CAH Capacity-Building Award Application Form: FY2011

Deadline: December 2, 2011
Facility Name:  
CEO Name:  
Contact Person:  
Contact Title:  
Contact Phone Number:  
Contact Email:  

Check the following that applies:

  

We are currently licensed as a Critical Access Hospital
We are seriously considering converting to Critical Access Hospital licensure
Has your hospital undergone a Federal A-133 audit within the past year? If yes, please send a copy of your audit report to Jen Dunn at 303.832.7496 or jd@coruralhealth.org.   Yes
No

Place a mark beside the funding option(s) you are requesting funds for and the total amount you would like to allocate towards each. Each CAH is eligible for up to $5,000 in funding--the total amount of your request should not exceed $5,000. Costs listed are estimates only. Costs in excess of your award amount will be the responsibility of your facility. Federal guidelines prohibit the use of these funds for equipment or construction. CRHC will notify your facility within 60 days after the deadline about the status of your funding request. All award activities must be completed by August 31, 2012. An interim progress report will be due in March 2012 and a final progress report with invoices (if applicable) will be due September 15, 2012. CRHC will notify you of each report prior to the due date.

Quality Improvement and Patient Safety Services
  Estimated Cost Amount Requested
On-Site Scorecard Training/Consultation $1,850 (travel included up to 4 hours one-way) $
Customized On-Site Staff Education and Consultation, One-day training $2,850 (some travel included) $
Customized On-Site Staff Education and Consultation, Three-day training $6,700 (some travel included) $
Lean Six Sigma/Baldrige $7,700 (travel included) $
Lean Sigma Healthcare Facility Assessment $1,725 + Travel $
Value Added Process Mapping $1,725 + Travel $
Lean Sigma Healthcare e-Master Black Belt, Single Project $20,125 + Travel $
Lean Sigma Healthcare e-Master Black Belt, Dual Project $30,475 + Travel $
Lean Sigma Healthcare Hybrid Onsite/Virtual eMaster Black Belt $10,925 + Travel $
Lean Sigma Healthcare Online Yellow Belt Training $400 per student $
Lean Sigma Healthcare Online Team Member Training $170 per student $
Lean Sigma Healthcare Black Belt Training and Certification Track $4,600-$5,750 $
Lean Sigma Healthcare Ad Hoc Executive and Team Training Sessions $1,725/day + Travel $
AHRQ Rural Patient Safety Survey Distribution and Data Collection $650 fixed fee + $10.25 per EE surveyed $
Operational and Financial Improvement Services
Remote Tech Support Help Desk Solutions Price Varies – indicate amount to allocate $
HIPAA Compliance Gap Analysis $5,500 $
Compliance Gap Analysis $8,000 $
HIPAA Security Risk Assessment $8,250 $
Mock Survey – On-site $6,500 $
Mock Survey - On-site, Plus billing review $7,500 $
Assistance with 855 Applications $300 $
EHR Physician Advisors Compliance Safety Net $1,545/mo $
Compliance A La Carte $1,500 plus $240-$450/case (min 2 cases/mo) $
Milliman or McKesson InterQual Guidelines Price Varies – indicate amount to allocate $
Financial Excellence in Revenue Management (FERM)
Per diem on-site coding, billing, and accounts receivable training $2,000/day/person + travel $
Unlimited off-site coding, billing, and accounts receivable assistance, with one site per month  $3,500/month $
On-site Billing Office Assessment $2,500/day/person + travel $
Hourly off-site coding, billing, and accounts receivable assistance $155/hour $
Off-site coding “catch-up” assistance $60/hour $
Off-site provider coding audits, with 15 evaluation & management notes per provider $400/provider $
On-site provider coding training and evaluation & management audit delivery $155/hour + travel $
On-site provider coding training $155/hour + travel $
Educational booklet preparation and printing $25/booklet $
Managed care contracting negotiation and contract review $750 set up fee plus $155/hour + travel $
Outmigration Studies
Outmigration Studies – using 2010 data $7,500 $
Outmigration Study using 2010 data and Key Informant Interview/Analysis $10,000 $
Outmigration Study using 2010 data and prior years’ data Price Varies – indicate amount to allocate $
Credentialing
Ongoing Credentialing Management (Health Plans and Hospitals, CAQH, etc.) $450 set up fee and $100/ month (per provider) $
New Provider Credentialing Management (Health Plans and Hospitals, CAQH, etc.) $4,500 per provider/4 months ($1,125/month) $
CareLearning
CareLearning $2,500 $
Health Network Development and Community Engagement Services
Trauma Designation Assistance and Consultation
Assistance with development of a new trauma program $9,000 $
Review of current policies & procedures on-site $1,850 $
Review of current policies & procedures off-site $1,200 $
Board Training
On-site Presentation $4,000 + travel $
Additional Funding Options
You may apply for up to $5,000 to support an innovative project or program. Use the space below to give a brief overview of your project budget, timeline, overview, goals and how it will benefit the healthcare infrastructure of your community. (500 character limit) $

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Federal guidelines prohibit the use of these funds for equipment or construction. Apply by December 2, 2011.

The CAH Capacity Building Award is provided through CRHC’s receipt of the Federal HRSA Rural Hospital Flexibility Grant: CFDA: 93.241; Grant Award No.: 2 H54RH00056-10-00.