FALLING THROUGH THE CRACKS: Appendix 4

Data Analysis Guide Summaries Worksheet

AGENCY:________________________________________________

I. Services Provided (Circle the one that best describes the agency’s services. Provide narrative or alternative if none of these fit.)

Medical OB only
Medical OB/Newborn and Family Planning
Medical OB/NB/FP with minimal affiliations with social services
Medical OB/NB/FP with some strong affiliations with social services and/or on-site social services (not including PHN)
Medical OB/NB/FP with some strong affiliations with social services and/or on-site social services, including PHN

II. State Goals and Objectives (Circle the one that best describes the agency’s services. Provide narrative or alternative if none of these fit.)

None
Non-perinatal goals
Perinatal goals with no indicators
Perinatal goals with indicators and minimal tracking
Perinatal goal with indicators and extensive tracking

Table of Racial Mix (see IIIB too)
Table of Payer Mix (See IIIB and IV table too)

ID. Write a statement about the intended populations served as indicated by the agency’s mission statement

IE. Write a few sentences describing the agency’s relationships with external partners.

II. Write a descriptive paragraph for IIA &B (Coalition Building and Internal and External Collaboration)

IID. Describe provider education provided

IIG. System direction—List how things are better and worse—summarize

III B Resource Advocacy (circle Y or N)
Eligibility MA/MNCare Y / N
Application MA/MNCare Y / N
Benefit Access Y / N
WIC Y / N
IIIC. Health Teaching
Tally
Descriptive—Describe any additional information about the clinic and its health teaching that will not be captured in a tally of this table.

IIID. Brief Counseling

IIIE. Case Management/Care Coordination

IIIE. Care Plan Development and Tracking (Circle the one that best describes the
agency’s services. Provide narrative or alternative if none of these fit.)

None
Some patients get care plan but there is no tracking
Some patients get care plan and some are tracked
Some patients get care plan and all are tracked
All patients get care plan and are tracked

IIIE #4—Tally answers to all questions (circle) Log Y /N

Handwritten / Electronic
Who Maintains Log?_______________________________________
Information tracked
Sign consent Y / N
Hospital Info. Occasionally / Somewhat regularly / Always
Contacting Pts. Post Partum Y / N
Tracking system for newborns Y /N

IIIE #5

Tally Column 2 (ON/OFF/No Response)
Tally column 3

IIIF. Referrals In—Write approximately one sentence describing this table for the agency.

IIIG. Write a descriptive sentence or paragraph for each agency regarding its outreach activities

IV. What percent of the agency’s budget (from the “percent of budget” column) is from insurance? __________________

Rank the next three top funding sources:
1._____________________________
2._____________________________
3._____________________________

Capacity—Write a sentence describing the agency’s capacity
Write one-two sentences describing the agency’s reimbursement problems.

V. Write 1-2 sentences describing how this agency is a model.

List recommendations:

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