| Grant Recipient Monthly Progress Report (MPR) – Optimizing Virtual Care (OVC) | |
| Version 4.0 Last Updated: 12/8/2022 | |
| I. Introduction | |
| This document is a suggested Monthly Progress Report (MPR) template for Optimizing Virtual Care (OVC) grant recipients to report project activities. We encourage you to use the Grant Recipient MPR to report information related to overall program implementation and the following OVC project objectives: A. Increase Access to Care and Information, B. Improve Clinical Quality and Health Outcomes, C. Enhance Patient Care Coordination, D. Promote Health Equity |
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| Please Note: Some questions included this document may not be relevant for all grant program’s activities. Grant recipients may choose to share additional information above and beyond the data requested in the "Share Additional Information" tab. | |
| II. Grant Recipient MPR Overview |
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| The Grant Recipient MPR template is organized into three sections and contains a total of 13 tabs, as described below. | |
| Section 1. Information and Instructions - Tabs in this section provide resources to support grant recipients in filling out the MPR Template sheets | |
| Introduction Tab | Provides an overview of the Grant Recipient MPR template and guidance for completing the form |
| Terms and Definitions Tab | Provides definitions for key terms used throughout the Grant Recipient MPR template |
| Section 2. Monthly Updates - This section of the Grant Recipient MPR Template provides table templates to support health centers with submitting MONTHLY progress report data and includes questions about A. Key Activity Implementation Tables and B. OVC Project Objective Updates, as listed below. | |
| Cover Page Tab | Enter grant recipient name, OVC grant number, BCHMIS ID, and reporting month |
| Key Activity 1 Tab Key Activity 2 Tab Key Activity 3 Tab Key Activity 4 Tab Key Activity 5 Tab |
Use the five activity tabs' tables to describe your health center’s experience implementing five key OVC project-related activities during the reporting month. Grant recipients are encouraged to list "activities" from their OVC Application Logic Model and Project Work Plan submissions. See “Attachment 2” in the OVC grant application for reference. Please enter only one activity per tab. |
| Section 3. Project Objective Updates and Additional Information - Tabs include reporting on OVC's four project objectives, and sharing information not otherwise reported. |
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| A. Access Tab B. Quality Tab C. Care Coordination Tab D. Health Equity Tab |
Describe your health center's progress implementing key activities related to the indicated OVC project objectives (A) Increasing Access to Patient Care and Information, B) Improving Clinical Quality and Health Outcomes, C) Enhancing Care Coordination, or D) Promoting Health Equity. Specific instructions are included on each tab. |
| Share Additional Information Tab | Grant recipients may use this tab to submit any additional information, comments, or data findings not requested in other areas of the template. For example, if your health center has a definable program for a specific patient population through the OVC grant, please report related data for OVC-specific telehealth visits and any other relevant information in the Share Additional Information tab. |
| III. Additional Guidance for Completing the Grant Recipient MPR Template | |
| Reporting Period: Monthly | |
| Submission Deadline: Monthly. Due to HRSA on the 5th of every month (Or the next regular business day if the 5th day falls on a Saturday, Sunday or federal holiday) | |
| Naming Convention: Rename this file using the following format before uploading to the EHB: OVC Grant Number_Reporting Month (example: X1XYZ10101_March 2022) | |
| IV. Version Updates Log | |
| Version (Last Updated) | Updates Made |
| 4.0 (12/8/22) | Throughout document, changed references to "2022" UDS Reporting Manual to the "most recent" UDS Reporting Manual, to support future MPR data reporting in 2023 and 2024. |
| 3.8 (8/31/22) | Key Activity tabs (1-5)- Added prompt 1a) Describe your health center's progress towards completing the Key Activity |
| 3.8 (8/31/22) | Terms and Definitions tab- Updated Terms and Definitions tab to align with the Terms and Definitions Tab in the Biannual Measures Report |
| 3.7 (6/13/22) | Cover Page tab- Removed the "BHCMIS ID #" item. |
| 3.7 (6/13/22) | C. Care Coordination tab- Removed Tables C.1.a., C.1.b., and C.2. |
| 3.7 (6/13/22) | C. Care Coordination tab- For Table C.3 Added row to report "supplies (Less than $5000)" purchased during the reporting month. Also combined rows for reporting on "Clinical" and "Non-Clinical" equipment purchases to instead report all "Equipment ($5,000 or more per unit cost)" purchased during the reporting month in one row. |
| 3.7 (6/13/22) | A. Access, B. Quality and C. Care Coordination tabs- Added an "Additional Comments" section on each tab to align with the Health Equity tab format |
| 3.7 (6/13/22) | Terms and Definitions tab- Added HRSA's definitions for "Equipment" and "Supplies" as referenced in Care Coordination Table C.3. |
| 3.7 (6/13/22) | Terms and Definitions tab- Updated relevant definitions to refer to the 2022 UDS manual, instead of the 2021 manual. |
| 3.6 (4/21/22) | Instructions tab- Added "Version Updates Log" to support version control |
| 3.6 (4/21/22) | Cover Page tab- Added text to clarify what to enter for 'Reporting Month/Year' |
| 3.6 (4/21/22) | Terms and Definitions tab - Added descriptions for each of the UDS service categories referenced in Care Coordination Tables C.1a and C.1b. Added the HHS definition of "community-based organization" referenced in Health Equity Table D.1 |
| 3.6 (4/21/22) | Key Activities tabs (1 to 5)- Added instruction to include 'n/a' in all free text boxes if there is no relevant information to report in a given month. |
| 3.6 (4/21/22) | Key Activities tabs (1 to 5) and Tabs A-D- Changed formatting so that if grant recipients enter incorrectly formatted data, an informational note will pop up. ('Informational' data validation) |
| 3.6 (4/21/22) | Quality tab, Table B.1.- Corrected 2 typos Clinical Activities items to read Breast "Cancer" and Cervical "Cancer" instead of "Care" |
| 3.6 (4/21/22) | Care Coordination tab, Tables C.1a and C.1b- Corrected format validation issue to allow grant recipients to enter positive with decimal points (prior validations only allowed whole numbers 1 to 100). Added clarification to 'Hired FTEs' and 'FTEs Completed Virtual Care Training', updated tab guidance to enter "0" in cells if applicable. Expanded the Service Categories to align with categories the 2021 UDS Table 5. Added all service category descriptions to the Terms and Definitions tab. Added guidance that to include "initial or reoccurring training" to clarify relevant FTE virtual care training types. |
| 3.6 (4/21/22) | Care Coordination tab, Table C.3- Added guidance to enter "0" in cells to indicate no spending for the given cell |
| 3.6 (4/21/22) | Health Equity tab, Table D.1- Updated "community organization" to "community-based organization" to align with HHS terminology. Added directions to reference the Terms and Definitions tab for the HHS definition. Added instruction to include 'n/a' in all free text boxes if there is no relevant information to report in a given month. |
| Key Term | Definition | Examples and References |
| Appointment Wait Time | Refers to the time (in days) patients must wait before they can see a health care provider for an appointment. | |
| Community-Based Organization | As defined by the HHS Office of the Secretary for Preparedness and Response, community-based organizations (CBOs) are public or private not-for-profit resource hubs that provide specific services to the community or targeted population within the community. CBOs include but are not limited to aging and disability networks, community health centers, childcare providers, home visiting programs, state domestic violence coalitions and local domestic violence shelters and programs, adult protective services programs, homeless services providers, and food banks that work to address the health and social needs of populations. | |
| Countable Visit | A documented in-person or virtual live video and/or audio (synchronous, real time) interaction between a patient and a licensed or credentialed provider who exercises his/her independent, professional judgment in the provision of services to the patient. | |
| Ethnicity | Self-reported patient ethnicity (Hispanic or Latina/o or Not Hispanic/Latina/o). | |
| Equipment | As defined by HRSA, tangible personal property (including information technology systems) having a useful life of more than one year and a per-unit acquisition cost which equals or exceeds the lesser of the capitalization level established by the non-federal entity for financial statement purposes, or $5,000. | |
| Face-to-Face (In-Person) Health Visit | Documented, in-person, face-to-face contact between a patient and a provider who exercises objective judgment in the provision of services to the patient. To be included as a visit, services rendered must be documented in the patient’s record. | |
| Limited English Proficient (LEP) | Describes individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English. | |
| Medical Insurance | Patient's primary medical insurance (Medicare, Medicaid/Children's Health Insurance Program (CHIP)/other public insurance, private insurance). | |
| Patient | A person who has at least one in-person or virtual encounter or countable visit in the last 12 months. | |
| Patient Encounter | An in-person or virtual interaction between an awardee health center and a patient for the purposes of health care. | |
| Patient Visit (Or Countable Visit) | A documented in-person or virtual live video and/or audio (synchronous, real time) interaction between a patient and a licensed or credentialed provider who exercises his/her independent, professional judgment in the provision of services to the patient. | |
| Race | Self-reported patient race (Asian, Native Hawaiian, Black, African American, White, More than one race). | |
| Special Populations | Migratory and seasonal agricultural workers, homeless populations, residents of public housing, patients from school-based health centers, veterans, and populations with limited English proficiency. | See the most recent Uniform Data System Reporting Manual, Appendix A. |
| Supplies | As defined by HRSA, all tangible personal property other than those described in Equipment. A computing device is a supply if the acquisition cost is less than the lesser of the capitalization level established by the non-federal entity for financial statement purposes or $5,000, regardless of the length of its useful life. | |
| Telehealth | The use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. | |
| Telemedicine | Telemedicine is a subset of telehealth services referring to remote clinical services. | |
| UDS Service Categories | Medical care services, dental services, mental health services, substance use disorder services, other professional services, vision services, enabling services, pharmacy personnel, other programs and services, quality improvement staff, total facility and non-clinical support staff. See the most recent Uniform Data System Reporting Manual. | |
| UDS Service Categories for Countable Visits | Includes medical care, dental, mental health, substance use disorder, vision, other professional services, enabling services. | See the most recent Uniform Data System Reporting Manual, Appendix A. |
| UDS Service Category: Dental Services | Personnel include general dental practitioners, oral surgeons, periodontists, endodontists, dental hygienists, dental therapists, dental assistants and advanced dental practice assistants, dental technicians, dental aides, and dental students (including hygienists students). | See the most recent Uniform Data System Reporting Manual, Appendix A. |
| UDS Service Category: Enabling Services | Personnel include case managers, case/referral coordinators, patient advocates, social workers, public health nurses, home health nurses, visiting nurses, registered nurses, licensed practical nurses/licensed vocational nurses, family planning counselors, health educators, outreach workers, patient transportation coordinators, drivers (including mobile van drivers), benefits assistance workers, pharmacy assistance program eligibility workers, eligibility workers, patient navigators, patient advocates, registration clerks, certified assisters, interpreters, translators, community health workers, community health advisors or representatives, lay health advocates, promotoras, and other enabling sevices personnel. | See the most recent Uniform Data System Reporting Manual, Appendix A. |
| UDS Service Category: Medical Care Services | Personnel include family practitioners, general practitioners, internists, obstetricians/gynecologists, pediatricians, licensed medical residents, allergists, cardiologists, dermatologists, endocrinologists, orthopedists, surgeons, urologists, other physician specialists and sub-specialists, nurse practitioners, physician assistants, certified nurse midwives, clinical nurse specialists, public health nurses, home health nurses, visiting nurses, registered nurses, licensed practical nurses/licensed vocational nurses, nurse emergency medical services/nurse emergency medical technicians, nurses aides/assistants (certified and uncertified), clinic aides/medical assistants (certified and uncertified medical technologists), unlicensed interns and residents, EMT/EMS personnel, pathologists, medical technologists, laboratory technicians, laboratory assistants, phlebotomists, radiologists, X-ray technologists, X-ray technicians, radiology assistants and ultrasound technicians. | See the most recent Uniform Data System Reporting Manual, Appendix A. |
| UDS Service Category: Mental Health Services | Personnel include psychiatrists, psychologists, clinical and psychiatric social workers, family therapists, psychiatric nurse practitioners, psychiatric and mental health nurses, and unlicensed mental health providers, including trainees (interns or residents), and "certified" personnel. | See the most recent Uniform Data System Reporting Manual, Appendix A. |
| UDS Service Category: Other Professional Services | Personnel include audiologists, acupuncturists, chiropractors, community health aides and practitioners, herbalists, massage therapists, naturopaths, registered dietitians (including nutritionists/dietitians), occupational therapists, podiatrists, physical therapists, respiratory therapists, speech therapists/pathologists, and traditional healers. | See the most recent Uniform Data System Reporting Manual, Appendix A. |
| UDS Service Category: Other Programs and Services | Personnel include WIC workers, Head Start workers, housing assistance workers, child care workers, food bank/meal delivery workers, employment/educational counselors, exercise trainers/fitness trainer personnel, adult day care and frail elderly support personnel. | See the most recent Uniform Data System Reporting Manual, Appendix A. |
| UDS Service Category: Pharmacy Personnel | Personnel include pharmacists, clinical pharmacists, pharmacy technicians, pharmacist assistants, and pharmacy clerks. | See the most recent Uniform Data System Reporting Manual, Appendix A. |
| UDS Service Category: Quality Improvement Staff | Personnel include QI nurses, QI technicians, QI data specialists, statisticians and analysts, quality assurance/quality improvement and HIT/EHR design and operation personnel. | |
| UDS Service Category: Substance Use Disorder Services | Personnel include unlicensed substance use disorder providers, including trainees (interns or residents), and "certified" personnel, alcohol and drug abuse counselors, and RN counselors. | See the most recent Uniform Data System Reporting Manual, Appendix A. |
| UDS Service Category: Total Facility and Non-Clinical Support Staff |
Personnel include project directors, chief executive officers/executive directors, chief financial officers/fiscal officers, chief information officers, chief medical officers, secretaries/administrative assistants, administrators, directors of planning and evaluation, clerk typists, personnel directors, receptionists, directors of marketing, marketing representatives, enrollment/service representatives, finance directors, accountants, bookkeepers, billing clerks, cashiers, data entry clerks, directors of data processing, programmers, IT help desk technicians, janitors/custodians, security guards, groundskeepers, equipment maintenance personnel, housekeeping personnel, medical and dental team clerks, medical and dental team secretaries, medical and dental appointment clerks, medical and dental patient health records clerks, patient health records supervisors, patient health records technicians, patient health records clerks, patient health records transcriptionists, and appointments clerks. | See the most recent Uniform Data System Reporting Manual, Appendix A. |
| UDS Service Category: Vision Services | Personnel include ophthalmologists, optometrists, ophthalmologist/optometric assistants, ophthalmologist/optometric aides, and ophthalmologist/optometric technicians. | See the most recent Uniform Data System Reporting Manual, Appendix A. |
| Virtual Care Encounter | A virtual interaction between an awardee health center and a patient for the purposes of health care. May include, but is not limited to virtual care visits. | |
| Virtual Care Type: Asynchronous Store and Forward (Store and Forward Telehealth, Asynchronous Telehealth) | Definition: Use of technology for the electronic transmission of medical information for remote evaluation, such as x-rays, sonograms, other digital images, data derived from questionnaires, and pre-recorded audio and/or videos that are not real-time interactions. Key Components: • Not real time (asynchronous). • Use of technology to electronically transmit x-rays, sonograms, other digital images, data derived from questionnaires, and pre-recorded audio and/or videos. • Includes evaluation by a provider, which is defined as interpretation and follow-up. • Includes e-consults: interprofessional provider to provider consultations that involve assessment and management services provided by a consultative physician, including report to the patient's treating/requesting physician or other qualified healthcare professional. • Guidance note: Medical information may be submitted by a patient and transmitted to a provider for remote evaluation, or transmitted provider to provider for remote evaluation. • Guidance note: Medical information may include data derived from questionnaires. Technology: Any technology that can electronically transmit x-rays, sonograms, other digital images, data derived from questionnaires, and pre-recorded audio and/or videos. |
Examples of provider to provider asynchronous store and forward: • Secure emails with photos or videos of patient examination • Sending patient x-rays or other images to provider for evaluation Examples of patient to provider asynchronous store and forward: • Youth completing a mental health assessment screener and sending to pediatrician through a patient portal • Email or text messages with follow-up instructions or confirmations (HHS) |
| Virtual Care Type: Mobile Health (mHealth) | Definition: Use of technologies, like smartphone and tablet apps, that enable patients to capture or track personal health, fitness, or wellness information, or to access general health education materials, independent of an interaction with a health care provider, AND do not meet the FDA definition of a device. Key Components: • Does not meet the FDA definition of a device. • Used to capture or track personal health, fitness, or wellness data. • Used to access general-purpose health education (e.g., tutorials, training videos, articles, info on accessing services etc.). • Independent of an interaction with a health care provider. Guidance note: a provider could suggest an app. Technology: Smart phone or tablet applications (apps) NOT meeting the definition of an FDA defined device. (FDA:https://www.fda.gov/industry/regulated-products/medical-device-overview#What%20is%20a%20medical%20device). |
Examples of mHealth: • Sleep tracker • Fitness tracker • Calmness app • Step counter Examples that are NOT mHealth: • Smart phone or tablet applications (apps) that are used as an accessory to FDA defined “device” used for remote patient monitoring (e.g., an app for a continuous glucose monitor or an app that collects blood pressure data from a self-monitoring device). • Automatic push notifications/reminders [see other telehealth]. |
| Virtual Care Type: Other Asynchronous Services | Definition: Includes any other asynchronous virtual care types not described in the categories above. | Examples of other virtual care technologies: • Chatbot interactions that simulate human interaction. • Asynchronous portal, email, or text messaging for general health promotion, disease prevention, promotion of health services, and/to provide care access information. • Use of automatic reminders. • Use of push notifications. |
| Virtual Care Type: Remote Patient Monitoring (RPM, Remote monitoring, remote physiologic monitoring, remote therapeutic monitoring, RTM) | Definition: Using a specific technology device to collect and transmit medical patient data such as vital signs, pulse, and blood pressure from patients in one location (typically a home) to health care providers in a different location for monitoring and evaluation. Criteria: • Can be synchronous or asynchronous. • Instrument or monitoring tool collecting patient data must meet the FDA definition of a device (see FDA link in Technology section below). Guidance question: Based on clinical judgement, would a Qualified Health Professional consider this a device? • Device must be prescribed or recommended by a provider and documented in the patient health record. Guidance note: Remote patient monitoring can be furnished/provided by other Qualified Health Professionals under the general supervision of a provider. (Note: the recommendation does need to be documented.) • Data must be able to be digitally uploaded or transferred (automatically) to a secure location where the data is available for analysis and interpretation by a Provider or other Qualified Health Professional. • Provider or other Qualified Health Professional uses the data to understand the patient’s status and/or develop a care plan (i.e. Remote Monitoring is an integral part of the patient’s care plan). Technology: Use of a technology that meets the FDA definition of a device, "Intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease" (https://www.fda.gov/industry/regulated-products/medical-device-overview#What%20is%20a%20medical%20device). *Guidance note: Includes smartphone or tablet application (apps) that are used as an accessory to a FDA defined “device” for remote patient monitoring (e.g., an app for a continuous glucose monitor or an app that collects blood pressure data from a self-monitoring device)". |
Examples of Remote Patient Monitoring: • Flash glucose monitor • Continuous glucose monitor (CGM) • Blood pressure monitor • Oximetry monitor • Pacemakers • Telemetry monitor (when automatically collected) • Remote Therapeutic Monitoring (e.g., inhaler that records use) Examples that are NOT Remote Patient Monitoring: • Patient independently chooses or receives a suggestion to use a Fitness tracker app (e.g. My Fitness Pal), but the app use does NOT meet the criteria for remote patient monitoring. |
| Virtual Care Type: Synchronous Real-time Telehealth - Audio-Only (Audio-only visits) |
Definition: Use of a two-way, interactive audio-only technology, such as a telephone for “live” or real-time interactions between a patient and provider. Key Components: • Live or real-time interaction. • Interaction is between patient and provider. • Evaluation/management and remote clinical services that meet the UDS definition of telemedicine. Technology: Telephone or other audio-only technology. |
Examples of audio-only synchronous real-time telehealth: • Audio only calls to confirm instructions (HHS). |
| Virtual Care Type: Synchronous Real-Time Telehealth Video (Live video) |
Definition: Use of a two-way video technology or other HIPAA compliant video connection to conduct a “live” or real-time interactive visit between a patient and provider. Key Components: • Live or real-time interaction. • Evaluation/management or remote clinical services that meet the UDS definition of telemedicine. Technology: Video (i.e., integrated video/audio conferencing technology) or other HIPAA compliant video connection. |
Examples of video-based synchronous real-time telehealth: • Video calls with remote physician to share progress or check on healing (HHS). |
| Virtual Care Types | 1. Synchronous Real-time Telehealth - Audio-Only (Audio-only visits) 2. Synchronous Real-Time Telehealth Video (Live video) 3. Asynchronous Store and Forward (Store and Forward Telehealth, Asynchronous Telehealth) 4. Remote Patient Monitoring (RPM, Remote monitoring, remote physiologic monitoring, remote therapeutic monitoring, RTM) 5. Mobile health (mHealth) 6. Other Asynchronous Services |
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| Virtual Care Visit | Virtual (telemedicine/telehealth) contact between a patient and a licensed or credentialed provider who exercises his/her independent, professional judgment in the provision of services to the patient. Virtual visits must be provided using interactive, synchronous audio and/or video telecommunication systems that permit real-time communication between the provider and a patient. Virtual visits should use codes that will result in accurate identification of virtual visits. These include telehealth-specific codes with the CPT or Healthcare Common Procedure Coding System (HCPCS) codes such as G0071, G0406-G0408, G0425-G0427, G2025, modifier “.95,” or Place of Service code “02” to identify virtual visits. See the most recent Uniform Data System Reporting Manual. |
| Grant Recipient Monthly Progress Report (MPR) – Optimizing Virtual Care (OVC) | ||
| Grant Recipient Information (Please complete below) | ||
| Grant Recipient Organization Name | OVC Grant Number | Reporting Month/Year* |
| *Reporting Month/Year refers to the calendar month and year for which data was collected. For example, for data collected between April 1-30; the Reporting Month and Year is April 2022. | ||
| Public Burden Statement: Data collection for the Optimizing Virtual Care (OVC) Grant program will provide HRSA with information to guide future program and policy decisions regarding virtual care. 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 0906 -XXXX and it is valid until XX/XX/202X. This information collection is required for HRSA-funded health centers to obtain or retain OVC grant funding. Public reporting burden for this collection of information is estimated to average 2 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 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov. |
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| Instructions: Please complete the "Key Activity 1" table each month to describe your health center’s engagement in one of at least five program-related activities identified in the “Optimizing Virtual Care Work Plan." See “Attachment 2” in the OVC grant application for reference. Please submit only one activity per table. In the Monthly Key Activity Table below, list 1) one key program-related activity reported in your health center’s "Optimizing Virtual Care Work Plan” and describe progress made towards completing the activity. For the activity listed, identify the OVC project (2) objective(s) the activity addresses, (3) changes to the activity work plan (4) activity status, (5) challenges/obstacles, (6) successes, (7) lessons learned, and (8) additional comments. |
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| 1) Key Activity 1: (Write In) Example: "Recruit, hire, and train new staff; integrate existing teams into the project” |
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| 1a) Describe your health center's progress towards completing Key Activity 1 this month, including components of the activity that you are currently working on: (Write In) Example: "Onboarded new virtual care team staff member" |
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| (Select (X) all that apply) | 2) Objective: What OVC objective(s) does this activity address? |
| A. Increase Access to Care and Information | |
| B. Improve Clinical Quality and Health Outcomes | |
| C. Enhance Patient Care Coordination | |
| D. Promote Health Equity | |
| (Select (X) One) | 3) Did you change the work plan for this activity during the reporting period? |
| No | |
| Yes | |
| 3a) [If yes] Please describe the change and the reasons for the change (100 Words Max): | |
| (Select (X) all that apply) | 4) Activity Status: This activity… |
| Is not started | |
| Is completed | |
| Is in progress and on schedule | |
| Is in progress and timing is delayed | |
| Is started but will not be completed in the grant period | |
| (Select (X) all that apply) | 5) Challenges: What challenges impacted your health center's ability to implement this activity during the reporting month? Challenges related to…. |
| Patient adoption | |
| Staff adoption | |
| Community engagement | |
| Telehealth technology or vendor issues | |
| Health center logistical space or workflow challenges | |
| Organizational structure (e.g., policies, processes, or governance) | |
| Cost and/or service reimbursements | |
| Information security, privacy, and confidentiality | |
| Technology infrastructure (e.g., broadband and/or telecommunication services) | |
| Local, state, and/or federal policies | |
| Other (Write in): ____________________________ | |
| 5a) How did challenges impact the activity? (Please consider impacts related to achieving OVC project objectives) (300 Word Max, enter 'n/a' if no challenges to report for this month) | |
| 6) Success: What activity-related achievements did the health center make during this reporting month? (i.e. organizational benchmarks, community recognitions) Please list achievements below. (300 Word Max, enter 'n/a' if none to report this month) |
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| 6a) What factors contributed to these achievements? (300 Word Max, enter 'n/a' if no factors to report for this month) | |
| 7) Lessons Learned: What lessons did the health center learn during the reporting month? (300 Word Max, enter 'n/a' if no lessons learned to report for this month) |
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| 8) Additional comments about this activity (Enter n/a if no additional comments to report for this month) | |
| Instructions: Please complete the "Key Activity 2" table each month to describe your health center’s engagement in one of at least five program-related activities identified in the “Optimizing Virtual Care Work Plan." See “Attachment 2” in the OVC grant application for reference. Please submit only one activity per table. In the Monthly Key Activity Table below, list 1) one key program-related activity reported in your health center’s "Optimizing Virtual Care Work Plan” and describe progress made towards completing the activity. For the activity listed, identify the OVC project (2) objective(s) the activity addresses, (3) changes to the activity work plan (4) activity status, (5) challenges/obstacles, (6) successes, (7) lessons learned, and (8) additional comments. |
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| 1) Key Activity 2: (Write In) Example:“Develop a standardized workflows for telehealth visits and virtual care patient training and support." |
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| 1a) Describe your health center's progress towards completing Key Activity 2 this month, including components of the activity that you are currently working on: (Write In) Example: "Key virtual care team members reviewed workflow draft." |
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| (Select (X) all that apply) | 2) Objective: What OVC objective(s) does this activity address? |
| A. Increase Access to Care and Information | |
| B. Improve Clinical Quality and Health Outcomes | |
| C. Enhance Patient Care Coordination | |
| D. Promote Health Equity | |
| (Select (X) One) | 3) Did you change the work plan for this activity during the reporting period? |
| No | |
| Yes | |
| 3a) [If yes] Please describe the change and the reasons for the change (100 Words Max): | |
| (Select (X) all that apply) | 4) Activity Status: This activity… |
| Is not started | |
| Is completed | |
| Is in progress and on schedule | |
| Is in progress and timing is delayed | |
| Is started but will not be completed in the grant period | |
| (Select (X) all that apply) | 5) Challenges: What challenges impacted your health center's ability to implement this activity during the reporting month? Challenges related to…. |
| Patient adoption | |
| Staff adoption | |
| Community engagement | |
| Telehealth technology or vendor issues | |
| Health center logistical space or workflow challenges | |
| Organizational structure (e.g., policies, processes, or governance) | |
| Cost and/or service reimbursements | |
| Information security, privacy, and confidentiality | |
| Technology infrastructure (e.g., broadband and/or telecommunication services) | |
| Local, state, and/or federal policies | |
| Other (Write in): ____________________________ | |
| 5a) How did challenges impact the activity? (Please consider impacts related to achieving OVC project objectives) (300 Word Max, enter 'n/a' if no challenges to report for this month.) |
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| 6) Success: What activity-related achievements did the health center make during this reporting month? (i.e. organizational benchmarks, community recognitions) Please list achievements below. (300 Word Max, enter 'n/a' if none to report this month) |
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| 6a) What factors contributed to these achievements? (300 Word Max, enter 'n/a' if no factors to report for this month.) | |
| 7) Lessons Learned: What lessons did the health center learn during the reporting month? (300 Word Max, enter 'n/a' if no lessons learned to report for this month.) | |
| 8) Additional comments about this activity (Enter n/a if no additional comments to report for this month) | |
| Instructions: Please complete the "Key Activity 3" table each month to describe your health center’s engagement in one of at least five program-related activities identified in the “Optimizing Virtual Care Work Plan." See “Attachment 2” in the OVC grant application for reference. Please submit only one activity per table. In the Monthly Key Activity Table below, list 1) one key program-related activity reported in your health center’s "Optimizing Virtual Care Work Plan" and describe progress made towards completing the activity. For the activity listed, identify the OVC project (2) objective(s) the activity addresses, (3) changes to the activity work plan (4) activity status, (5) challenges/obstacles, (6) successes, (7) lessons learned, and (8) additional comments. |
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| 1) Key Activity 3: (Write In) Example:“Purchase and install new cameras and speakers for exam rooms and to optimize telehealth visits." |
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| 1a) Describe your health center's progress towards completing Key Activity 3 this month, including components of the activity that you are currently working on: (Write In) Example: "Received and compared quotes from four vendors for new cameras." |
|
| (Select (X) all that apply) | 2) Objective: What OVC objective(s) does this activity address? |
| A. Increase Access to Care and Information | |
| B. Improve Clinical Quality and Health Outcomes | |
| C. Enhance Patient Care Coordination | |
| D. Promote Health Equity | |
| (Select (X) One) | 3) Did you change the work plan for this activity during the reporting period? |
| No | |
| Yes | |
| 3a) [If yes] Please describe the change and the reasons for the change (100 Words Max): | |
| (Select (X) all that apply) | 4) Activity Status: This activity… |
| Is not started | |
| Is completed | |
| Is in progress and on schedule | |
| Is in progress and timing is delayed | |
| Is started but will not be completed in the grant period | |
| (Select (X) all that apply) | 5) Challenges: What challenges impacted your health center's ability to implement this activity during the reporting month? Challenges related to…. |
| Patient adoption | |
| Staff adoption | |
| Community engagement | |
| Telehealth technology or vendor issues | |
| Health center logistical space or workflow challenges | |
| Organizational structure (e.g., policies, processes, or governance) | |
| Cost and/or service reimbursements | |
| Information security, privacy, and confidentiality | |
| Technology infrastructure (e.g., broadband and/or telecommunication services) | |
| Local, state, and/or federal policies | |
| Other (Write in): ____________________________ | |
| 5a) How did challenges impact the activity? (Please consider impacts related to achieving OVC project objectives) (300 Word Max, enter 'n/a' if no challenges to report for this month) | |
| 6) Success: What activity-related achievements did the health center make during this reporting month? (i.e. organizational benchmarks, community recognitions) Please list achievements below. (300 Word Max, enter 'n/a' if none to report this month) |
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| 6a) What factors contributed to these achievements? (300 Word Max, enter 'n/a' if no factors to report for this month) | |
| 7) Lessons Learned: What lessons did the health center learn during the reporting month? (300 Word Max, enter 'n/a' if no lessons learned to report for this month) | |
| 8) Additional comments about this activity (Enter n/a if no additional comments to report for this month) | |
| Instructions: Please complete the "Key Activity 4" table each month to describe your health center’s engagement in one of at least five program-related activities identified in the “Optimizing Virtual Care Work Plan." See “Attachment 2” in the OVC grant application for reference. Please submit only one activity per table. In the Monthly Key Activity Table below, list 1) one key program-related activity reported in your health center’s "Optimizing Virtual Care Work Plan" and describe progress made towards completing the activity. For the activity listed, identify the OVC project (2) objective(s) the activity addresses, (3) changes to the activity work plan (4) activity status, (5) challenges/obstacles, (6) successes, (7) lessons learned, and (8) additional comments. |
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| 1) Key Activity 4: (Write In) Example:"Purchase remote monitoring devices (pulse oximeters and RPM scales) and distribute to eligible patients." |
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| 1a) Describe your health center's progress towards completing Key Activity 4 this month, including components of the activity that you are currently working on: (Write In) Example: "Identified patients eligible for receiving remote monitoring devices." |
|
| (Select (X) all that apply) | 2) Objective: What OVC objective(s) does this activity address? |
| A. Increase Access to Care and Information | |
| B. Improve Clinical Quality and Health Outcomes | |
| C. Enhance Patient Care Coordination | |
| D. Promote Health Equity | |
| (Select (X) One) | 3) Did you change the work plan for this activity during the reporting period? |
| No | |
| Yes | |
| 3a) [If yes] Please describe the change and the reasons for the change (100 Words Max): | |
| (Select (X) all that apply) | 4) Activity Status: This activity… |
| Is not started | |
| Is completed | |
| Is in progress and on schedule | |
| Is in progress and timing is delayed | |
| Is started but will not be completed in the grant period | |
| (Select (X) all that apply) | 5) Challenges: What challenges impacted your health center's ability to implement this activity during the reporting month? Challenges related to…. |
| Patient adoption | |
| Staff adoption | |
| Community engagement | |
| Telehealth technology or vendor issues | |
| Health center logistical space or workflow challenges | |
| Organizational structure (e.g., policies, processes, or governance) | |
| Cost and/or service reimbursements | |
| Information security, privacy, and confidentiality | |
| Technology infrastructure (e.g., broadband and/or telecommunication services) | |
| Local, state, and/or federal policies | |
| Other (Write in): ____________________________ | |
| 5a) How did challenges impact the activity? (Please consider impacts related to achieving OVC project objectives) (300 Word Max, enter 'n/a' if no challenges to report for this month) | |
| 6) Success: What activity-related achievements did the health center make during this reporting month? (i.e. organizational benchmarks, community recognitions) Please list achievements below. (300 Word Max, enter 'n/a' if none to report this month) |
|
| 6a) What factors contributed to these achievements? (300 Word Max, enter 'n/a' if no factors to report for this month) | |
| 7) Lessons Learned: What lessons did the health center learn during the reporting month? (300 Word Max, enter 'n/a' if no lessons learned to report for this month) | |
| 8) Additional comments about this activity (Enter n/a if no additional comments to report for this month) | |
| Instructions: Please complete the "Key Activity 5" table each month to describe your health center’s engagement in one of at least five program-related activities identified in the “Optimizing Virtual Care Work Plan." See “Attachment 2” in the OVC grant application for reference. Please submit only one activity per table. In the Monthly Key Activity Table below, list 1) one key program-related activity reported in your health center’s "Optimizing Virtual Care Work Plan" and describe progress made towards completing the activity. For the activity listed, identify the OVC project (2) objective(s) the activity addresses, (3) changes to the activity work plan (4) activity status, (5) challenges/obstacles, (6) successes, (7) lessons learned, and (8) additional comments. |
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| 1) Key Activity 5: (Write In) Example:"Collaborate with community organization partners to enhance remote monitoring patient experience and utilization" |
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| 1a) Describe your health center's progress towards completing Key Activity 5 this month, including components of the activity that you are currently working on: (Write In) Example: "Met with food pantry to discuss setting up a device distribution site." |
|
| (Select (X) all that apply) | 2) Objective: What OVC objective(s) does this activity address? |
| A. Increase Access to Care and Information | |
| B. Improve Clinical Quality and Health Outcomes | |
| C. Enhance Patient Care Coordination | |
| D. Promote Health Equity | |
| (Select (X) One) | 3) Did you change the work plan for this activity during the reporting period? |
| No | |
| Yes | |
| 3a) [If yes] Please describe the change and the reasons for the change (100 Words Max): | |
| (Select (X) all that apply) | 4) Activity Status: This activity… |
| Is not started | |
| Is completed | |
| Is in progress and on schedule | |
| Is in progress and timing is delayed | |
| Is started but will not be completed in the grant period | |
| (Select (X) all that apply) | 5) Challenges: What challenges impacted your health center's ability to implement this activity during the reporting month? Challenges related to…. |
| Patient adoption | |
| Staff adoption | |
| Community engagement | |
| Telehealth technology or vendor issues | |
| Health center logistical space or workflow challenges | |
| Organizational structure (e.g., policies, processes, or governance) | |
| Cost and/or service reimbursements | |
| Information security, privacy, and confidentiality | |
| Technology infrastructure (e.g., broadband and/or telecommunication services) | |
| Local, state, and/or federal policies | |
| Other (Write in): ____________________________ | |
| 5a) How did challenges impact the activity? (Please consider impacts related to achieving OVC project objectives) (300 Word Max, enter 'n/a' if no challenges to report for this month) | |
| 6) Success: What activity-related achievements did the health center make during this reporting month? (i.e. organizational benchmarks, community recognitions) Please list achievements below. (300 Word Max, enter 'n/a' if none to report this month) |
|
| 6a) What factors contributed to these achievements? (300 Word Max, enter 'n/a' if no factors to report for this month) | |
| 7) Lessons Learned: What lessons did the health center learn during the reporting month? (300 Word Max, enter 'n/a' if no lessons learned to report for this month) | |
| 8) Additional comments about this activity (Enter n/a if no additional comments to report for this month) | |
| Instructions: Please complete the "A. Access" table below to describe your health center's efforts related to: A) Increasing Patient Access to Care and Information |
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| A. Access: Increase Patient Access to Care and Information | ||
| A.1. What types of virtual care did your a) overall health center and b) Specific OVC grant-funded project* use during the reporting month? (See Terms and Defininitions tab for descriptions of virtual care types) (Select (X) below for all that apply) |
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| a) Overall Health Center | b) Specific OVC project (optional*) | Virtual Care Type |
| Face-to-Face (In-Person) Visits | ||
| Synchronous – Live Audio Only | ||
| Synchronous – Live Video | ||
| Asynchronous Store and Forward | ||
| Remote Monitoring | ||
| Mobile Health (mHealth) | ||
| Other Asynchronous Technology (Write In): ____________________ | ||
| *If applicable, for health centers that have different data for OVC-specific activities to report in a given month | ||
| A.2. Additional Comments: (300 Word Max, enter 'n/a' if none to report for this month) | ||
| Instructions: Please complete the "B.Quality" table below to describe your health center's efforts related to: B) Improving Clinical Quality and Health Outcomes |
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| B. Quality: Improve Clinical Quality and Health Outcomes | ||
| B.1. Which of the following clinical activities, from the most recent UDS Clinical Quality Measures, did your a) overall health center and b) specific OVC grant-funded project* implement using virtual care during the reporting month? (Select (X) all that apply) | ||
| a) Overall Health Center | b) Specific OVC project (optional*) | Clinical Activities |
| None of These or Technology Not Offered | ||
| Breast Cancer Screening | ||
| Cervical Cancer Screening | ||
| Childhood Immunization Status | ||
| Colorectal Cancer Screening | ||
| Depression Screening and Follow-Up Plan | ||
| Diabetes Eye Exam** | ||
| HIV Screening | ||
| Diabetes Control (Hemoglobin A1C) | ||
| High Blood Pressure Control | ||
| Depression Remission, 12 months | ||
| Other (Write In): _____________________________________ | ||
| Other (Write In): _____________________________________ | ||
| Other (Write In): _____________________________________ | ||
| *If applicable, for health centers that have different data for OVC-specific activities to report in a given month | ||
| ** 'Diabetes Eye Exam' is a CMS electronic clinical quality measure (eCQM CMS131V10), not a current UDS Measure | ||
| B.2. Additional Comments: (300 Word Max, enter 'n/a' if none to report for this month) | ||
| Instructions: Please complete the "C. Care Coordination" tables below to describe your health center's efforts related to: C) Enhancing Care Coordination |
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| C. Care Coordination: Enhance Patient Care Coordination | ||
| C.3. Please describe your health centers OVC-grant fund spending on clinical and non-clinical equipment and supplies* during the reporting month. Use Column A to record the total amount spent. Please enter "0" to indicate no spending during the reporting month. Use Column B to describe purchases made during the reporting month. | ||
| Equipment or Supply Type | A. Total Amount | B. Description |
| Equipment ($5,000 or more per unit cost) | ||
| Supplies (Less than $5,000 per unit cost) | ||
| *See Terms and Definitions tab for HRSA's full definitions of 'supplies' and 'equipment' | ||
| C.3. Additional Comments: (300 Word Max, enter 'n/a' if none to report for this month) | ||
| Instructions: Please complete the "C. Health Equity" tables below to describe your health center's efforts related to: D) Promoting Health Equity |
|
| D. Promote Health Equity | |
| D.1. List and describe the community-based organizations* your health center partnered with to support virtual care. Please list one organization per row and add additional rows if needed. (Enter 'n/a' if none to report for this month.) | |
| Community-Based Organization Name (City, State) | Describe partnership activity |
| *See Terms and Definitions tab for HHS' definition of community-based organizations | |
| D.2. Which standardized screener(s) for social risk factors, if any, did your health center use during the reporting month? | |
| Select (X) all that apply | Standardized screeners (Click embedded link for more information) |
| Accountable Health Communities Screening Tool | |
| Upstream Risks Screening Tool and Guide | |
| iHELP/ HELLP (Income, Housing, Education, Legal Status, Literacy, Personal, Safety Questionnaire) | |
| Recommend Social and Behavioral Domains for EHRs | |
| (PRAPARE) Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences | |
| (WE CARE) Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education | |
| WellRx | |
| Health Leads Screening Toolkit | |
| Other: (Please describe): _______________________________________ | |
| We DO NOT use a standardized screener | |
| D.3. List and describe the processes, events, and materials your health center used to educate staff about disparities in access to virtual care among patients served during the reporting month. (Enter 'n/a' if none to report for this month.) | |
| Process/Event/Material Name | Description (50 Word Max each) |
| D.4. What did you hear from providers about virtual care use during the reporting month? (Consider challenges, successes, and lessons shared formally and/or informally) (300 Word Max, enter 'n/a' if none to report for this month.) |
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| D.5. What did you hear from patients about virtual care use during the reporting month? (Consider challenges, successes, and lessons shared formally and/or informally) (300 Word Max, enter 'n/a' if none to report for this month) |
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| D.6. Additional Comments: (300 Word Max, enter 'n/a' if none to report for this month) | |
| Share Additional Information | |||||||||||||
| Grant recipients may use this tab to submit any additional information, comments, or data findings not requested in other areas of the template. |
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| (Please briefly describe each item and why it is significant to your health center or the broader OVC program.) | |||||||||||||
| For example: If your Health Center has a definable program for a specific patient population through the OVC grant, |
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| please report related data for OVC-specific telehealth visits and any other relevant information in this tab. |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |