Form 1 Rural Health Care Services Outreach Program

OMB Number: 0906-0009

Expiration date: XX/XX/202X

Federal Office of Rural Health Policy

Community-Based Division

Rural Health Care Services Outreach Program

Performance Measures

Public Burden Statement: This collection seeks to compile data that may be useful in the continued improvement of the Rural Health Care Services Outreach Program. The measures are utilized by FORHP to capture the impact and scope of HRSA’s FORHP funding on rural communities. 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 0906-0009 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (Government Performance and Results Act of 1993, P.L. 113-62, Section 1116). Data will be kept private to the extent allowed by law. Public reporting burden for this collection of information is estimated to average 8 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14NWH04, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

1. Section: ACCESS TO CARE

This section is applicable to ALL Outreach grantees.

Table Instructions: This table collects information about an aggregate count of the number of people served through the program and the types of services that were provided during this budget period. Please report responses using a numeric figure. If the total number is zero (0), please put zero in the appropriate section. Do not leave any sections blank. There should not be an N/A (not applicable) response since all measures are applicable to all grantees.

1	Target Population	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
	Number of counties served in project Note: This should be consistent with the figures reported in your grant application and should reflect your project’s service area. Please specify the names of the counties served. (Text box entry)
	Number of people in the target population Note: This is the number of people in your target population, but not the number of people who actually received your direct services. This should be consistent with the figures reported in your grant application.
2	Services Provided	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
	Number of Direct Services Please report the number of unique (i.e. unduplicated count) patients/clients that received direct services from your organization during this budget period.
	Type of Services Provided (Select All That Apply) Using the selection list, please select the type of services provided through this grant funding during the reporting period of grant funded direct services provided during the budget period (end of budget period reporting only).	Baseline: End of Budget Period (Yr. 1) Selection List	End of Budget Period (Yrs. 2-4) Selection List
	Cardiovascular disease prevention
	Cardiovascular disease treatment and management
	Case management
	Dental/oral health education
	Dental/oral health treatment
	Diabetes prevention
	Diabetes treatment and management
	Emergency medical services
	Health education
	Maternal and child health
	Mental/behavioral health treatment and/or education
	Nutrition
	Obesity prevention
	Obesity treatment and management
	All other chronic disease prevention
	All other chronic disease treatment and management
	All other health promotion/disease prevention
	Primary care
	Substance abuse treatment and/or education
	Telehealth/telemedicine
	Transportation
	Workforce recruitment and/or retention
	Health literacy education and/or services
	Culturally competent care/services
	All other services – please specify in form comment box
3	Health Education and/or Counseling Activities	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
	Number of health education and counseling activities held Please report on the total number of activities held that aimed to improve knowledge, attitudes, self-efficacy and individual capacity to change.
	Number of health education and counseling participants Please report on the total number of people who participated in health education and counseling activities. The number of participants can include duplications.

4	Social Determinants of Health Activities	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
	Number of social determinants of health (SDoH) activities provided If your grant project provided SDoH related activities and/or services that aimed to improve the social, economic, education, physical infrastructure and/or the quality of or access to healthcare, please report the total number of these activities and/or services provided and specify the types of reported SDOH activities and/or services provided.
	Number of participants screened and referred to social determinants of health related services and/or support Please report the total number of people screened for social determinants of health using an appropriate standardized tool and if a screen was positive, received appropriate follow-up.
	Number of participants with reported improvements to their social determinants if health as a result of services and/or support provided by social determinants of health related grant funded activities. Please report the total number of people with self-reported improvements to social, economic, education, physical infrastructure and/or the quality of or access to healthcare improved as a result of grant funded services and/or support received.

2. SECTION: POPULATION DEMOGRAPHICS

This section is applicable to ALL Outreach grantees.

Table Instructions: This table collects information about an aggregate count of the people served by race, ethnicity, age and insurance status. The total for each of the following questions should equal the total of the number of unique individuals who received only direct services reported in the previous section. Please do not leave any sections blank. If the number for a particular category is zero (0), please put zero in the appropriate section (e.g., if the total number that is Hispanic or Latino is zero (0), enter zero in that section).

Hispanic or Latino Ethnicity

• Hispanic/Latino: Report the number of persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, broken down by their racial identification and including those Hispanics/Latinos born in the United States. Do not count persons from Portugal, Brazil, or Haiti whose ethnicity is not tied to the Spanish language.

• Non-Hispanic/Latino: Report the number of all other people except those for whom there are neither racial nor Hispanic/Latino ethnicity data. If a person has chosen a race (described below) but has not made a selection for the Hispanic /non-Hispanic question, the patient is presumed to be non-Hispanic/Latino.

• Unknown: Report on only individuals who did not provide information regarding their race or ethnicity.

Race

All people must be classified in one of the racial categories (including a category for persons who are “Unknown”). This includes individuals who also consider themselves to be Hispanic or Latino. People who self-report race, but do not separately indicate if they are Hispanic or Latino, are presumed to be non-Hispanic/Latino and are to be reported on the appropriate race line.

People sometimes categorized as “Asian/Other Pacific Islander” in other systems are divided into three separate categories:

• Asian: Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Indonesia, Thailand, or Vietnam

• Native Hawaiian: Persons having origins in any of the original peoples of Hawaii

• Other Pacific Islander: Persons having origins in any of the original peoples of Guam, Samoa, Tonga, Palau, Truk, Yap, Saipan, Kosrae, Ebeye, Pohnpei or other Pacific Islands in Micronesia, Melanesia, or Polynesia

American Indian/Alaska Native (Line 4): Persons who trace their origins to any of the original peoples of North and South America (including Central America) and who maintain Tribal affiliation or community attachment.

More than one race: Use this line only if your system captures multiple races (but not a race and an ethnicity) and the person has chosen two or more races. “More than one race” must not be used as a default for Hispanics/Latinos who do not check a separate race.

5	Number of people served by ethnicity:	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown
	Total (equal to the total of the number of unique individuals who received direct services)	(Automatically calculated by system)	(Automatically calculated by system)
6	Number of people served by race:	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
	American Indian or Alaska Native
	Asian
	Black
	Native Hawaiian or Other Pacific Islander
	White
	More than one race
	Unknown
	Total (equal to the total of the number of unique individuals who received direct services)	(Automatically calculated by system)	(Automatically calculated by system)
7         8	Number of people served, by age group:	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
	Children (0-12)
	Adolescents (13-17)
	Adults (18-64)
	Elderly (65 and over)
	Unknown
	Total (equal to the total of the number of unique individuals who received direct services)	(Automatically calculated by system)	(Automatically calculated by system)
	Number of people served, by insurance status:	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
	Private Insurance (Employer and/or Individual Health Insurance)
	Uninsured
	Dual Eligible (covered by both Medicaid and Medicare)
	Medicaid/CHIP only
	Medicare only
	Medicare plus supplemental
	Other third party
	Unknown
	Total (equal to the total of the number of unique individuals who received direct services)	(Automatically calculated by system)	(Automatically calculated by system)

3. SECTION: CONSORTIUM/NETWORK

This section is applicable to ALL Outreach grantees

Table Instructions: This table collects information about an aggregate count of consortium/network member types. Consortium/network members are defined as members who have signed a Memorandum of Understanding or Memorandum of Agreement for your funded grant project.

9	Type of Member Organizations in the Consortium/Network		Baseline: End of Budget Period (Yr.1) / End of Budget Period (Yrs. 2-4) Number
	Non-Profit Organization	Area Health Education Center
		Behavioral/Mental Health Organization
		Community College
		Community Health Center/Federally Qualified Health Center (FQHC)
		Critical Access Hospital
		Emergency Medical Service
		Faith-based organization
		Free Clinic
		Health Department
		Hospice
		Hospital, not critical access
		Migrant Health Center
		Private Practice
		Pharmacy
		Professional Association
		Philanthropic Organization
		Rural Emergency Hospital
		Rural Health Clinic (includes independent and hospital-owned)
		School District
		Social Services Organization
		University
		LGBTQ+ Organization
		Other – Specify type
		TOTAL for non-profit organization	(Automatically calculated by system)
10	For-Profit Organization	Behavioral/Mental Health Organization
		Critical Access Hospital
		Emergency Medical Service
		Hospice
		Hospital, not critical access
		Private Practice
		Pharmacy
		Professional Association
		Rural Health Clinic includes independent and hospital-owned)
		Social Services Organization
		LGBTQ+ Organization
		Other – Specify Type
		TOTAL for-profit organization	(Automatically calculated by system)
11	Total number of NEW member organizations that joined the consortium/network and signed the MOU/A during this budget period.		Baseline: End of Budget Period (Yr.1) / End of Budget Period (Yrs. 2-4) Number

4. SECTION: SUSTAINABILITY

This section is applicable to ALL Outreach grantees.

Table Instructions: This table collects information/data about the grant’s programmatic sustainability. There should not be a N/A (not applicable) response since the measures are applicable to all grantees.

12	Program Sustainability	Baseline: End of Budget Period (Yr.1) / End of Budget Period (Yrs. 2-4) Dollar amount
	Annual program revenue Please report the amount of annual program revenue made through the services offered through the program. Program revenue is defined as payments received for the services provided by the program that the grant supports. These services should be the same services outlined in your grant application work plan. Please do not include donations. If the total amount of annual revenue made is zero (0), please put zero in the appropriate section.
13	Additional Funding Secured Please report the total amount of additional funding secured during the reporting period to assist in sustaining your funded grant project after funding ends.	Baseline: End of Budget Period (Yr.1) / End of Budget Period (Yrs. 2-4) Dollar amount
14	Sources of Sustainability Select the type(s) of sources of funding for sustainability. Please check all that apply.	Baseline: End of Budget Period (Yr.1) / End of Budget Period (Yrs. 2-4) Selection List
	Program revenue
	In-kind Contributions (In-Kind contributions are defined as donations of anything other than money, including goods or services/time.)
	Membership fees/dues
	Fundraising/ Monetary donations
	Contractual Services
	Other grants
	Fees charged to individuals for services
	Reimbursement from third-party payers (e.g. private insurance, Medicare, Medicaid)
	Product sales
	Government (non-grant)
	Other – specify type
	None
15	Which of the following activities have you engaged in to enhance your sustained impact?  Check all that apply. If applicable, please specify the related activities for items selected in the form comment box.	Baseline: End of Budget Period (Yr.1) / End of Budget Period (Yrs. 2-4) Selection List
	Local, State and Federal Policy changes
	Media Campaigns
	Community Engagement Activities
	Other – Specify activity
Year 4 Sustainability Measures – To be collected during Year 4 reporting period only
*15a.	What is your ratio for Economic Impact vs. HRSA Program Funding?	End of Budget Period Year 4
	Use the HRSA’s Economic Impact Analysis Tool (https://www.ruralhealthinfo.org/econtool) to identify your ratio. Reponses should reflect the ratio for the annual economic impact across the 4 year project period of your funded grant.	Ratio
*15b.	Will the consortium/network sustain?	Yes/No
*15c.	Will any of the program’s activities be sustained after the project period?	End of Budget Period Year 4
	If yes, please select how the program activities will be sustained (drop down menu) Absorption of services or other means of in-kind support Reimbursement by third party payers Grant funding Fees Other: please describe	Yes/No Selection List

5. SECTION: PROJECT SPECIFIC DOMAINS

The following measures are not applicable to all grantees. Grantees will report on measures applicable only to their program activities.

1. CARE COORDINATION

This section is only applicable to projects receiving Outreach funding for care coordination activities funded by this grant. If applicable, this section INCLUDES grantees receiving grant funding under the HRHI program track.

Table Instructions: If your project supported grant funded care coordination activities, select the mechanisms/activities that were implemented during the reporting period. Care coordination is defined as care that is coordinated across all elements of the broader healthcare system. If your grant supported care coordination activities, but you do not know the information requested, please select/enter DK (do not know) for your response. If your grant did not support care coordination activities, please leave this section blank.

1	Care Coordination Activities Which of the following care coordination mechanisms/activities have you implemented during this budget year? Select all that apply.	Baseline: End of Budget Period (Yr. 1) Selection List	End of Budget Period (Yrs. 2-4) Selection List
	Facilitate transitions across settings
	Linkage to community resources
	Referral management, tracking and follow-up (includes primary, dental, mental and other specialty services)
	Patient support and engagement
	Case management
	Create care plans
	Health Literacy/Cultural Competency
	Multidisciplinary Care Team(s)
	Medication management
	Other – please specify

2. HEALTH PREVENTION AND SCREENING

This section is only applicable to projects receiving Outreach funding for community health prevention and screening activities. If applicable, this section INCLUDES grantees receiving grant funding under the HRHI program track.

Table Instructions: This table collects information about the number and types of grant funded health prevention activities, and their respective outputs, were provided to rural residents. Please use the definition for Preventive Health Activities referenced in this document’s appendix to complete responses to this section. If your grant supported preventive health activities were provided, but you do not know the information, please select/enter DK (do not know) for your response. If your grant did not support preventive health activities as part of your funded grant, please leave this section blank.

	Preventive Health Activities	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
1	Total number of preventive health screenings or activities held in clinical and non-clinical settings
2	Total number of participants who received preventive health screenings or activities and were referred to a health care provider for follow-up care.

3. BEHAVIORAL HEALTH

This section is only applicable to projects receiving Outreach funding for mental health activities. If applicable, this section INCLUDES grantees receiving grant funding under the HRHI program track.

Table Instructions: This table collects information about an aggregate number of people receiving grant funded mental and/or behavioral health services among the unique (e.g., an unduplicated count of persons) individuals who received direct services. This number should not exceed the number of unique individuals receiving direct services. If your grant supported mental/behavioral health activities, but you do not know the information, please select/enter DK (do not know) for your response. If your grant did not support any mental/behavioral health activities, please leave this section blank.

1	Mental and/or Behavioral Health Services	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
	Services Provided Number of people receiving mental and/or behavioral health services (among the unique individuals receiving direct services).	Should not exceed the # of unique individuals receiving direct services	Should not exceed the # of unique individuals receiving direct services
2	Integration of Primary Care and Mental and/or Behavioral Health Services If your project included activities that integrated primary care and mental/behavioral health services during the reporting period, please select from the list below all that apply.	Baseline: End of Budget Period (Yr. 1) Selection List	End of Budget Period (Yrs. 2-4) Selection List
	Care team expertise – develop a unified care plan that builds a team—with necessary members and functions—to care for a given patient
	Clinical workflow – clinical protocols and workflows are clearly documented for integration of care
	Patient identification – establish systematic methods to identify individuals for integrated care
	Clinical outcomes – monitor patient’s clinical outcomes to assess impact of integration of care
	Other – please specify

4. ORAL HEALTH

This section is only applicable to projects receiving Outreach funding for oral health activities. If applicable, this section INCLUDES grantees receiving grant funding under the HRHI program track.

Table Instructions: This table collects information about an aggregate number of people receiving grant funded oral health services the unique (e.g., an unduplicated count of persons) individuals who received direct services. This number should not exceed the number of unique individuals receiving direct services. If your project supported grant funded dental/oral health activities, but you do not know the information requested, please select/enter DK (do not know) for your response. If your grant did not support dental/oral activities, please leave this section blank.

1	Number of Individuals who Received Oral Health Services	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
	Please report the number of individuals who received oral health services during the reporting period (among the total number of unique individuals receiving direct services)	Should not exceed the # of unique individuals receiving direct services	Should not exceed the # of unique individuals receiving direct services
2	Type(s) and quantity of oral health services provided. Please report the number of persons who received oral health services during the reporting period for each oral health service category listed. Please respond N/A for “not applicable” for any services your grant project did not fund.	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
	Screenings / Exams
	Sealants
	Varnish
	Oral Prophylaxis
	Restorative
	Extractions
	Health education
	Other (please specify):

5. WORKFORCE/ RECRUITMENT & RETENTION

This section is only applicable to projects receiving Outreach funding for student/resident workforce recruitment and retention. If applicable, this section INCLUDES grantees receiving grant funding under the HRHI program track.

Table Instructions: This table collects information about grant funded student/resident workforce recruitment and/or retention activities implemented during the reporting period. Please refer to the detailed definitions and guidelines to provide responses for the following measures. Please report a numeric figure; if the total number is zero, please put zero (0) in the appropriate section. Do not leave any sections blank. If your project supported grant funded workforce recruitment and/or retention activities, but you do not know the information, please select/enter DK (do not know) for your response. If your project did not support student/resident workforce recruitment and/or retention activities, please leave this section blank.

Definitions: For the purposes of this data collection, “trainees” are persons who are working towards a professional degree.

1. Trainees (students and residents) are considered “New” if:

   • They have never engaged in a training/rotation within a rural community as a part of their certificate/degree/residency program and/or

   • They do not self-identify as “having lived”/ “living”/ “claiming residence” within a rural area.

2. Trainees (students and residents) are considered “Existing” if:

   • They have had prior exposure to rural areas by either engaging in a training/rotation within a rural area as a part of their certificate/degree/residency program prior to the respective budget year and/or

   • They self-identify as “having lived”/ “living”/ “claiming residence” within a rural area.

1	Workforce Recruitment, Training & Retention
	Using the following table, please report the number of trainees by type that complete the trainings/rotations; this figure should not exceed the total number of all trainees recruited by type. Please also report the number of trainees by type that plan to practice in a rural area after completing their trainings/rotations. Of those trainees that completed their trainings/rotations, please specify the number that returned to formally practice in rural areas; for this measure, please report a numeric figure or indicate DK for “do not know”. For example, if zero (0) students completed their trainings/rotations and returned to formally practice in a rural area, please put zero (0) in the appropriate section. If this section is applicable to your grant funded project, do not leave any sections blank.
		STUDENTS		RESIDENTS
	Number of New Trainees Recruited to Work on the Program	Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	Baseline: End of Budget Period (Yr. 1) Number		End of Budget Period (Yrs. 2-4) Number
	Number of New
	Number of Existing
	TOTAL	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)
	Of the total number recruited, how many completed the training/rotation
	Of the total number who completed the training/rotation, how many plan to practice in a rural area
	Percentage trained that plan to practice in a rural area (automatically calculated by the system)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)
	Of the total number who completed the training/rotation, how many returned to formally practice in rural areas
	Percentage trained that returned to formally practice in rural areas (automatically calculated by the system)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)	(Automatically calculated by system)
2	Trainee Primary Care Focus Area(s):				Number
	Medical
	Mental/Behavioral Health
	Oral Health
3	Trainee Discipline Type(s):				Selection List
	Note that psychiatrists are either allopathic (MD) or osteopathic (DO) physicians. Also, please specify the types of non-physician practitioners, nurses, and allied health professionals as appropriate. For example, physician assistants, nurse practitioners, certified nurse mid-wives, and certified registered nurse anesthesiologists are considered non-physician practitioners. Allied health professionals include dental hygienists, diagnostic medical sonographers, dietitians, medical technologists, occupational therapists, physical therapists, pharmacists, radiographers, respiratory therapists, community health workers, and speech language pathologists. If the targeted trainee does not fall under the listed categories, please refer to the detailed definition for Allied Health Professionals and specify the discipline(s) in the Allied Health Professionals category. Please check all that apply.
	Allied Health Professional – Please specify type(s)
	Dentist
	Non-physician practitioners – Please specify type(s)
	Nurse – Please specify type(s)
	Physician (DO)
	Physician (MD)
4	Number of New Trainings/Rotations provided:				Number
	Please report the number of trainings/rotations provided during the respective budget period. Please report a numeric figure. If the total number of trainings/rotations is zero (0), please put zero in the appropriate section. Do not leave any sections blank.
5	Number of Training Site(s) by Type:				Number
	Please report the number of training sites by type where the trainings/rotations were conducted. Please report a numeric figure. If the total number of training sites is zero (0), please put zero in the appropriate section. Do not leave any sections blank
	Critical Access Hospital
	Other Rural Hospital (non-CAH)
	Rural Health Clinic
	Other Rural Clinic (non-RHC)
	Community Health Center
	Federally Qualified Health Center (FQHC)
	Health Department
	Indian Health Service (IHS) or Tribal Health Sites
	Migrant Health Center (MHC)
	Other Community Based Site – Please specify type(s)

6. TELEHEALTH

This section is only applicable to projects receiving Outreach funding for telehealth services. If applicable, this section INCLUDES grantees receiving grant funding under the HRHI program track.

Table Instructions: Based on the telehealth definition, please complete the responses for each of the following items, as applicable.

1		Telecommunication Technology Type		Selection
		Based on the telehealth definition; select the telecommunication technology type(s) used in your project: (check all that apply)
		mobile health
		video conferencing (with or without video),
		digital photography
		store-and forward/asynchronous imaging
		streaming media
		wireless communication
		telephone calls
		remote patient monitoring through electronic devices such as wearables
		mobile devices
		smartphone apps
		internet-enabled computers
		specialty portals or platforms that enable secure electronic messaging and/or audio or video communication between providers or staff and patients not including EMR/EHR systems
2	Directly Served Individuals
	Based on the telehealth definition please indicate the number of individuals directly served. *Note individuals who view a website or webinar should only be counted if they meet the definition of directly served.
	Remote clinical services (number)		Remote non-clinical services* (number)
3	Telehealth Activities
	Please provide selection responses for the telehealth activities indicated above for each of the following items:
	Select box (Select all that apply)		If checked…
	Increase billable services and organizational sustainability.		Indicate the amount billed per program year
	Improve access to care through mitigating travel burden for patients.		Indicate miles saved (or indicate if services were provided in-home or at new locations (schools, libraries, clinics, etc) and/or Indicate percent change in no-show rates
	Increase access to care through providing a wider range of primary and/or specialty care services.		Indicate service types offered through telehealth

7. HEALTHY RURAL HOMETOWN INITITATIVE (HRHI) PROJECT MEASURES

This section is applicable to grantees receiving grant funding under the Healthy Rural Hometown Initiative (HRHI) track ONLY.

Instructions: The tables included in this section collects health outcomes and estimated cost savings information resulting from related to project activities funded under the program’s HRHI Track focusing on addressing the Nation’s five leading causes of death in rural communities.

Please refer to each individual table included under this section for specific instructions.

• Tables H.1-H.4: Responses should be provided by HRHI funded projects for sections which align with your grant project’s HRHI FOCUS AREA identified in your awarded grant application proposal ONLY. More than one section can be completed if more than one focus area applies. Sections that are not applicable to grant project’s focus area should be left blank. If a section is applicable to your funded project focus area, but measure responses are unknown, please select “d/k” for do not know as your response and include a statement in the form comment box explaining why the response was completed “d/k.”

• Tables H.5: This table is applicable to ALL HRHI funded projects.

H.1. HRHI Program - Cardiovascular Disease and/or Stroke

This section is only applicable to HRHI funded projects that include a focus on Cardiovascular Disease (CV) and/or Stroke.

Cardiovascular Disease and/or Stroke
Table Instructions: Please complete the following responses for grant funded HRHI participants between the ages of 40-79 successfully measured using the ASCVD Risk Estimator Tool during the reporting period. Please note, the ASCVD Risk Estimator is meant to be used for individuals 40 to 79 years old with no history of cardiovascular disease (e.g., heart attack, stroke, peripheral artery disease, or heart failure). *All measures are required for respondents to this section
10-Year Cardiovascular Disease Risk		Baseline: End of Budget Period (Yr. 1)	End of Budget Period (Yrs. 2-4)
1a	Total number of participants enrolled in your HRHI Cardiovascular Disease and/or Stroke program during the reporting.	Number	Number
1b	Number of participants between the ages of 40-79 who successfully completed an ASCVD risk measurement during the reporting period.	Number	Number
1c	Average 10-year risk for program participants between the ages of 49-70 with an initial visit (baseline) ASCVD risk measurement completed during the reporting period.	Percent (Average 10-Year Risk – Initial)	Percent (Average 10-Year Risk – Initial)
1d	Average 10-year risk for program participants between the ages of 49-70 with a follow-up ASCVD risk measurement completed during the reporting period.	Percent (Average 10-Year Risk – Follow-Up)	Percent (Average 10-Year Risk – Follow-Up)
1e	Average 10-year optimal risk for program participants between the ages of 49-70 with an ASCVD risk measurement completed during the reporting period.	Percent (Average 10-Year Optimal)	Percent (Average 10-Year Optimal)

H.2 HRHI Program - Chronic Lower Respiratory Disease (CLRD)

This section is only applicable to HRHI funded projects that include a focus on CLRD.

Chronic Lower Respiratory Disease
Table Instructions: Please complete responses for each of the following items as they relate to your funded grant project’s HRHI Chronic Lower Respiratory Disease Program participants. All respondents to this section must complete the required measure response (2a) and a minimum of at least 1 of the 2 total optional measures indicated (2b and 2c). Participants who are able to report to more than one optional measure are encouraged to do so.
CLRD Participants *Required		Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
2a	Total number of participants with one or more classifications of CLRD enrolled in your HRHI CLRD program during the reporting.
CLRD Activities *Minimum response to at least one of the following options is required.		Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
2b	Number of program participants with one or more classifications of CLRD who received appropriate CLRD *care management services and referred to follow-up care and/or or other recommended CLRD services, if appropriate during the reporting period. *includes care management services and recommended prevention, treatment and/or management focused patient education consistent with current clinical guideline recommendations for CLRD
2b	HRQOL–14: Healthy Days/Activity Limitations Module Number of program participants with one or more classifications of CLRD who reported *improved disease management during the reporting period. *Improved management includes participants evaluated during the reporting period using the CDC’s HRQOL–14: Healthy Days, Activity Limitations Module from the State-based Behavioral Risk Factor Surveillance System (BRFSS) or comparable self-reported questionnaires that evaluates one or more of the following: 1) self-reported increase in health status, 2) decrease in self-reported number of poor health days, and/or 3) reduction in self-reported disease-related activity limitations.

H.3. HRHI Program – Cancer Prevention

This section is only applicable to HRHI participants with a project focus that includes Cancer Prevention.

Cancer Prevention
Table Instructions: Please complete responses for each of the following items as they relate to your funded grant project HRHI Cancer Program. Respondents to this section are required to complete all measures as feasible and applicable.
Cancer Prevention Participants & Activities		Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
3a	Total number of participants or individuals enrolled in your HRHI Cancer Prevention Program during the reporting period.
3b	Total number of participants or individuals in your HRHI Cancer Program’s target population *screened for cancer and referred to appropriated follow-up care during the reporting period. *consistent with current clinical guidelines for cancer screening
3c	Total number of participants or individuals in your HRHI Cancer Program’s target population with a positive cancer screen detected in time for *early intervention *as defined by clinical standards
3d	Total number of participants or individuals in your HRHI Cancer Program’s target population who received education about cancer risk factors and prevention during the reporting period.

H.4. HRHI Program - Unintentional Injury/Substance Use

This section is only applicable to HRHI participants with a project focus that includes Unintentional Injury/Substance Use.

Unintentional Injury/Substance Use
Table Instructions: Please complete responses for each of the following items as they relate to your funded grant project HRHI Unintentional Injury/Substance Use Program target population or enrolled participants, as applicable. All respondents to this section must complete the required measure response (4a and 4b) and a minimum of at least one relevant optional measure (5a-5c and 6a-6e), as feasible and applicable for your funded HRHI grant project. Respondents who are able to report to more than one optional measure are encouraged to do so.
Unintentional Injury/Substance Use Prevention Participants *Required		Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
4a	Total number of individuals in your HRHI Program’s target population who received preventive-focused services, education and/or training related to intentional injury and/or substance use during the reporting period.
4b	Total number of new local policies related to unintentional injury/substance use prevention implemented during the reporting period as a result of grant-funded activities.
Unintentional Injury *Minimum response to at least one of the following options is required. Responses are exclusive to unintentional injury focused HRHI projects (excludes substance use focus)		Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
5a	Total number of participants or individuals enrolled in your HRHI Unintentional Injury Prevention Program during the reporting period.
5b	Total number of unintentional injury related emergency department admissions in your project’s service area in the last 12 months.
5c	Total number of unintentional injury related fatalities reported in your project’s service in the last 12 months.
Substance Use *Minimum response to at least one of the following options is required. Responses are exclusive to substance use focused HRHI projects (excludes other unintentional injury focus)		Baseline: End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number
6a	Total number of participants or individuals enrolled in your HRHI Substance Use Prevention Program during the reporting period.
6b	Total number of HRHI program participants with substance use disorder identified and referred to clinically appropriate substance use services and/or treatment during the reporting period.
6c	Total number of HRHI program participants identified with a substance use disorder who successfully received clinically appropriate substance use services and/or treatment during the reporting period.
6d	Total number of non-fatal *substance use related overdoses that occurred in your project’s service area in the past 12 months. *Includes any substance use specific to focus of funded grant project related overdose/poisoning (ex. opioid, alcohol, methamphetamine, etc.)
6e	Total number of fatal *substance use related overdoses that occurred in your project’s service area in the past 12 months. *Includes any substance use specific to focus of funded grant project related overdose/poisoning (ex. opioid, alcohol, methamphetamine, etc.)

H.5. HRHI Program - Health Outcomes & Cost Savings

This section is applicable to ALL HRHI participant focus areas.

Instructions: All HRHI funded projects are required to complete responses for each measure relative to your funded grant project HRHI program focus area(s)’s target population/ enrolled participants. Responses to measures should include responses for all applicable HRHI focus areas feasible to complete.

• For enrolled HRHI program target populations/participants who fall under more than one than one focus area in response to measure under this section, please include these individuals/participants in the total count for each item (i.e. may appear more than once). Respective related demographic categories may reflect this count, as appropriate

• For measure responses that are applicable, but you do not know the information requested, please select/enter DK (do not know) for your response. For measure responses that are not applicable to your grant funded HRHI project, please provide a response indicating ‘n/a’ for ‘not applicable.’

Focus Area Categories: Responses to each measure should reflect the values for each of the following categories identified for each measure:

• Cardiovascular Disease and/or Stroke (CV/Stroke)

• Chronic Lower Respiratory Disease (CLRD)

• Cancer

• Unintentional Injury/Substance Use (Unintentional Injury/SU)

Health Outcomes
Table Instructions: Measures under this section are optional. Only HRHI grantees able to successfully collect and report the information requested for their specific HRHI focus area and HRHI participants/target population(s) should respond to measures under this section.
7a	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease CMS347v6/ Quality ID #438 Percentage of patients 21 years of age and older at high risk of cardiovascular events who were prescribed or were on statin therapy	Baseline End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	HRHI Focus
	Total Patients Aged 21 and Older at High Risk of Cardiovascular Events			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Number of Patients Prescribed or On Statin Therapy			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/SU
7b	Blood Pressure NQF 0018/CMS165v11 Percentage of patients 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90mmHg) during the measurement period.	Baseline End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	HRHI Focus
	Total Patients 18 through 85 Years of Age with a diagnosis of Hypertension			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Number of patients 18 through 85 Years of Age with one or more blood pressure readings greater than 140/90			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Number of patients whose most recent blood pressure was adequately controlled			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
7c	Body Mass Index (BMI) Screening and Follow-Up NQF 0421/CMS69v11 Percentage of patients 18 years of age and older with (1) BMI documented and (2) follow-up plan documented if BMI is outside normal parameters.	Baseline End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	HRHI Focus
	Total Patients Aged 18 and Older			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Total Patients with BMI outside normal parameters *Normal Parameters: Age 65 years and older BMI > or = 23 and < 30; Age 18 – 64 years BMI > or = 18.5 and < 25			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Number of Patients with BMI Outside Normal Parameters and Follow-Up Plan Documented as Appropriate			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
7d	Diabetes Care - Hemoglobin A1c (HbA1c) Poor Control NQF 0059/CMS122v11: Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period	Baseline End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	HRHI Focus
	Total patients 18 through 75 Years of Age with Diabetes			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Total Diagnosed Diabetics with a Hemoglobin A1c (HbA1c) > 9.0%			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Number of patients with HbA1c >9%			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
7e	Diabetes Short Term Complications Admissions Rate (PQI01-AD) The rate of admissions for a principal diagnosis of diabetes with short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 population, ages 18 years and older.	Baseline End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	HRHI Focus
	The number of people ages 18 years and older in the target service area.			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Number of discharges for patients 18 years and older, with a principal ICD-9-CM diagnosis code for diabetes short term complications (ketoacidosis, hyperosmolarity, or coma).			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
7f	Tobacco Use NQF 0028/CMS138v11: Percentage of patients aged 18 years of age and older who (1) were screened for tobacco use one or more times within 24 months, and (2) if identified to be a tobacco user received cessation counseling intervention.	Baseline End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	HRHI Focus
	Total Patients Aged 18 and Older			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Number of patients identified as a current smoker			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Number of Patients Assessed for Tobacco Use and Provided Intervention if a Tobacco User			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
7g	Cervical Cancer Screening CMS124v11 Percentage of women 23–64 years of age who were screened for cervical cancer	Baseline End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	HRHI Focus
	Total Female Patients Aged 23 through 64			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Number of Patients Tested			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
7h	Breast Cancer Screening CMS125v11: Percentage of women 51–73 years of age who had a mammogram to screen for breast cancer	Baseline End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	HRHI Focus
	Total Female Patients Aged 51 through 73			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Number of Patients with Mammogram			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
7i	Colorectal Cancer Screening (NQF 0034/Quality ID: 113) CMS130v11: Percentage of patients 50 through 74 years of age who had appropriate screening for colorectal cancer	Baseline End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	HRHI Focus
	Total Patients Aged 50 through 74			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Number of Patients with Appropriate Screening for Colorectal Cancer			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
7j	Initiation and Engagement of Alcohol and Other Drug Dependence Treatment CMS137v11 : Percentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received appropriate follow-up	Baseline End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	HRHI Focus
	Total patients age 13 years of age and older diagnosed with a new episode of alcohol, opioid, or other drug abuse or dependency			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
	Number of patients that initiated AOD abuse or dependency treatment with either an intervention or medication within 14 days of the diagnosis.			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
Cost Savings
Table Instructions: Please complete responses for each of the following measures, as applicable and as feasible to complete, relative to your funded grant project HRHI program’s target population/ enrolled participants and respective HRHI program focus area(s). Emergency Department (ED) Admission Measures: 8a-8c (Optional) Only HRHI grantees able to successfully collect and report the information requested should respond to measures under this section. For focus area specific ED measure please include in responses multiple admissions for same participant, if applicable. This also applies if admissions or multiple admissions for participant is related to more than one focus area Cost of Delivery Measures 9a-9b (Required) Please refer to the guidance provided by FORHP for completing program delivery cost of per participant calculations for HRHI program
Emergency Department (ED) Use *Optional		Baseline End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	HRHI Focus
8a	Total number all cause of Emergency Department Admissions that occurred for all individuals within your HRHI project’s service area during the last 12 months.			n/a
8b	Total number of HRHI Program focus area(s) related Emergency Department Admissions that occurred for all individuals within your HRHI grant project’s service area during the last 12 months			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
8c	Total number of Emergency Department Admissions that occurred for HRHI Program participants/individuals served within your HRHI grant project’s service area during the last 12 months for each applicable HRHI program focus area.			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
Cost of Program Delivery *Required		Baseline End of Budget Period (Yr. 1) Number	End of Budget Period (Yrs. 2-4) Number	HRHI Focus
9a	Estimated annual HRHI program delivery cost per participant / per individual provided grant funded HRHI program services and/or activities during the reporting period.			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU
9b	Total number of participants or individuals provided HRHI program services and/or activities during the reporting period.			CV/Stroke
				CLRD
				Cancer
				Unintentional Injury/ SU

8. CLINICAL MEASURES

This section is only applicable to projects receiving Outreach funding for direct outpatient care services. This section is NOT applicable for grantees receiving grant funding under the HRHI program track.

Table Instructions: This table collects information about measures for the clinical outcomes of certain direct outpatient care services provided to the unique individuals who received direct services funded by this grant during the reporting period. The denominator for all measures should correlated with the population of unique persons (i.e., an unduplicated count of persons) who received direct services during the reporting period for your grant.

If your project supported grant funded workforce recruitment and/or retention activities, but you do not know the information, please select/enter DK (do not know) for your response. If your project did not support student/resident workforce recruitment and/or retention activities, please leave this section blank.

• If your project supported grant funded direct outpatient care services, but you are unable to complete the information for any particular clinical measure(s), please select/enter DK (do not know) for your response.

• If your project supported grant funded direct outpatient care services, but information requested is not applicable for a particular measure(s), please select/enter N/A (not applicable).

• If your project did not support direct outpatient care services, leave this section blank.

1	Diabetes Short Term Complications Admissions Rate (PQI01-AD) The rate of admissions for a principal diagnosis of diabetes with short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 population, ages 18 years and older.
	Number (Denominator) The number of people ages 18 years and older in the target service area.	Number (Numerator) Discharges for patients 18 years and older, with a principal ICD-9-CM diagnosis code for diabetes short term complications (ketoacidosis, hyperosmolarity, or coma).
2	Depression Screening CMS2v12 Percentage of patients 12 years of age and older who were (1) screened for depression with a standardized tool and, if screening was positive, (2) had a follow-up plan documented
	Number (Denominator) Total Patients Aged 12 and Older in the funded grant project target patient population during the reporting period	Number (Numerator) Patients screened for clinical depression using an age appropriate standardized tool AND, if screening was positive, had a follow-up plan documented during the reporting period
3	Blood Pressure NQF 0018/CMS165v11 Percentage of patients 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90mmHg) during the measurement period.
	Number (Denominator) Total Patients 18 through 85 Years of Age in the funded grant project target patient population who had a diagnosis of Hypertension during the reporting period	Number (Numerator) Number of Patients in the funded grant project target patient population whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the reporting period.
4	Diabetes Care - Hemoglobin A1c (HbA1c) Poor Control NQF 0059/CMS122v11 Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
	Number (Denominator) Total Patients 18 through 75 Years of Age with Diabetes in the funded grant project target patient population during the reporting period	Number (Numerator) Patients with HbA1c >9% in the funded grant project target patient population during the reporting period
5	Tobacco Use NQF 0028 CMS138v11 Percentage of patients aged 18 years of age and older who (1) were screened for tobacco use one or more times within 24 months, and (2) if identified to be a tobacco user received cessation counseling intervention
	Number (Denominator) All patients aged 18 years and older in the funded grant project target patient population seen for at least two visits or at least one preventive visit during the reporting period.	Number (Numerator) Number of Patients in the funded grant project target patient population Screened for Tobacco Use* and who received tobacco cessation counseling intervention during the budget period** if identified as a Tobacco User *Includes use of any type of tobacco ** Cessation counseling intervention includes brief counseling (3 minutes or less), and/or pharmacotherapy
6	Weight Assessment and Counseling for Children/Adolescents NQF 0024/CMS155v11 Percentage of patients 3–17 years of age with a body mass index (BMI) percentile and counseling on nutrition and physical activity documented.
	Number (Denominator) Total number of patients 3-17 years of age in the funded grant project target patient population with at least one outpatient visit with a primary care physician (PCP) or an obstetrician/gynecologist (OB/GYN) during the budget period	Number (Numerator) Total patients aged 3 through 17 in the funded grant project target patient population who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of the following during the budget period: patients who had height, weight, and BMI percentile documentation patients who had counseling for nutrition patients who had counseling for physical activity
7	Body Mass Index (BMI) Screening and Follow-Up NQF 0421/CMS69v11 Percentage of patients 18 years of age and older with (1) BMI documented and (2) follow-up plan documented if BMI is outside normal parameters (Normal Parameters: Age 65 years and older BMI > or = 23 and < 30; Age 18 – 64 years BMI > or = 18.5 and < 25)
	Number (Denominator) Total Patients Aged 18 and Older in the funded grant project target patient population during the reporting period	Number (Numerator) Number of Patients in the funded grant project target patient population with BMI Outside Normal Parameters and Follow-Up Plan documented during the encounter or during the previous twelve months of the encounter.

Appendix A

Section Definitions

Definitions: Access to Care

Direct Services: A documented interaction between a patient/client and a clinical or non-clinical health professional that has been funded with FORHP grant dollars. Examples of direct services include (but are not limited to) patient visits, counseling and education. This includes both face-to-face in-person encounters as well as non face-to-face encounters.

Target Population: Refers to the target population identified in your grant project’s funded application proposal served by organizations directly engaged in grant funded activities.

Baseline Data: Data that is collected prior to the start of the grant project or intervention. This data will be collected 60 days after the start of the project period.

Mid Year: Data that is collected 6 months after the start of a new project year.

First Year - Fourth Year: Data that is collected after the end of the respective budget period.

Definitions: Population Demographics Insurance Status/Coverage

Private Insurance (Employer and/or Individual Health Insurance): Health insurance provided by commercial and not for profit companies. Individuals may obtain insurance through employers or on their own.

Uninsured: Those without health insurance.

Medicare (Only): Federal insurance for the aged, blind, and disabled (Title XVIII of the Social Security Act). For the purposes of this reporting, coverage reported under Medicare, should also be inclusive of all Medicare coverage (other than dual eligible and Medicare supplemental coverage including Medicare Advantage as well as beneficiaries with supplemental coverage such as Medigap, employer sponsored or Veteran’s Administration (VA) coverage).

Medicare Plus Supplemental: A Medicare Supplement Insurance (Medigap) policy helps pay some of the health care costs that. Original Medicare doesn't cover, like copayments or coinsurance. Coverage including Medicare Advantage as well as beneficiaries with supplemental coverage such as Medigap, employer sponsored or Veteran’s Administration (VA) coverage.

Medicaid: is defined as State-run programs operating under the guidelines of Titles XIX (and XXI as appropriate) of the Social Security Act. For the purposes of this reporting, insurance coverage under Children’s Health Insurance Program (CHIP) should be included within the reporting for this category.

Dual Eligible: Covered by both Medicaid and Medicare

Children’s Health Insurance Program (CHIP): Jointly funded state and federal government program which provides health coverage to eligible children, through both Medicaid and separate CHIP programs administered by states, in accordance to federal requirements. For the purposes of this reporting, please report Medicaid (not including CHIP) separately from those including CHIP under Medicaid.

Other Third Party: Includes coverage through state and/or local government programs such as

State-sponsored or public assistance programs only.

Definitions: Health Prevention & Screening

Preventive Health Activities: Activities used to prevent disease, detect health problems early, or provide people with the information they need to make good decisions about their health. This includes activities such as preventive health screening, counseling, immunizations and/or or medications. While preventive activities are traditionally delivered in clinical settings, preventive activities delivered in community settings such as, but not limited to, work sites, schools, residential treatment centers, or homes, is included in this definition.

Definitions: Sustainability

Annual Program Revenue: Payments received for the services provided by the program that the grant supports. These services should be the same services outlined in your grant application work plan. Please do not include donations. If the total amount of annual revenue made is zero (0), please put zero in the appropriate section.

Additional Funding: Funding already secured to assist in sustaining the project. Donations should be included in this section.

In-Kind Contributions: Donations of anything other than money, including goods or services/time.

Definitions: Consortium/Network

Consortium/Network: A consortium or network is defined as collaboration between two or more separately owned organizations. These should be consortium/network partners related directly to the implementation of the funded grant project.

Definitions: Telehealth

Telehealth: The use of electronic information and telecommunication technologies¹ to support remote clinical services² and remote non-clinical services³.

1. Telecommunication technologies include but are not limited to: mobile health, video conferencing (with or without video), digital photography, store-and forward/asynchronous imaging, streaming media, wireless communication, telephone calls, remote patient monitoring through electronic devices such as wearables, mobile devices, smartphone apps; internet-enabled computers, specialty portals or platforms that enable secure electronic messaging and/or audio or video communication between providers or staff and patients not including EMR/EHR systems;

2. Remote clinical services include but are not limited to: telemedicine, physician consulting, screening and intake, diagnosis and monitoring, treatment and prevention, patient and professional health-related education, and other medical decisions or services for a patient

3. Remote non-clinical services include but are not limited to: provider and health professionals training, research and evaluation, the continuation of medical education, online information and education resources, individual mentoring and instruction, health care administration including video conferences for managers of integrated health systems, utilization and quality monitoring;

NOTE: If a telecommunication technology, remote clinical or remote non-clinical service is missing, please reach out to your PO for further clarification.

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