the Category B strategies that the individual is working on. If staff do not have benefits (i.e. are temporary) please write 0 for their benefits. Items in yellow will automatically be populated due to the Excel formula within each cell. | |||||||||||||||||||
| State: | |||||||||||||||||||
| Health/Community Organization | |||||||||||||||||||
| Reporting Period: | |||||||||||||||||||
| Total Personnel Costs: | $- | ||||||||||||||||||
| List names of all staff positions (insert extra rows if there is not enough space, delete extra rows if not needed) | |||||||||||||||||||
| Job Title | Full-Time Employee (FTE) or Part-Time Employee (PTE) (Dropdown) |
Actual monthly salary for job title (Write-in) |
Average monthly benefits for job title (Write-in) |
Total Personnel Costs | Start date of job position (month and year) during reporting period (Write-in) | Is this a new position for this reporting period? (Yes/No) (Dropdown) |
# months worked on CVD stratgies during reporting period (Dropdown) | # months position has been vacant in last 12 months (Dropdown) | Total # of hours per week allocated to CVD strategies (Write-In) | % time dedicated to CVD strategies (Write-In) |
Select which of the strategies each staff member and contractor is working on (Yes/No) (Dropdown) |
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| B.1 | B.2 | B.3 | B.4 | B.5 | B.6 | B.7 | |||||||||||||
| EHRs/HIT | CQMs | TBC | MTM | CHWs | SMBP | Referrals | |||||||||||||
| $- | |||||||||||||||||||
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| TOTAL | N/A | $- | $- | $- | N/A | N/A | N/A | N/A | N/A | 0% | |||||||||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | ||||||||
| Office Equipment, Supplies, and Materials | ||||||||
| Instructions: Please fill out both tables below, General Equipment (Table 1) and Strategy-Specific Supplies/Materials (Table 2). For the General Equipment table, please fill out the equipment used for Category B. Same equipment have been inputted below for guidance. Please add additional office equipment to column B as needed. Office equipment is defined as a long-term assest such as computers, printers, copiers, etc. For the second table, Strategy-Specific Supplies/Materials are materials needed for activities related to the Category B strategies such as training rental costs, paper, folders, website maintenance costs, etc. Sample supplies have been inputted below for guidance. Please adjust the cells within table 2 as needed. Note that Table 1 and 2 are different materials and therefore different costs. Items in yellow will automatically be populated due to the Excel formula within each cell. | ||||||||
| State: | ||||||||
| Health/Community Organization | ||||||||
| Reporting Period: | ||||||||
| Total Costs for Equipment and Supplies: | $- | |||||||
| Table 1. General Equipment | ||||||||
| Office equipment is defined as a long-term assest such as computers, printers, copiers, etc. The items below are examples of office equipment. Please update the chart below with the office equipment purchase for 1815. | ||||||||
| Office Equipment | Unit Cost (Write-In) |
Quantity (Write-In) |
Total costs | # of strategies implemented (Dropdown) |
Shared with Category A Strategies (Yes/No) (Dropdown) |
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| desktop computer | $- | |||||||
| laptop computer | $- | |||||||
| computer monitor | $- | |||||||
| software | $- | |||||||
| printer | $- | |||||||
| ink cartridge | $- | |||||||
| $- | ||||||||
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| $- | ||||||||
| TOTAL | N/A | N/A | $- | N/A | N/A | |||
| Table 2. Strategy Specific Supplies/Materials | ||||||||
| Please update the table below for strategy-specific supplies/materials that are needed for activities related to the Category B strategies such as training rental costs, paper, folders, website maintenance costs, etc. Sample supplies have been inputted below only as examples. Please adjust the cells within table 2 as needed. | ||||||||
| Strategy | Materials/Supplies | Unit Cost (Write-In) |
Quantity (Write-In) |
Total Costs | ||||
| Strategy B.1 | Printing costs | $- | ||||||
| Strategy B.1 | Training cost - venue rental | $- | ||||||
| Strategy B.1 | Website maintenance costs | $- | ||||||
| Strategy B.1 | $- | |||||||
| Strategy B.2 | Printing costs | $- | ||||||
| Strategy B.2 | Paper | $- | ||||||
| Strategy B.2 | $- | |||||||
| Strategy B.2 | $- | |||||||
| Strategy B.3 | Communication/informational materials about TBC | $- | ||||||
| Strategy B.3 | Printing costs | $- | ||||||
| Strategy B.3 | $- | |||||||
| Strategy B.3 | $- | |||||||
| Strategy B.4 | Communication/informational materials about MTM | $- | ||||||
| Strategy B.4 | Printing costs | $- | ||||||
| Strategy B.4 | $- | |||||||
| Strategy B.4 | $- | |||||||
| Strategy B.5 | Communication/informational materials about CHW | $- | ||||||
| Strategy B.5 | CHW training materials -printing cost | $- | ||||||
| Strategy B.5 | Training cost- venue rental | $- | ||||||
| Strategy B.5 | $- | |||||||
| Strategy B.6 | Communication/informational materials about SMBP | $- | ||||||
| Strategy B.6 | Printing costs | $- | ||||||
| Strategy B.6 | Self-monitoring equipment | $- | ||||||
| Strategy B.6 | $- | |||||||
| Strategy B.7 | $- | |||||||
| Strategy B.7 | $- | |||||||
| Strategy B.7 | $- | |||||||
| Strategy B.7 | $- | |||||||
| $- | ||||||||
| TOTAL | N/A | N/A | N/A | $- | ||||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | ||||||||||||||||||||||||||||||
| Travel Costs | ||||||||||||||||||||||||||||||
| Instructions: Please fill out the following table for 1815-related travel only. Travel for 1815 may include, but is not limited to: conferences where the attendee is attending/presenting for 1815; site visits; meetings with sites, partners, etc. For columns Y to AE please indicate whether the travel supported any of the Category B strategies. Items in yellow will automatically be populated due to the Excel formula within each cell. | ||||||||||||||||||||||||||||||
| State: | ||||||||||||||||||||||||||||||
| Health/Community Organization | ||||||||||||||||||||||||||||||
| Reporting Period: | ||||||||||||||||||||||||||||||
| Total Travel Costs: | $0.00 | |||||||||||||||||||||||||||||
| Conference | CarTravel | Air Travel | Lodging | Per Diem | Other Ground Transportaion | Other Travel Costs | Did travel support any of these strategies? (Yes/No) (Dropdown) |
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| Purpose of travel (Write-In) |
In-state/ out of state travel? (Dropdown) |
State traveled to (if applicable) (Write-In) |
# of 1815-funded staff traveling (Dropdown) |
Conference Registration Fees (if applicable) (Write-In) |
Total Conference Registration Fees | If Driving - Total number of miles (Write-In) |
Cost per mile (Write-In) |
Number of people per car (Dropdown) |
Total ground travel | Cost of airfare (unit cost) (Write-In) |
Total Air Travel | Hotel cost per night (Write-In) |
Number of nights (Write-In) |
Total Lodging | Per Diem rate (Write-In) |
Number of days (Write-In) |
Total Per Diem | Unit cost (Write-In) |
Total cost |
Other travel costs (Write-In) |
Total other costs | TOTAL TRAVEL COSTS | B.1 | B.2 | B.3 | B.4 | B.5 | B.6 | B.7 | |
| EHRs/HIT | Disparities | TBC | MTM | CHWs | SMBP | Referrals | ||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
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| TOTAL | N/A | N/A | N/A | $- | N/A | N/A | N/A | $- | N/A | $- | N/A | N/A | $- | N/A | N/A | $- | N/A | $- | N/A | $- | $- | |||||||||
| clarify | ||||||||||||||||||||||||||||||
| DP18-1815 Category B: Resource Use and Cost Inventory Tool | |||||||||||||
| Other Resources | |||||||||||||
| Instructions: For the in-kind funding table, it is encouraged that principal investigators fill out this information in conjunction with other principal investigators in charge of other heart-disease prevention programs as in-kind funding may overlap with 1815 activities. Items in yellow will automatically be populated due to the Excel formula within each cell. | |||||||||||||
| State: | |||||||||||||
| Reporting Period: | |||||||||||||
| Total Additional Funding: | $- | ||||||||||||
| Does this funding source support the following strategies (Yes/No) (Dropdown) |
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| B.1 | B.2 | B.3 | B.4 | B.5 | B.6 | B.7 | |||||||
| List of Other Funding Source(s) (State budget, other CDC program, other Federal program, other funding) (Write-In) |
Total Amount ($) (Write-In) |
List Services/ Programs Supported (i.e. YMCA, Million Hearts, etc.) (Write-In) |
EHRs/HIT | CQMs | TBC | MTM | CHWs | SMBP | Referrals | ||||
| TOTAL | $- | N/A | |||||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |