Form 20 Project Work Plan (track changes)

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

PROJECT WORK PLAN

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration PROJECT WORK PLAN	FOR HRSA USE ONLY
	Application Tracking Number	Grant Number

Section A - Training and Technical Assistance (T/TA) in Fiscal and Program Management (Program Requirements)Focus Area/Target Area

For PCAs: Address each of the three required Focus Areas.

For NCAs: Address one Target Area.

Measure		Each Focus Area/Target Area includes pre-defined measures. These measures are required and may not be edited.
Baseline Data		For PCAs: Baseline data is pre-populated. This field is read-only and may not be edited. For NCAs: Baseline data for some measures is pre-populated, and for some measures must be entered by the NCA.
Baseline Narrative		Provide a narrative description of baseline data informed by recent needs assessments and aligned with described key factors that impact performance.
Goal A1: Percent of Health Center Program grantees in the state/region with no program conditions on their Notice of Awards (NoAs).
Projected Goal Data Percentage	Provide a numerical value Goal to be achieved by the end of the project period for each required measure.
Impact NarrativeNumerator Description	Describe the overall impact the planned activities are predicted to have on the measure by the end of the project period. Reference data sources used to determine the expected impact.Total number of Health Center Program grantees with no program conditions.
Denominator Description	Total number of Health Center Program grantees in the State or region.
Data Source	HRSA Program Reports
Notes: Minimum of 3 and maximum of 5 Key Factors can be added under the goal. Minimum of 1 restricting key factor and 1 contributing key factor is required for the goal.
Key Factors #1 (maximum 500 characters)	Identify the factors that will contribute to and restrict progress on achieving the Goal.  Cite supporting data sources, (e.g., needs assessments, focus groups).  A minimum of 2 and a maximum of 5 Key Factors may be included.  At least 1 Contributing and 1 Restricting Key Factor must be identified.Type: [_] Contributing [_] Restricting Description:
Formal Training and Technical Assistance (T/TA) Session Target Key Factor #2	Provide the number of formal T/TA sessions planned (e.g., structured T/TA sessions with specific objectives and outcomes) through the end of the project period in order to meet this goal. Note that for some NCA measures, this data is not collected.Type: [_] Contributing [_] Restricting Description:
Participation TargetKey Factor #3	Provide the number of health center representatives that will participate in the formal T/TA sessions through the end of the project period in order to meet this goal. Note that for some NCA measures, this data is not collected.Type: [_] Contributing [_] Restricting Description:
Activity Area (PCAs only)Key Factor #4	For PCAs: Select at least 2 Activity Areas under each Goal to address.Type: [_] Contributing [_] Restricting Description:
Activity Audience (NCAs only)Key Factor #5	For NCAs: Select one predefined Activity Audience for each proposed Activity: Learning Collaborative or National Audience. At least two activities must be proposed for each audience type for each goal.Type: [_] Contributing [_] Restricting Description:

Activity Details

(limit 500 characters)

Notes:

For PCAs: Propose 2-5 activities under for at least 3 of theeach required T/TA FocusActivity Area (minimum of 4 activities total)s listed below.

For NCAs: Propose 4-10 Activities for each Goal, with at least two Activities for each Activity Audience.Minimum of 2 and maximum of 5 Activities can be added under each proposed T/TA Focus Area.

If the activities you propose do not belong to the pre-defined T/TA Focus Areas listed below, propose additional focus areas under ‘Other Focus Areas’. Maximum of 2 Other Focus Areas can be proposed under this section.

Select a Training and Technical Assistance (T/TA) Focus Area

[_] Need: Provide T/TA in the development and implementation of periodic community and/or population needs assessments focusing on overcoming access issues, minimizing barriers to care and maximizing community collaboration.

[_] Services: Provide T/TA in the development and implementation of quality improvement/quality assurance (QI/QA) systems (i.e., appropriate risk management, medical malpractice including Federal Tort Claims Act (FTCA), credentialing, patient satisfaction and quality of care reporting). (NOTE: excludes the UDS T/TA sessions hosted by PCAs).

[_] Management and Finance: Provide T/TA on fiscal operations/system requirements (i.e., billing systems, coding, Medicare and Medicaid, cost reports, budget tracking, financial reports, and financial audits).

[_] Management and Finance: Provide T/TA on workforce recruitment and retention of health center staff (i.e., health center managers, providers/staff, and board members).

[_] Governance: Provide T/TA on governance requirements for health centers (i.e., board authority, functions/responsibilities, composition, training, recruitment and evaluation tools).

Other Focus Area(s):

Focus Area	Details
Other Focus Area 1:	Focus Area Title: (100 characters maximum limit) Focus Area Description: (200 characters maximum limit)
Other Focus Area 2:	Focus Area Title: (100 characters maximum limit) Focus Area Description: (200 characters maximum limit)
Note: If you update the title or description of any previously proposed ‘Other Focus Area’, system will automatically update the focus area details for all the activities for which this ‘Other Focus Area’ was selected.

Activity Description (200 characters maximum limit)

Progress Report (1000 characters maximum limit)

Person/Area Responsible (limit 200 characters maximum limit for each entry)		Identify the person/position that will be responsible and accountable for carrying out each Activity.
Serial Number	Description
1
2
3
4
5

Time Frame (limit 5200 characters maximum limit for each entry)		Provide a timeline for carrying out each Activity.
Serial Number	Description
1
2
3
4
5

Expected Outcome (limit 200 characters maximum limit for each entry)		Identify the principal outcome for each Activity.
Serial Number	Description
1
2
3
4
5

Comments (limit 2,500 characters maximum limit)

Update/provide supplementary information related to entries in the project work plan, as desired. Not required; this field can be left blank.

Progress Report (limit 1,000 characters)

Provide a progress description for each activity.

Note: This field is only used when providing progress on the Non-Competing Continuation Progress Report

Section B - Training and Technical Assistance (T/TA) in Performance Improvement (Clinical)

Goal B1: Improvements in Clinical Measures a) Percent of Health Center Program grantees in the State/region that meet or exceed performance on one or more Healthy People 2020 performance measure goal(s). b) Percent of Health Center Program grantees with Patient-Centered Medical Home (PCMH).
Projected Goal Percentage for B1.a
Numerator Description	Total number of Health Center Program grantees in the State/region that meet or exceed performance on one or more Healthy People 2020 performance measure goal(s).
Denominator Description	Total number of Health Center Program grantees in the State or region.
Data Source	HRSA Program Reports
Projected Goal Percentage for B1.b
Numerator Description	Total number of Health Center Program grantees in the State/region that receive PCMH recognition.
Denominator Description	Total number of Health Center Program grantees in the State or region.
Data Source	HRSA Program Reports
Notes: Minimum of 3 and maximum of 5 Key Factors can be added under the goal. Minimum of 1 restricting key factor and 1 contributing key factor is required for the goal.
Key Factor #1	Type: [_] Contributing [_] Restricting Description:
Key Factor #2	Type: [_] Contributing [_] Restricting Description:
Key Factor #3	Type: [_] Contributing [_] Restricting Description:
Key Factor #4	Type: [_] Contributing [_] Restricting Description:
Key Factor #5	Type: [_] Contributing [_] Restricting Description:

Activity Details

Notes:

Propose activities under the required T/TA Focus Areas listed below.

Minimum of 2 and maximum of 5 Activities can be added under each proposed T/TA Focus Area.

If the activities you propose do not belong to the pre-defined T/TA Focus Area listed below, propose additional focus areas under ‘Other Focus Areas’. Maximum of 2 Other Focus Areas can be proposed under this section.

Select a Training and Technical Assistance (T/TA) Focus Area

[_] Clinical Performance Measures: Provide T/TA to Health Center Program grantees on how to improve clinical performance on one or more clinical performance measures (e.g. outreach/quality of care and health outcomes/disparities).

Other Focus Area(s):

Focus Area	Details
Other Focus Area 1:	Focus Area Title: (100 characters maximum limit) Focus Area Description: (200 characters maximum limit)
Other Focus Area 2:	Focus Area Title: (100 characters maximum limit) Focus Area Description: (200 characters maximum limit)
Note: If you update the title or description of any previously proposed ‘Other Focus Area’, system will automatically update the focus area details for all the activities for which this ‘Other Focus Area’ was selected.

Activity Description (200 characters maximum limit)

Progress Report (1000 characters maximum limit)

[This field is used when providing progress on the Non-Competing Continuation Progress Report]

Activity Audience [For NCAs Only]
Serial Number	Description
1

Person/Area Responsible (200 characters maximum limit for each entry)
Serial Number	Description
1
2
3
4
5

Time Frame (200 characters maximum limit for each entry)
Serial Number	Description
1
2
3
4
5

Expected Outcome (200 characters maximum limit for each entry)
Serial Number	Description
1
2
3
4
5

Comments (500 characters maximum limit)

Section B - Training and Technical Assistance (T/TA) in Performance Improvement (Financial)

Goal B2: Improvements in Financial Measures a) Percent of Health Center Program grantees with cost increase less than National average. b) Percent of Health Center Program grantees without going concern issues.
Projected Goal Percentage for B2.a
Numerator Description	Total number of Health Center Program grantees in the State/region that have cost increase less than the National average.
Denominator Description	Total number of Health Center Program grantees in the State or region.
Data Source	HRSA Program Reports
Projected Goal Percentage for B2.b
Numerator Description	Total number of Health Center Program grantees in the State/region that do not have going concern issues.
Denominator Description	Total number of Health Center Program grantees in the State or region.
Data Source	HRSA Program Reports
Notes: Minimum of 3 and maximum of 5 Key Factors can be added under the goal. Minimum of 1 restricting key factor and 1 contributing key factor is required for the goal.
Key Factor #1	Type: [_] Contributing [_] Restricting Description:
Key Factor #2	Type: [_] Contributing [_] Restricting Description:
Key Factor #3	Type: [_] Contributing [_] Restricting Description:
Key Factor #4	Type: [_] Contributing [_] Restricting Description:
Key Factor #5	Type: [_] Contributing [_] Restricting Description:

Activity Details

Notes:

Propose activities under the required T/TA Focus Areas listed below.

Minimum of 2 and maximum of 5 Activities can be added under each proposed T/TA Focus Area.

If the activities you propose do not belong to the pre-defined T/TA Focus Area listed below, propose additional focus areas under ‘Other Focus Areas’. Maximum of 2 Other Focus Areas can be proposed under this section.

Select a Training and Technical Assistance (T/TA) Focus Area

[_] Financial Performance Measures: Provide T/TA to Health Center Program grantees to improve financial performance on one or more financial performance measures (e.g. costs/ financial viability).

Other Focus Area(s):

Focus Area	Details
Other Focus Area 1:	Focus Area Title: (100 characters maximum limit) Focus Area Description: (200 characters maximum limit)
Other Focus Area 2:	Focus Area Title: (100 characters maximum limit) Focus Area Description: (200 characters maximum limit)
Note: If you update the title or description of any previously proposed ‘Other Focus Area’, system will automatically update the focus area details for all the activities for which this ‘Other Focus Area’ was selected.

Activity Description (200 characters maximum limit)

Progress Report (1000 characters maximum limit)

Person/Area Responsible (200 characters maximum limit for each entry)
Serial Number	Description
1
2
3
4
5

Time Frame (200 characters maximum limit for each entry)
Serial Number	Description
1
2
3
4
5

Expected Outcome (200 characters maximum limit for each entry)
Serial Number	Description
1
2
3
4
5

Comments (500 characters maximum limit)

Section C - Statewide/Regional Program Assistance

Activity Details

Notes:

• Propose activities under all the required T/TA Focus Areas listed below.

• Minimum of 2 and maximum of 5 Activities can be added under each proposed T/TA Focus Area.

• If the activities you propose do not belong to the pre-defined T/TA Focus Areas listed below, propose additional focus areas under ‘Other Focus Areas’. Maximum of 2 Other Focus Areas can be proposed under this section.

Select a Training and Technical Assistance (T/TA) Focus Area

[_] Information on Available Resources: Provide T/TA to all interested organizations seeking, regardless of PCA membership or grant status, section 330 resources and how they can be used to meet community health needs.

[_] T/TA Needs Assessment: Conduct T/TA needs assessment of existing health centers in the State/region with annual updates.

[_] Special Populations: Develop strategies for addressing the unique health needs and barriers to care for Special Populations in the State/region including identifying a Special Population Point of Contact, as appropriate.

[_] Collaboration: Support collaboration and coordination among existing health centers and other safety-net providers seeking to improve and expand access to services throughout the State/region.

[_] Emergency Preparedness: Provide statewide or regional T/TA on emergency preparedness and response plans, including participation with State and local emergency planners.

[_] Statewide/Regional Surveillance Analysis: Statewide/regional surveillance analysis on emerging primary care issues affecting health centers and their patients, including key regional and State regulatory and administrative activities.

[_] Newly Funded Health Centers: Provide T/TA on implementation start up needs for newly funded health centers in the State/region (e.g., recruitment, billing number, site enrollments).

Other Focus Area(s):

Focus Area	Details
Other Focus Area 1:	Focus Area Title: (100 characters maximum limit) Focus Area Description: (200 characters maximum limit)
Other Focus Area 2:	Focus Area Title: (100 characters maximum limit) Focus Area Description: (200 characters maximum limit)
Note: If you update the title or description of any previously proposed ‘Other Focus Area’, system will automatically update the focus area details for all the activities for which this ‘Other Focus Area’ was selected.

Activity Description (200 characters maximum limit)

Progress Report (1000 characters maximum limit)

Person/Area Responsible (200 characters maximum limit for each entry)
Serial Number	Description
1
2
3
4
5

Time Frame (200 characters maximum limit for each entry)
Serial Number	Description
1
2
3
4
5

Expected Outcome (200 characters maximum limit for each entry)
Serial Number	Description
1
2
3
4
5

Comments (500 characters maximum limit)

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0285. Public reporting burden for this collection of information is estimated to average 5 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 14N-39, Rockville, Maryland, 20857.