2020-2021 SHIP HOSPITAL APPLICATION FORM

2021 - 2022 Small Rural Hospital Improvement Grant Program (SHIP) Application Form
DUE JANUARY 22, 2021 DUE
Directions:

Please complete the following sections of the SHIP application below.
- Since the form does not auto-save, it is highly recommended that all necessary information is available and ready before entering data into the online report form. To save time, it is suggested that the form be printed, reviewed, and required information obtained and then entered in the online form. After reviewing and signing the application, the applicant may click the "Print Form" button to print a hard copy of the application form.
- Please Note: The applicant MUST click the "Submit Form" button for the application to be submitted. The applicant will receive an email verifying the submission and a copy of the application.
Applications must be submitted/received on or before

January 22, 2021 by 5:00 p.m. central time

If you have questions or need assistance completing the SHIP application, please contact the SORH Regional Coordinator for your facility:

South Region: Vacant   RuralHealth@TexasAgriculture.gov

Panhandle Region: Ryan Horsak   Ryan.Horsak@TexasAgriculture.gov

West Region: Kathy Johnston Kathy.Johnston@TexasAgriculture.gov

East Region: Trish Rivera Trish.Rivera@TexasAgriculture.gov

North Region: Robert Shaw   Robert.Shaw@TexasAgriculture.gov

Central Gulf Region: Shari Wyatt   Shari.Wyatt@TexasAgriculture.gov

For immediate assistance call 512-923-9000 or email RuralHealth@TexasAgriculture.gov .
SECTION A: GENERAL INFORMATION
Hospital Tax Identification Number or Employer Identification Number*
CMS Certification Number (CCN) for Hospital*
Data Universal Number System (DUNS) for Hospital*
Legal Business Name of Hospital*
DBA (if applicable) *
Mailing and Physical Address*

Mailing Address

Physical Address

CityState / Province

Postal / Zip Code
Hospital Phone Number*

Area CodePhone Number
County in which Hospital Applicant is Located:*
SORH REGION:
Is the hospital classified as a Tribally operated hospital under Titles I and V of P.L. 93-638:

YESNO
SECTION B: CONTACT INFORMATION - CEO/Administrator

The individual who is authorized to enter into legal agreements on behalf of the organization. This person's name will appear on the grant agreement for signature.
Title:*
Name of Hospital Authorizing Official (CEO/CFO, etc.)*

First NameLast Name
Title of Hospital Authorizing Official:*
Email - Authorizing Official *
Phone Number*

Area CodePhone Number
SECTION C: CONTACT INFORMATION - SHIP Project Director
Title:*
Name of Hospital SHIP Project Director*

First NameLast Name
Title of SHIP Project Director*
Email - SHIP Director *
Phone Number*

Area CodePhone Number
Email - Additional Contact Person
SECTION D: HOSPITAL INFORMATION
Indicate which of the following applies to your hospital:*

Returning SHIP Hospital (awarded $10,286.95 in 2020 for current SHIP project)New SHIP Hospital (did not apply or was not awarded $10,286.95 SHIP funds in 2020)
Is your hospital a critical access hospital (CAH)?*

YESNO
Number of licensed beds per Line 14 of the most recently filed Medicare Cost Report:*
Number of Staffed Beds:*
Medicare Cost Reporting Period:*
mm/yy - mm/yy
Note: If hospital reports a licensed bed count greater than 49 on Line 14 but staffs 49 beds or fewer, eligibility may be certified by submitting a written statement to the Texas State Office of Rural Health that includes: 1.) the number of staffed beds at the time of the most recent cost report submission, 2.) the cost reporting period of the most recently filed cost report and 3.) the signature of the certifying official. If the bed count is greater than 49, email a scanned version of the written statement to RuralHealth@TexasAgriculture.gov or to the SORH Regional Coordinator for your facility.
Indicate if your hospital is participating in the following Centers for Medicare and Medicaid Services (CMS) programs:
Medicare Shared Savings Program*

YESNO
Other Accountable Care Organization (ACO) Model*

YESNO
Hospital Inpatient Quality Reporting Program*

YESNO
Hospital Compare*

YESNO
Hospital Value-Based Purchasing Program (PPS hospitals only)*

YESNONA
2020 (CURRENT) SHIP FUNDING PRIORITIES:
Has the hospital implemented ICD-10 (ICD-10 is currently in use)?*

YESNO
Has your hospital fully implemented Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (e.g., reported for at least one quarter during SHIP budget period?)*

YESNO
Is your hospital's HCAHPS data publicly reported on Hospital Compare?*

YESNO
RETURNING SHIP HOSPITALS PROGRESS:

SHIP Project Progress Status and Evaluation of Current 2020-2021 SHIP Project
Please indicate if any of the following has changed since the 2020-2021 SHIP application was submitted in 2020 (select all that apply). Provide the updated information in the box below.

Hospital NameAddressAdministrator/CEOSHIP Project Director
Provide the updated information:
Example: SHIP Project Director - Tom Smith, email
Briefly describe the progress status and activity for each SHIP Purchasing Menu Investment Category that was selected by your hospital for this current 2020-2021 SHIP Project (June 2020 - May 2021).
VALUE-BASED PURCHASING ACTIVITIES (June 2020 - May 2021)*

IN PROGRESS (2020-21 hospital project is in progress; hospital is actively working to implement the activities)COMPLETED (Hospital has fully completed the 2020-21 SHIP project and has submitted the project completion report to the State Office of Rural Health)NOT APPLICABLE (Hospital did not select VBP activities)NOT APPLICABLE (Hospital did not apply for 2020-21 SHIP funding)
Describe progress, lessons learned, and/or impact of the VBP activity(ies) from your 2020-21 SHIP project.*
Example: Our hospital contracts with PressGaney. HCAHPS survey response rate increased from 29% to 34%.
ACCOUNTABLE CARE ORGANIZATION (ACO) SHARED SAVING (SS) PURCHASING ACTIVITIES (June 2020 - May 2021)*

IN PROGRESS (2020-21 hospital project is in progress; hospital is working to implement the activities)COMPLETED (Hospital has fully completed the 2020-21 SHIP project and has submitted the project completion report to the State Office of Rural Health)NOT APPLICABLE (Hospital did not select ACO/SS activities)NOT APPLICABLE (Hospital did not apply for 2020-21 SHIP funding)
Describe progress, lessons learned, and/or impact of the ACO/SS activity(ies) from your 2020-21 SHIP project, if applicable.*
Example: 2020 SHIP project is to purchase telehealth software subscription and hardware. Our project is in progress and not yet completed.
PAYMENT BUNDLING (PB) or PROSPECTIVE PAYMENT SYSTEM (PPS) PURCHASING ACTIVITIES (June 2020 - May 2021)*

IN PROGRESS (2020-21 hospital project is in progress; hospital is working to implement the activities)COMPLETED (Hospital has fully completed the 2020-2021 SHIP project and has submitted the project completion report to the State Office of Rural Health)NOT APPLICABLE (Hospital did not select PB or PPS activities)NOT APPLICABLE (Hospital did not apply for 2020-2021 SHIP funding)
Describe progress, lessons learned, and/or impact of the PB or PPS activity(ies) from your 2020-21 SHIP project if applicable.*
Example: Our hospital has contracted with a company to provide training for the 2021 changes to E&M documentation and coding. The training will occur in February 2021.
Are any of the 2020-2021 project activities conducted in a SHIP or other type of network or consortium?*

YESNODID NOT RECEIVE 2020-2021 SHIP FUNDING
Do you anticipate expending all $10,286.95 of the 2020-2021 SHIP funds by the end of the grant period (May 31, 2021)?*

YESNODID NOT RECEIVE 2020-2021 SHIP FUNDING
SECTION E: 2021 - 2022 SHIP Purchasing Menu:
2021 SHIP FUNDING PRIORITIES

PLEASE NOTE:

This year the Federal Office of Rural Health Policy's (FORHP) is suspending the previous priority items (HCAHPS and ICD-10) for the 2021 SHIP program year (June 1, 2021 - May 31, 2022). The suspension of the HCAHPS priority for the SHIP program is in alignment with FORHP's announcement to suspend the MBQIP eligibility requirements for the 2021 FLEX grant year. SHIP hospitals may select any activity on the 2021 SHIP Purchasing Menu, whether or not they have fully implemented HCAHPS or ICD-10.

In lieu of a funding priority, FORHP recommends that hospitals utilize funding to support quality improvement and/or healthcare finance requirements related to activities that:
- supports the application and expansion of telehealth and/or telemedicine
- assist with CMS's Transparency rule
2021-2022 SHIP BUDGET PURCHASING MENU

(June 1, 2021 - May 31, 2022)

Following the instructions/priorities above, the applicant hospital plans to utilize 2021-2022 SHIP funds for one or more of the following activities. The estimated maximum budget of $11,855 should be used to support and implement eligible activities. The actual selected activities and expenditures for each activity will be shown on the Project Completion Report that will be submitted when the project is completed. The Project Completion Report will require an invoice and proof of payment for each activity that is selected.
Value-Based Purchasing (VBP) Activities

A. Quality reporting data collection/related training or softwareB. HCAHPS data collection process/related trainingC. Efficiency or quality improvement training in support of VBP initiativesD. Provider-Based Clinic quality measures education (Applicable to Provider-Based RHCs of eligible SHIP hospitals)E. Alternative Payment Model and Quality Payment Program training/education
Briefly describe the planned VBP activity or activities:
Ex: B. HCAHPS data collection process - the hospital will contract with PressGaney
Budget Request for VBP Activities:*
VBP %
Accountable Care Organization (ACO) or Shared Savings(SS) Activities

A. Computerized provider order entry implementation and/or trainingB. Pharmacy servicesC. Disease registry training and/or software/hardware Population Health softwareD. Social Determinants of Health Screening software/trainingE. Efficiency or quality improvement training/project in support of ACO or shared savings related initiativesF. Systems performance training in support of ACO or shared savings related initiativesG. Mobile health and telehealth hardware/softwareH. Community paramedicine hardware/software and trainingI. Health Information Technology (HIT) training for value and ACOs
Briefly describe the planned ACO or SS activity or activities:
Ex: G. purchase telemedicine cart and service agreement
Budget Request for ACO or SS Activities:*
ACO or SS %
Payment Bundling (PB) or Prospective Payment System (PPS) Activities

A. ICD-10 softwareB. ICD-10 trainingC. Efficiency or quality improvement training in support of PB or PPS related initiativesD. S-10 Cost Reporting training/projectE. Price Transparency training or software
Briefly describe the PB or PPS activity or activities:
Ex: upgrade ICD-10 software, ICD-10 coding training class
Budget Request for PB or PPS Activities:*
PB or PPS %
TOTAL BUDGET REQUEST FOR ACTIVITIES:*
Total Budget Request Must Equal $11,855
TOTAL BUDGET REQUEST MUST EQUAL $11,855
Will the 2021-22 SHIP funds be allocated to a SHIP network/consortium? (A network solely for the purpose of SHIP activities)?*

YESNO
If yes, provide name of network. If no please type "NA":*
Will the 2021-22 SHIP funds be allocated to any other network/consortium? (A network formed for purposes other than SHIP that offers programs/services that SHIP hospitals can "buy into" with SHIP funds?)?*

YESNO
Will the 2021-22 SHIP funds be allocated to a Special Innovation Project (SIP)?*

YESNO
If yes, provide description. If no, please type "NA":*
Please provide any recommendations you have for improving the SHIP program.*
For example, list any new purchasing items that would be beneficial to your hospital, changes that would improve the SHIP program, or needs of your hospital.
SECTION F: Application Submission
By submitting this application, the Applicant certifies/acknowledges:

1) That you are affirming adherence to all FY2021 SHIP eligibility and program requirements including the selection of menu investment(s) based upon the specific selection priorities listed in the SHIP Purchasing Menu Instructions. Hospitals that do not follow purchase priorities, and/or purchase hardware and/or software or services that are not listed on the SHIP Purchasing Menu, will be subject to penalties including suspension from the next SHIP funding opportunity.

2) That you are not only selecting an investment, but also a measure that correlates to your purchase. Your hospital will be expected to report to your State Office of Rural Health regarding progress at the end of the year.

3) That all information provided in connection with this application is true and correct to the best of Applicant’s knowledge.

4) That any misrepresentation or false statement made by Applicant, or an authorized agent of Applicant, in connection with this application, whether intentional or not, will constitute grounds for denial of this application.

5) That the acceptance of funds in connection with this application acts as an acceptance of the authority of the Health Resources and Services Administration (HRSA) Federal Office of Rural Health Policy (FORHP), TDA, and the State Auditor’s Office (SAO) or any successor agency to conduct an investigation in connection with those funds, and Applicant further agrees to cooperate fully with FORHP, TDA, and/or SAO or its successor in the conduct of the audit or investigation, including allowing FORHP, TDA, and/or SAO to inspect Applicant’s premises and providing all records requested.

6) That this application and any payments owed to Applicant in connection with this application may be reduced or denied because of Applicant’s owing any debt to the State of Texas.

7) The applicant acknowledges as a condition of receipt of grant funds under this program the Applicant will be required to execute a grant agreement with the Texas Department of Agriculture, and further acknowledges that failure to timely execute the grant agreement will result in withdrawal of any grant funds awarded, and those funds will be redistributed to other qualified applicants in accordance with state law and TDA rules.
Type the full name of person submitting this application:*
Title of person submitting application:*
Signature of Person Submitting Application:*

Clear
(Use mouse to provide the signature of the person submitting the application.)
Should be Empty:

2021 - 2022 Small Rural Hospital Improvement Grant Program (SHIP) Application Form

SECTION A: GENERAL INFORMATION

SECTION B: CONTACT INFORMATION - CEO/Administrator

SECTION C: CONTACT INFORMATION - SHIP Project Director

SECTION D: HOSPITAL INFORMATION

2020 (CURRENT) SHIP FUNDING PRIORITIES:

RETURNING SHIP HOSPITALS PROGRESS:

SECTION E: 2021 - 2022 SHIP Purchasing Menu:

SECTION F: Application Submission