Form 1 Data Collection Instruments Flex Program 0915-0363

Medicare Rural Hospital Flexibility Program Performance
OMB Number: 0915-0363
Expiration date: 7/31/22
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 0915-0363, and it expires on
7/31/22. Public reporting burden for this collection of information is estimated to average XX
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 14N39, Rockville, Maryland, 20857.

A Web Page
http:// FLEX FORM 1 - Selection Page

Welcome

NAVIGATION

Recently Accessed

What's New

Guide Me

Medicare Hospital Flexibility

<<

Grantee Data Entry

^

1. Selection
1.
SelectionPage
Page
2. CAH Quality
Improvement



3. CAH Operational
and Financial Improvement
4. CAH Population
Health Improvement
5. Rural EMS Improvement
6. Innovative Model

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 0915-0363. Public reporting burden for this collection of information is estimated to average 70 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 14N39, Rockville, Maryland, 20857.

Development
7. CAH Designation
8. Flex Spending
Program Data

^

1. Flex Facility Information
2. Cohort Management
Admin

^

Program Selection

Federal Office of Rural Health Policy
Flex Selection Page
Applicable
Measure ?

Downloads logs
Admin Home

Measure

Collection Periods
Role Assignment
Reports

^

Reporting Tools
Grantee Raw Data
Report
Comparison Summary
Report
Comparision Trend
Report
Summary
Submissions Matrix
PDF Version

^

09/01/2015 - 08/31/2016
09/01/2016 - 08/31/2017
09/01/2017 - 08/31/2018
09/01/2018 - 08/31/2019
09/01/2019 - 08/31/2020
Grantee Info

^

Grantee information

OMB Number: 0915-0363
Expiration Date: 07/30/2022
Save

For technical help please call the HRSA Contact Center 1-877-Go4-HRSA (1-877-464-4772) or click to submit help request.
If Adobe Reader is not installed on your computer, please download to view PDF files.
Copyright © HRSA. All Rights Reserved.

A Web Page
http:// FLEX FORM 2 - CAH Quality Improvement

Welcome

NAVIGATION

Recently Accessed

What's New

Guide Me

Medicare Hospital Flexibility

<<

Grantee Data Entry

^

1. Selection Page
2.
2. CAH
CAHQuality
Quality
Improvement
Improvement



3. CAH Operational
and Financial Improvement
4. CAH Population
Health Improvement
5. Rural EMS Improvement
6. Innovative Model

CAH Quality Improvement

Development
7. CAH Designation

Core MBQIP Measures

8. Flex Spending
Program Data

^

Additional MBQIP Measures

1. Flex Facility Information

Core MBQIP Measures

2. Cohort Management

Please indicate which CAHs participated and improved in each MBQIP activity category during the budget period. Select all that apply.

Admin

^

Program Selection

1.1 - Report and improve Core Patient Safety/Inpatient Measures, including develop antibiotic stewardship programs

Downloads logs
Collection Periods
Role Assignment
Reports

Historical
Participation

CAH Name

Admin Home

Participation

Improvement

Participation

Improvement

Participation

Improvement

Participation

Improvement

Select All

^

123456-abc

Reporting Tools
Grantee Raw Data

234567-def

Report

Total

Comparison Summary

1.2 - Report and improve Core Patient Engagement Measures

Report
Comparision Trend
Report

Historical
Participation

CAH Name

Summary
Submissions Matrix
PDF Version

^

09/01/2015 - 08/31/2016

123456-abc

09/01/2016 - 08/31/2017

234567-def

09/01/2017 - 08/31/2018

Total

09/01/2018 - 08/31/2019

1.3 - Report and improve Core Care Transitions Measures (required annually)

09/01/2019 - 08/31/2020
Grantee Info
Grantee information

Select All

^

Historical
Participation

CAH Name
Select All

123456-abc
234567-def
Total

1.4 - Report and improve Core Outpatient Measures (required annually)
Historical
Participation

CAH Name
Select All

123456-abc
234567-def
Total

 Return to Top (Index)

Additional MBQIP Metrics
Please indicate which CAHs participated and improved in each additional quality activity during the budget period. Select all that apply.

1.5 - Report and improve Additional Patient Safety Measures (optional)
CAH Name

Historical
Participation

Participation

Improvement

Participation

Improvement

Participation

Improvement

Participation

Improvement

Select All

123456-abc
234567-def
Total

1.6 - Report and improve Additional Patient Engagement Measures (optional)
CAH Name

Historical
Participation

Select All

123456-abc
234567-def
Total

1.7 - Report and improve Additional Care Transitions Measures (optional)
CAH Name

Historical
Participation

Select All

123456-abc
234567-def
Total

1.8 - Report and improve Additional Outpatient Measures (optional)
CAH Name

Historical
Participation

Select All

123456-abc
234567-def
Total

 Return to Top (Index)

OMB Number: 0915-0363
Expiration Date: 07/30/2022

For technical help please call the HRSA Contact Center 1-877-Go4-HRSA (1-877-464-4772) or click to submit help request.
If Adobe Reader is not installed on your computer, please download to view PDF files.
Copyright © HRSA. All Rights Reserved.

A Web Page
http:// FLEX FORM 3 - CAH Operational and Financial Improvement

Welcome

NAVIGATION

Recently Accessed

What's New

Guide Me

Medicare Hospital Flexibility

<<

Grantee Data Entry

^

1. Selection Page
2. CAH Quality
Improvement
3. CAH
CAH Operational
Operational
3.
andand
Financial
Improvement
Financial
Improvement



4. CAH Population
Health Improvement
5. Rural EMS Improvement
6. Innovative Model

CAH Operational and Financial Improvement

Development
7. CAH Designation
8. Flex Spending
Program Data

^

1. Flex Facility Information

CAH Operational and Financial Improvement
Please indicate which CAHs participated and improved in Operational and Financial Improvement activities. Please select all that apply.

2. Cohort Management
Admin

^

2.2 - Individual CAH-specific needs assessment and action planning (optional)

Program Selection
Downloads logs

CAH Name

Admin Home
Collection Periods

Participation

Improvement

Historical
Participation

Participation

Improvement

Historical
Participation

Participation

Improvement

Historical
Participation

Participation

Improvement

Select All

Role Assignment
Reports

Historical
Participation

^

123456-abc

Reporting Tools

234567-def

Grantee Raw Data

Total

Report
Comparison Summary

2.3 - Financial improvement (optional)

Report
Comparision Trend
Report

CAH Name

Summary
Submissions Matrix
PDF Version

^

Select All

09/01/2015 - 08/31/2016

123456-abc

09/01/2016 - 08/31/2017

234567-def

09/01/2017 - 08/31/2018

Total

09/01/2018 - 08/31/2019
09/01/2019 - 08/31/2020
Grantee Info

^

2.4 - Operational improvement (optional)

Grantee information

CAH Name
Select All

123456-abc
234567-def
Total

2.5 - Value-based payment projects (optional)
CAH Name
Select All

123456-abc
234567-def
Total

OMB Number: 0915-0363
Expiration Date: 07/30/2022

For technical help please call the HRSA Contact Center 1-877-Go4-HRSA (1-877-464-4772) or click to submit help request.
If Adobe Reader is not installed on your computer, please download to view PDF files.
Copyright © HRSA. All Rights Reserved.

A Web Page
http:// FLEX FORM 4 - CAH Population Health Improvement

Welcome

NAVIGATION

Recently Accessed

What's New

Guide Me

Medicare Hospital Flexibility

<<

Grantee Data Entry

^

1. Selection Page
2. CAH Quality
Improvement



3. CAH Operational
and Financial Improvement
4. CAH Population
Population
Health
Improvement
Health
Improvement

5. Rural EMS Improvement
6. Innovative Model

CAH Population Health Improvement

Development
7. CAH Designation
8. Flex Spending
Program Data

^

1. Flex Facility Information
2. Cohort Management
Admin

^

CAH Population Health Improvement
Please indicate which CAHs participated in a Population Health Improvement Activity within this budget period. Please select all that apply.

3.1 - Support CAHs identifying community and resource needs (optional)

Program Selection
Downloads logs

CAH Name

Admin Home
Collection Periods

Participation

Improvement

Select All

Role Assignment
Reports

Historical
Participation

^

123456-abc

Reporting Tools

234567-def

Grantee Raw Data

Total

Report

3.2 - Assist CAHs to build strategies to prioritize and address unmet needs of the community (optional)

Comparison Summary
Report
Comparision Trend

CAH Name

Report
Summary
Submissions Matrix
PDF Version

^

Improvement

123456-abc
234567-def

09/01/2016 - 08/31/2017

Total

09/01/2017 - 08/31/2018
09/01/2018 - 08/31/2019

3.3 - Assist CAHs to engage with community stakeholders and public health experts and address specific health needs (optional)

09/01/2019 - 08/31/2020

Grantee information

Participation

Select All

09/01/2015 - 08/31/2016

Grantee Info

Historical
Participation

^

CAH Name

Historical
Participation

Participation

Improvement

Select All

123456-abc
234567-def
Total

OMB Number: 0915-0363
Expiration Date: 07/30/2022

For technical help please call the HRSA Contact Center 1-877-Go4-HRSA (1-877-464-4772) or click to submit help request.
If Adobe Reader is not installed on your computer, please download to view PDF files.
Copyright © HRSA. All Rights Reserved.

A Web Page
http:// FLEX FORM 5 - Rural EMS Improvement

Welcome
NAVIGATION

Recently Accessed

What's New

Guide Me

Medicare Hospital Flexibility

<<

Grantee Data Entry

^

1. Selection Page
2. CAH Quality
Improvement



3. CAH Operational
and Financial Improvement
4. CAH Population
Health Improvement
5. Rural
Rural EMS
5.
EMSImprovement
Improvement
6. Innovative Model

Rural EMS Improvement

Development
7. CAH Designation
8. Flex Spending
Program Data

^

1. Flex Facility Information
2. Cohort Management
Admin

^

Program Selection

Rural EMS Improvement
Please indicate the number of EMS assessments and/or EMS entities participating in Rural EMS Improvement during the budget period.

4.2 - Community-level rural EMS assessments and action planning (optional)
Number of EMS assessments completed

Downloads logs
Admin Home
Collection Periods

4.3 - EMS operational improvement (optional)

Role Assignment
Reports

^

Number of EMS entities participating

Reporting Tools
Grantee Raw Data

4.4 - EMS quality improvement (optional)

Report
Comparison Summary
Report

Number of EMS entities participating

Comparision Trend
Report
Summary
Submissions Matrix
PDF Version

^

09/01/2015 - 08/31/2016
09/01/2016 - 08/31/2017
09/01/2017 - 08/31/2018
09/01/2018 - 08/31/2019
09/01/2019 - 08/31/2020
Grantee Info

^

Grantee information

OMB Number: 0915-0363
Expiration Date: 07/30/2022

For technical help please call the HRSA Contact Center 1-877-Go4-HRSA (1-877-464-4772) or click to submit help request.
If Adobe Reader is not installed on your computer, please download to view PDF files.
Copyright © HRSA. All Rights Reserved.

A Web Page
http:// FLEX FORM 6 - Innovative Model Development

Welcome
NAVIGATION

Recently Accessed

What's New

Guide Me

Medicare Hospital Flexibility

<<

Grantee Data Entry

^

1. Selection Page
2. CAH Quality
Improvement



3. CAH Operational
and Financial Improvement
4. CAH Population
Health Improvement
5. Rural EMS Improvement
Innovative Model
6. Innovative
Model
Development
Development

Innovative Model Development

7. CAH Designation
8. Flex Spending
Program Data

^

1. Flex Facility Information
^

Program Selection
Downloads logs

Historical
Participation

CAH Name

Participation

Select All

Admin Home
Collection Periods

123456-abc

Role Assignment
Reports

Please indicate which CAHs participated in Innovated Model Development activities during this budget period. Please select all that apply.

5.1 - Develop and test innovative models and publish report or documentation of the innovation (optional)

2. Cohort Management
Admin

Innovative Model Development

234567-def
Total

^

Number of reports or documents published

Reporting Tools
Grantee Raw Data
Report

5.2 - Develop and test CAH outpatient clinic (including CAH-owned rural health clinics) quality reporting and publish report or documentation (optional)

Comparison Summary
Report
Report

Participation

Select All

Summary
Submissions Matrix
PDF Version

Historical
Participation

CAH Name

Comparision Trend

^

09/01/2015 - 08/31/2016

123456-abc
234567-def
Total

09/01/2016 - 08/31/2017
09/01/2017 - 08/31/2018

Number of reports or documents published

09/01/2018 - 08/31/2019
09/01/2019 - 08/31/2020
Grantee Info

^

Grantee information

OMB Number: 0915-0363
Expiration Date: 07/30/2022
For technical help please call the HRSA Contact Center 1-877-Go4-HRSA (1-877-464-4772) or click to submit help request.
If Adobe Reader is not installed on your computer, please download to view PDF files.
Copyright © HRSA. All Rights Reserved.

A Web Page
http:// FLEX FORM 7 - CAH Designation

Welcome
NAVIGATION

Recently Accessed

What's New

Guide Me

Medicare Hospital Flexibility

<<

Grantee Data Entry

^

1. Selection Page
2. CAH Quality
Improvement



3. CAH Operational
and Financial Improvement
4. CAH Population
Health Improvement
5. Rural EMS Improvement
6. Innovative Model

CAH Designation

Development

7.CAH
CAHDesignation
Designation
7.
8. Flex Spending
Program Data

^

1. Flex Facility Information
2. Cohort Management
Admin

^

CAH Designation
Please enter the number of hospitals requesting and receiving assistance in conversion to CAH status during the budget period.

6.1 - CAH conversions (required if assistance is requested by rural hospitals)
Number of hospitals requesting and receiving assistance in conversion to CAH status
Number of hospitals successfully converting to CAH status

Program Selection
Downloads logs

Number of hospitals receiving assistance in conversion to CAH status that did not convert

Admin Home
Collection Periods

Please list the hospitals receiving assistance that did not convert to CAH status

Role Assignment

6.2 - CAH transitions (required if assistance is requested by CAHs)

Reports

^

Please indicate which CAHs requested assistance in transitioning to another designation during this budget period. Select all that apply.

Reporting Tools
Grantee Raw Data

CAH Name

Report
Comparison Summary

Participation

Select All

Report
Comparision Trend

123456-abc

Report

234567-def

Summary

Total

Submissions Matrix
PDF Version

Historical
Participation

^

09/01/2015 - 08/31/2016
09/01/2016 - 08/31/2017
09/01/2017 - 08/31/2018
09/01/2018 - 08/31/2019
09/01/2019 - 08/31/2020
Grantee Info

^

Grantee information

OMB Number: 0915-0363
Expiration Date: 07/30/2022

For technical help please call the HRSA Contact Center 1-877-Go4-HRSA (1-877-464-4772) or click to submit help request.
If Adobe Reader is not installed on your computer, please download to view PDF files.
Copyright © HRSA. All Rights Reserved.

A Web Page
http:// FLEX FORM 8 - Flex Spending

Welcome
NAVIGATION

Recently Accessed

What's New

Guide Me

Medicare Hospital Flexibility

<<

Grantee Data Entry

^

1. Selection Page
2. CAH Quality
Improvement



3. CAH Operational
and Financial Improvement
4. CAH Population
Health Improvement
5. Rural EMS Improvement
6. Innovative Model

Flex Spending

Development
7. CAH Designation

Award Information CAH Quality Improvement

8. Flex
FlexSpending
Spending
8.
Program Data

^

1. Flex Facility Information
2. Cohort Management
Admin

^

Program Selection

Innovative Model Development CAH Designation

List your Flex program award amounts, any approved carryover, and any unspent funds in the fields below. Actual program spending for the year will calculate automatically.

Spending Summary
Total award for Current Report Period
Enter 0 if none.
Total approved carryover for Current Report Period
Enter 0 if none.
Total unspent funds for Current Report Period

Downloads logs
Admin Home
Collection Periods
Role Assignment
Reports

CAH Operational and Financial Improvement CAH Population Health Improvement Rural EMS Improvement

Award Information

Actual Program Spending for Current Report Period

^

 Return to Top (Index)

Reporting Tools

CAH Quality Improvement

Grantee Raw Data
Report

Please enter the amount of Flex Funds utilized in the following activity categories. The amount should be a whole number.

Comparison Summary
Report
Comparision Trend

1.1 - Report and improve Core Patient Safety/Inpatient Measures, including develop antibiotic stewardship programs

Report
Summary

Flex Funds utilized toward Activity Category 1.1

Submissions Matrix
PDF Version

^

09/01/2015 - 08/31/2016

1.2 - Report and improve Core Patient Engagement Measures
Flex Funds utilized toward Activity Category 1.2

09/01/2016 - 08/31/2017
09/01/2017 - 08/31/2018

1.3 - Report and improve Core Care Transitions Measures (required annually)

09/01/2018 - 08/31/2019
09/01/2019 - 08/31/2020
Grantee Info
Grantee information

^

Flex Funds utilized toward Activity Category 1.3

1.4 - Report and improve Core Outpatient Measures (required annually)
Flex Funds utilized toward Activity Category 1.4

1.5 - Report and improve Additional Patient Safety Measures (optional)
Flex Funds utilized toward Activity Category 1.5

1.6 - Report and improve Additional Patient Engagement Measures (optional)
Flex Funds utilized toward Activity Category 1.6

1.7 - Report and improve Additional Care Transitions Measures (optional)
Flex Funds utilized toward Activity Category 1.7

1.8 - Report and improve Additional Outpatient Measures (optional)
Flex Funds utilized toward Activity Category 1.8

Subtotal
Flex Funds Utilized Towards CAH Quality Improvement

 Return to Top (Index)

CAH Operational and Financial Improvement
Please enter the amount of Flex Funds utilized in the following activity categories. The amount should be a whole number.

2.1 - Statewide operation and financial needs assessment (required annually)
Flex Funds utilized toward Activity Category 2.1

2.2 - Individual CAH-specific needs assessment and action planning (optional)
Flex Funds utilized toward Activity Category 2.2

2.3 - Financial improvement (optional)
Flex Funds utilized toward Activity Category 2.3

2.4 - Operational improvement (optional)
Flex Funds utilized toward Activity Category 2.4

2.5 - Value-based payment projects (optional)
Flex Funds utilized toward Activity Category 2.5

Subtotal
Flex Funds Utilized Towards CAH Operational and Financial Improvement

 Return to Top (Index)

CAH Population Health Improvement
Please enter the amount of Flex Funds utilized in the following activity categories. The amount should be a whole number.

3.1 - Support CAHs identifying community and resource needs (optional)
Flex Funds utilized toward Activity Category 3.1

3.2 - Assist CAHs to build strategies to prioritize and address unmet needs of the community (optional)
Flex Funds utilized toward Activity Category 3.2

3.3 - Assist CAHs to engage with community stakeholders and public health experts and address specific health needs (optional)
Flex Funds utilized toward Activity Category 3.3

Subtotal
Flex Funds Utilized Towards CAH Population Health Improvement

 Return to Top (Index)

Rural EMS Improvement
4.1 - Statewide rural EMS needs assessment and action planning (optional)
Flex Funds utilized toward Activity Category 4.1

4.2 - Community-level rural EMS assessments and action planning (optional)
Flex Funds utilized toward Activity Category 4.2

4.3 - EMS operational improvement (optional)
Flex Funds utilized toward Activity Category 4.3

4.4 - EMS quality improvement (optional)
Flex Funds utilized toward Activity Category 4.4

Subtotal
Flex Funds Utilized Towards Rural EMS Improvement

 Return to Top (Index)

Innovative Model Development
Please enter the amount of Flex Funds utilized in the following activity category. The amount should be a whole number.

5.1 - Develop and test innovative models and publish report or documentation of the innovation (optional)
Flex Funds utilized toward Activity Category 5.1

5.2 - Develop and test CAH outpatient clinic (including CAH-owned rural health clinics) quality reporting and publish report or documentation (optional)
Flex Funds utilized toward Activity Category 5.2

Subtotal
Flex Funds Utilized Towards Innovative Model Development

 Return to Top (Index)

CAH Designation

Please enter the amount of Flex Funds utilized in the following activity category. The amount should be a whole number.

6.1 - CAH conversions (required if assistance is requested by rural hospitals)
Flex Funds utilized toward Activity Category 6.1

6.2 - CAH transitions (required if assistance is requested by CAHs)
Flex Funds utilized toward Activity Category 6.2

Subtotal
Flex Funds Utilized Towards CAH Designation

 Return to Top (Index)

Actual Flex Program Spend
Total
Total Flex Funds Utilized

OMB Number: 0915-0363
Expiration Date: 07/30/2022
For technical help please call the HRSA Contact Center 1-877-Go4-HRSA (1-877-464-4772) or click to submit help request.
If Adobe Reader is not installed on your computer, please download to view PDF files.
Copyright © HRSA. All Rights Reserved.

Actual Flex Program Spend