SFY 2016-2019 Small Rural Hospital Improvement Program

ORGANIZATIONAL INFORMATION & SIGNATURE SHEET

Organization Name:______

Organization EIN:______

Organization DUNS Number: ______

Mailing Address:______

______

Organization Fiscal Year:______

Organization Type: ______

Hours of Operation:______

Grant Request:$______

Summary of Proposal – Provide a brief one to two sentence description of your request.

Contact Person:______

Email Address:______

Phone Number:______

Grant Application Submitted By (person authorized to enter into contracts for your organization)

Signature:______Date: ______

Name:______Title: ______

Organization Name: ______

SFY 2016-2019 Small Rural Hospital Improvement Program

SUMMARY OF EVALUATION CRITERIA & BASELINE DATA

IF THIS FORM IS NOT COMPLETED YOUR REQUEST WILL NOT BE CONSIDERED FOR FUNDING.

For each measure, you will need to include the following information:

  • Data Source: where will you obtain the information you report for your performance measures?
  • Collection Process and Calculation: what method will you use to collect the information?
  • Collection Frequency: how often will you collect the information?
  • Data Limitations: what may prevent you from obtaining data for your performance measures?

Evaluation Criteria– Please complete the required performance measures.

Evaluation Criteria / Baseline Values/Measures as of 06/01/2016 / Target to Be Reached
by 05/31/2019
Example:
Increase uninsured patient visits from 300 to 348 encounters per month by adding one evening clinic per week. / 300 encounters per month / 348 encounters per month
REQUIRED: # of FTEs supported by this grant (see Appendix A in SHIP RFA Instructions Mar 2016 release.doc for instructions on calculating FTEs)
Data Source: _____
Collection Process and Calculation: _____
Collection Frequency: _____
Data Limitations: _____ / Year 1: 0.00 FTE(s)
Year 2: 0.00 FTE(s)
Year 3: 0.00 FTE(s) / Year 1: ______FTE(s)
Year 2: ______FTE(s)
Year 3: ______FTE(s)
REQUIRED:Number of hospitals participating in Value-Based Purchasing activities
Data Source: _____
Collection Process and Calculation: _____
Collection Frequency: _____
Data Limitations: _____ / Year 1: _____ hospitals participating in Value-Based Purchasing activities
Year 2: _____ hospitals participating in Value-Based Purchasing activities
Year 3: _____ hospitals participating in Value-Based Purchasing activities / Year 1: _____ hospitals participating in Value-Based Purchasing activities
Year 2: _____ hospitals participating in Value-Based Purchasing activities
Year 3: _____ hospitals participating in Value-Based Purchasing activities
REQUIRED: Number of hospitals participating in Accountable Care Organization activities
Data Source: _____
Collection Process and Calculation: _____
Collection Frequency: _____
Data Limitations: _____ / Year 1: _____ hospitals participating in Accountable Care Organization activities
Year 2: _____ hospitals participating in Accountable Care Organization activities
Year 3: _____ hospitals participating in Accountable Care Organization activities / Year 1: ______hospitals participating in Accountable Care Organization activities
Year 2: _____ hospitals participating in Accountable Care Organization activities
Year 3: _____ hospitals participating in Accountable Care Organization activities
REQUIRED: Number of hospitals participating in Payment Bundling / Prospective Payment System activities
Data Source: _____
Collection Process and Calculation: _____
Collection Frequency: _____
Data Limitations: _____ / Year 1: _____ hospitals participating in Payment Bundling / Prospective Payment System activities
Year 2: _____ hospitals participating in Payment Bundling / Prospective Payment System activities
Year 3: _____ hospitals participating in Payment Bundling / Prospective Payment System activities / Year 1: ______hospitals participating in Payment Bundling / Prospective Payment System activities
Year 2: ______hospitals participating in Payment Bundling / Prospective Payment System activities
Year 3: ______hospitals participating in Payment Bundling / Prospective Payment System activities

SFY 2016-2019 Small Rural Hospital Improvement Program

NEW GRANT APPLICATION

See attachment fileSHIP RFA Instructions Mar 2016 Release.doc for guidance on how to complete each section. Thegrant narrative should not exceed six (6) pages excluding the budget template.

PART I Overview of Organization (1-2 paragraphs) 05 points

PART IIProject Description (up to 4pages) 50 points

PART III Project Evaluation (1 page) 15 points

PART IVProject Budget Feasibility (complete template) 30 points

Complete the Program Budget Template. See attachment file SHIP RFA Budget Mar 2016 Release.xls.