Monthly Community/Provider Log

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Monthly Community/Provider Log Powered By Docstoc
					                      Monthly Community / Provider Log
                      Deliverable C.3 (due the last day of each month)
                        Updated: [Enter Month/Year]

                       Submitted by: [QIO Name & State]
                            Submitted on: [Date]

         QIOs should name their 10th SOW QIO deliverables using the following naming convention:

State (two-letter abbreviation), Deliverable #, due date of deliverable (month [2 digits], date [2 digits], year [2
                   digits]), any additional description, with each group separated by a dash.

                                           Please see example below:

                                           AA-C3-123111-monthlylog




                                           (Template revised 12.01.11)
                                         Community Characteristics
State: [enter state abbreviation]; Updated: [enter month/year]

Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                        Hospitals (#)
                                        Skilled Nursing Facilities (#)
                                        Home Health Providers (#)
Provider Types                          Outpatient Physician Providers (#)
                                        Dialysis (#)
                                        Hospice (#)
                                        Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                        Hospitals (#)
                                        Skilled Nursing Facilities (#)
                                        Home Health Providers (#)
Provider Types                          Outpatient Physician Providers (#)
                                        Dialysis (#)
                                        Hospice (#)
                                        Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                       Hospitals (#)
                                       Skilled Nursing Facilities (#)
                                       Home Health Providers (#)
Provider Types                         Outpatient Physician Providers (#)
                                       Dialysis (#)
                                       Hospice (#)
                                       Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                       Hospitals (#)
                                       Skilled Nursing Facilities (#)
                                       Home Health Providers (#)
Provider Types                         Outpatient Physician Providers (#)
                                       Dialysis (#)
                                       Hospice (#)
                                       Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                          Hospitals (#)
                                          Skilled Nursing Facilities (#)
                                          Home Health Providers (#)
Provider Types                            Outpatient Physician Providers (#)
                                          Dialysis (#)
                                          Hospice (#)
                                          Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                          Hospitals (#)
                                          Skilled Nursing Facilities (#)
                                          Home Health Providers (#)
Provider Types                            Outpatient Physician Providers (#)
                                          Dialysis (#)
                                          Hospice (#)
                                          Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
                                     Hospitals (#)



Provider Types
                                     Skilled Nursing Facilities (#)
                                     Home Health Providers (#)
Provider Types                       Outpatient Physician Providers (#)
                                     Dialysis (#)
                                     Hospice (#)
                                     Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Coalition Charter established &
                                     Hospitals (#)
                                     Skilled Nursing Facilities (#)
                                     Home Health Providers (#)
Provider Types                       Outpatient Physician Providers (#)
                                     Dialysis (#)
                                     Hospice (#)
                                     Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Coalition Charter established &
signed (Yes/No & date)
                                     Hospitals (#)
                                     Skilled Nursing Facilities (#)
                                     Home Health Providers (#)
Provider Types                       Outpatient Physician Providers (#)
                                     Dialysis (#)
                                     Hospice (#)
                                     Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                     Hospitals (#)
                                     Skilled Nursing Facilities (#)
                                     Home Health Providers (#)
Provider Types                       Outpatient Physician Providers (#)
                                     Dialysis (#)
                                     Hospice (#)
                                     Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000
Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                     Hospitals (#)
                                     Skilled Nursing Facilities (#)
                                     Home Health Providers (#)
Provider Types                       Outpatient Physician Providers (#)
                                     Dialysis (#)
                                     Hospice (#)
                                     Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                     Hospitals (#)
                                     Skilled Nursing Facilities (#)
                                     Home Health Providers (#)
Provider Types                       Outpatient Physician Providers (#)
                                     Dialysis (#)
                                     Hospice (#)
                                     Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                       Hospitals (#)
                                       Skilled Nursing Facilities (#)
                                       Home Health Providers (#)
Provider Types                         Outpatient Physician Providers (#)
                                       Dialysis (#)
                                       Hospice (#)
                                       Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                       Hospitals (#)
                                       Skilled Nursing Facilities (#)
                                       Home Health Providers (#)
Provider Types                         Outpatient Physician Providers (#)
                                       Dialysis (#)
                                       Hospice (#)
                                       Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                          Hospitals (#)
                                          Skilled Nursing Facilities (#)
                                          Home Health Providers (#)
Provider Types                            Outpatient Physician Providers (#)
                                          Dialysis (#)
                                          Hospice (#)
                                          Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                          Hospitals (#)
                                          Skilled Nursing Facilities (#)
                                          Home Health Providers (#)
Provider Types                            Outpatient Physician Providers (#)
                                          Dialysis (#)
                                          Hospice (#)
                                          Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Coalition Charter established &
signed (Yes/No & date)
                                     Hospitals (#)
                                     Skilled Nursing Facilities (#)
                                     Home Health Providers (#)
Provider Types                       Outpatient Physician Providers (#)
                                     Dialysis (#)
                                     Hospice (#)
                                     Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                     Hospitals (#)
                                     Skilled Nursing Facilities (#)
                                     Home Health Providers (#)
Provider Types                       Outpatient Physician Providers (#)
                                     Dialysis (#)
                                     Hospice (#)
                                     Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000
Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                     Hospitals (#)
                                     Skilled Nursing Facilities (#)
                                     Home Health Providers (#)
Provider Types                       Outpatient Physician Providers (#)
                                     Dialysis (#)
                                     Hospice (#)
                                     Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                     Hospitals (#)
                                     Skilled Nursing Facilities (#)
                                     Home Health Providers (#)
Provider Types                       Outpatient Physician Providers (#)
                                     Dialysis (#)
                                     Hospice (#)
                                     Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                       Hospitals (#)
                                       Skilled Nursing Facilities (#)
                                       Home Health Providers (#)
Provider Types                         Outpatient Physician Providers (#)
                                       Dialysis (#)
                                       Hospice (#)
                                       Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                       Hospitals (#)
                                       Skilled Nursing Facilities (#)
                                       Home Health Providers (#)
Provider Types                         Outpatient Physician Providers (#)
                                       Dialysis (#)
                                       Hospice (#)
                                       Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                          Hospitals (#)
                                          Skilled Nursing Facilities (#)
                                          Home Health Providers (#)
Provider Types                            Outpatient Physician Providers (#)
                                          Dialysis (#)
                                          Hospice (#)
                                          Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                          Hospitals (#)
                                          Skilled Nursing Facilities (#)
                                          Home Health Providers (#)
Provider Types                            Outpatient Physician Providers (#)
                                          Dialysis (#)
                                          Hospice (#)
                                          Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Coalition Charter established &
signed (Yes/No & date)
                                     Hospitals (#)
                                     Skilled Nursing Facilities (#)
                                     Home Health Providers (#)
Provider Types                       Outpatient Physician Providers (#)
                                     Dialysis (#)
                                     Hospice (#)
                                     Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000


Community Name
Formally recruited (Yes/No &
Date)
Coalition Charter established &
signed (Yes/No & date)
                                     Hospitals (#)
                                     Skilled Nursing Facilities (#)
                                     Home Health Providers (#)
Provider Types                       Outpatient Physician Providers (#)
                                     Dialysis (#)
                                     Hospice (#)
                                     Others (#, include type)
ZIP Codes (#)
ZIP Code List (reference ZIP Code List tab)
ZIP Code Overlap (%)
Hospitals (#, including CAHs)
Hospital ID list (reference Hospital IDs tab)
Medicare Beneficiaries in the Target Region (#)
Number of Medicare Discharges in the Target Region per Year (#)
Total Population in ZIP Codes (#)
30-day Baseline Community Rehospitalization/ Readmission Rate per 1000
Baseline Community Hospitalization/ Admission Rate per 1000
acteristics
h/year]




          Please reference 'ZIP Code List' tab


          Please reference 'Hospital IDs' tab




          Please reference 'ZIP Code List' tab


          Please reference 'Hospital IDs' tab
Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab




Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab
Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab




Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab
Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab




Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab
Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab




Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab
Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab




Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab
Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab




Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab
Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab




Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab
Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab




Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab
Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab




Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab
Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab




Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab
Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab




Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab
Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab




Please reference 'ZIP Code List' tab


Please reference 'Hospital IDs' tab
                                                                                                                                              Monthly Community/Provider Log
                                                                                                                      This log is intended to track communities utilizing QIO consultative services and support.
                                                                                                                                                 Updated: [enter month/year]




                                                                                             Complete Columns A - K for all Communities




                                                                               Has this           Is this
                            Has this                                         community        community
                                                                                                                Will this community         Readiness Score
                          community                                        established and    eligible for a
                                                                                                               apply for a formal care
                         been officially                                       signed a       formal care
                                           If not formally recruited, why?                                      transitions program?      (Readiness for formal    Support Provided to the
State   Community Name     recruited?                                         Coalition        transitions
                                                 (briefly list reasons)                                                                  program participation)     Community (brief list)
                                                                              Charter?          program?
                                                                                                                 (Enter N/A; 0=No;
                         (Enter 0=No;
                                                                                                                       1=Yes)            (Columns C + E + F + G)
                            1=Yes)                                          (Enter 0=No;      (Enter 0=No;
                                                                               1=Yes)            1=Yes)




                                                                                                                                                   0




                                                                                                                                                   0




                                                                                                                                                   0




                                                                                                                                                                                                            36
                                                                               Has this          Is this
                            Has this                                         community       community
                                                                                                               Will this community         Readiness Score
                          community                                        established and   eligible for a
                                                                                                              apply for a formal care
                         been officially                                       signed a      formal care
                                           If not formally recruited, why?                                     transitions program?      (Readiness for formal    Support Provided to the
State   Community Name     recruited?                                         Coalition       transitions
                                                 (briefly list reasons)                                                                 program participation)     Community (brief list)
                                                                              Charter?         program?
                                                                                                                (Enter N/A; 0=No;
                         (Enter 0=No;
                                                                                                                      1=Yes)            (Columns C + E + F + G)
                            1=Yes)                                          (Enter 0=No;     (Enter 0=No;
                                                                               1=Yes)           1=Yes)




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                                                            37
                                                                               Has this          Is this
                            Has this                                         community       community
                                                                                                               Will this community         Readiness Score
                          community                                        established and   eligible for a
                                                                                                              apply for a formal care
                         been officially                                       signed a      formal care
                                           If not formally recruited, why?                                     transitions program?      (Readiness for formal    Support Provided to the
State   Community Name     recruited?                                         Coalition       transitions
                                                 (briefly list reasons)                                                                 program participation)     Community (brief list)
                                                                              Charter?         program?
                                                                                                                (Enter N/A; 0=No;
                         (Enter 0=No;
                                                                                                                      1=Yes)            (Columns C + E + F + G)
                            1=Yes)                                          (Enter 0=No;     (Enter 0=No;
                                                                               1=Yes)           1=Yes)




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                                                            38
                                                                               Has this          Is this
                            Has this                                         community       community
                                                                                                               Will this community         Readiness Score
                          community                                        established and   eligible for a
                                                                                                              apply for a formal care
                         been officially                                       signed a      formal care
                                           If not formally recruited, why?                                     transitions program?      (Readiness for formal    Support Provided to the
State   Community Name     recruited?                                         Coalition       transitions
                                                 (briefly list reasons)                                                                 program participation)     Community (brief list)
                                                                              Charter?         program?
                                                                                                                (Enter N/A; 0=No;
                         (Enter 0=No;
                                                                                                                      1=Yes)            (Columns C + E + F + G)
                            1=Yes)                                          (Enter 0=No;     (Enter 0=No;
                                                                               1=Yes)           1=Yes)




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                                                            39
                                                                               Has this          Is this
                            Has this                                         community       community
                                                                                                               Will this community         Readiness Score
                          community                                        established and   eligible for a
                                                                                                              apply for a formal care
                         been officially                                       signed a      formal care
                                           If not formally recruited, why?                                     transitions program?      (Readiness for formal    Support Provided to the
State   Community Name     recruited?                                         Coalition       transitions
                                                 (briefly list reasons)                                                                 program participation)     Community (brief list)
                                                                              Charter?         program?
                                                                                                                (Enter N/A; 0=No;
                         (Enter 0=No;
                                                                                                                      1=Yes)            (Columns C + E + F + G)
                            1=Yes)                                          (Enter 0=No;     (Enter 0=No;
                                                                               1=Yes)           1=Yes)




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                                                            40
                                                                               Has this          Is this
                            Has this                                         community       community
                                                                                                               Will this community         Readiness Score
                          community                                        established and   eligible for a
                                                                                                              apply for a formal care
                         been officially                                       signed a      formal care
                                           If not formally recruited, why?                                     transitions program?      (Readiness for formal    Support Provided to the
State   Community Name     recruited?                                         Coalition       transitions
                                                 (briefly list reasons)                                                                 program participation)     Community (brief list)
                                                                              Charter?         program?
                                                                                                                (Enter N/A; 0=No;
                         (Enter 0=No;
                                                                                                                      1=Yes)            (Columns C + E + F + G)
                            1=Yes)                                          (Enter 0=No;     (Enter 0=No;
                                                                               1=Yes)           1=Yes)




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                  0




                                                                                                                                                                                            41
ovider Log
 consultative services and support.
h/year]
                                                                                                Complete column N for
                                                                                           communities that have not been
                                                            Complete columns L & M only
                                                                                               accepted to formal care
                                                             for communities applying to
                                                                                           transitions programs, and/or are
                                                          formal care transitions programs
                                                                                              not applying to formal care
                                                                      (Track 1)
                                                                                                 transitions programs
                                                                                                        (Track 2)
                                                           If the community
                                                             will apply for a
                                                               formal Care
                                                                                Has the application   Has this community demonstrated 4 time
                                                               Transitions
                                                                                 been accepted?        series graphs showing positive trending
                             Barriers      Strengths       program, has the
                                                                                                                        data?
                            (brief list)   (brief list)    application been
                                                                                    (Enter N/A;        (Enter N/A if data are not yet available;
                                                               submitted?
                                                                                   0=No; 1=Yes)                      0=No; 1=Yes)
                                                          (Enter N/A; 0=No;
                                                                1=Yes)




                                                                                                                                                   42
                              If the community
                                will apply for a
                                  formal Care
                                                   Has the application   Has this community demonstrated 4 time
                                  Transitions
                                                    been accepted?        series graphs showing positive trending
 Barriers      Strengths      program, has the
                                                                                           data?
(brief list)   (brief list)   application been
                                                       (Enter N/A;        (Enter N/A if data are not yet available;
                                  submitted?
                                                      0=No; 1=Yes)                      0=No; 1=Yes)
                              (Enter N/A; 0=No;
                                    1=Yes)




                                                                                                                      43
                              If the community
                                will apply for a
                                  formal Care
                                                   Has the application   Has this community demonstrated 4 time
                                  Transitions
                                                    been accepted?        series graphs showing positive trending
 Barriers      Strengths      program, has the
                                                                                           data?
(brief list)   (brief list)   application been
                                                       (Enter N/A;        (Enter N/A if data are not yet available;
                                  submitted?
                                                      0=No; 1=Yes)                      0=No; 1=Yes)
                              (Enter N/A; 0=No;
                                    1=Yes)




                                                                                                                      44
                              If the community
                                will apply for a
                                  formal Care
                                                   Has the application   Has this community demonstrated 4 time
                                  Transitions
                                                    been accepted?        series graphs showing positive trending
 Barriers      Strengths      program, has the
                                                                                           data?
(brief list)   (brief list)   application been
                                                       (Enter N/A;        (Enter N/A if data are not yet available;
                                  submitted?
                                                      0=No; 1=Yes)                      0=No; 1=Yes)
                              (Enter N/A; 0=No;
                                    1=Yes)




                                                                                                                      45
                              If the community
                                will apply for a
                                  formal Care
                                                   Has the application   Has this community demonstrated 4 time
                                  Transitions
                                                    been accepted?        series graphs showing positive trending
 Barriers      Strengths      program, has the
                                                                                           data?
(brief list)   (brief list)   application been
                                                       (Enter N/A;        (Enter N/A if data are not yet available;
                                  submitted?
                                                      0=No; 1=Yes)                      0=No; 1=Yes)
                              (Enter N/A; 0=No;
                                    1=Yes)




                                                                                                                      46
                              If the community
                                will apply for a
                                  formal Care
                                                   Has the application   Has this community demonstrated 4 time
                                  Transitions
                                                    been accepted?        series graphs showing positive trending
 Barriers      Strengths      program, has the
                                                                                           data?
(brief list)   (brief list)   application been
                                                       (Enter N/A;        (Enter N/A if data are not yet available;
                                  submitted?
                                                      0=No; 1=Yes)                      0=No; 1=Yes)
                              (Enter N/A; 0=No;
                                    1=Yes)




                                                                                                                      47
                    ZIP Code List by Community
         Please list one ZIP Code per row, by community

Community 1   Community 2   Community 3   Community 4   Community 5
Community 6   Community 7   Community 8   Community 9   Community 10
Community 11   Community 12   Community 13   Community 14   Community 15
Community 15   Community 16   Community 17   Community 18   Community 19
Community 20   Community 21   Community 22   Community 23   Community 24
Community 25
                   Hospital ID List by Community
        Please list one Hospital ID per row, by community

Community 1   Community 2   Community 3   Community 4   Community 5
Community 6   Community 7   Community 8   Community 9   Community 10
Community 11   Community 12   Community 13   Community 14   Community 15
Community 15   Community 16   Community 17   Community 18   Community 19
Community 20   Community 21   Community 22   Community 23   Community 24
Community 25

				
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