2019-2020 SHIP PROJECT COMPLETION REPORT FORM

2019 - 2020 Small Rural Hospital Improvement Grant Program (SHIP) Project Completion Report Form
DUE JUNE 12, 2020 DUE

SHIP Project Completion Report is due when the project is completed or no later than June 12, 2020
Directions:
The SHIP Project Completion Report should be completed and submitted to the State Office of Rural Health when the 2019-20 SHIP project has been completed and your SHIP funds ($10,376) have been utilized. The deadline for the 2019-20 SHIP Project Completion Report is June 12, 2020 for reimbursement of the SHIP grant project expenditures. Expenditures must follow SHIP priorities and the category activities found on the SHIP Purchasing Menu. Please complete the fields below. The auto-save feature is NOT enabled on this form. After completing the form, click on the "Print Button" to print a copy for your facility. You MUST click the "Submit" button to submit the report to our office. You will receive an email verifying your submission with your report attached as a .pdf file. When the project completion report is approved by the State Office of Rural Health, you will receive an approval letter and your project reimbursement should be received within 60 days. If you need assistance in completing the 2019-20 SHIP project completion report, please contact the SORH Regional Coordinator for your facility:

Maria Bustamante - maria.bustamante@texasagriculture.gov

Kathy Johnston - kathy.johnston@texasagriculture.gov

Trish Rivera - trish.rivera@texasagriculture.gov

Robert Shaw - robert.shaw@texasagriculture.gov
Shari Wyatt - shari.wyatt@texasagriculture.gov

For immediate assistance call 512-463-0018 or email ruralhealth@texasagriculture.gov.
SECTION A: HOSPITAL INFORMATION
Select Your SHIP Grant Contract Number (SHIP Grant Number is found on SHIP Contract)
(Your 2019-20 SHIP Grant Number is found on 2019-20 SHIP Docusign Contract)
Legal Business Name of Hospital:*
DBA (if applicable) *
Hospital Mailing and Physical Address*

Mailing Address

Physical Address

CityState / Province

Postal / Zip Code
Hospital Phone Number*

Area CodePhone Number
Hospital CCN Number*
Hospital Tax Identification Number or Employer Identification Number*
County in which Hospital is Located*
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.
Name of Hospital Authorizing Official*

First NameLast Name
Official Position Title*
Email - Authorizing Official *
Phone Number*

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

First NameLast Name
Official Position Title*
Email - SHIP Director *
Phone Number*

Area CodePhone Number
SECTION D: 2019-20 SHIP PROJECT STATUS & EVALUATION
Is the 2019-2020 SHIP project completed?*

YESNO
Please indicate if any of the following has changed during the 2019-2020 SHIP project. (select all that apply)
Provide updated information:
SHIP Project Director - Tom Smith, email
From January 2019 through May 2020, which quarters did your hospital report HCAHPS?

2019 Q12019 Q22019 Q32019 Q42020 Q12020 Q2Our hospital did not report HCAHPS measures, but selected ICD-10 SHIP priority activities.
Quantitative Project Evaluation: Provide an estimated annual number of patient encounters from all hospital departments who will benefit or have benefited from the project.*
Quantitative Project Evaluation: Provide an estimated annual number of hospital employees who will benefit or have benefited from the project.*
Qualitative Project Evaluation: How has the implementation of this SHIP project improved the quality and efficiency of the hospital? What financial and/or operational impact has the implementation of this SHIP project had on the hospital? *
SECTION E: SHIP PROJECT REIMBURSEMENT REQUEST:
1. Hospitals must meet SHIP funding priorities before selecting other SHIP funding activities. Hospitals may select more than 1 category to participate in if priorities are followed and available funds exist
2. Hospitals must be able to demonstrate and report measurable outputs/outcomes to the SORH
3. SHIP funded investments must be prioritized as follows:
First Priority: HCAHPS (CAHs) and ICD-10 (all hospitals) - both of these must be fully implemented and HCAHPS must be publicly reported to Hospital Compare before your hospital can select any other investment options. Priority is not given to one over the other. Your hospital may choose one or both.

Second Priority: If your hospital is already participating fully in HCAHPS and ICD-10, you may select a different investment listed on the SHIP purchasing menu

Third Priority: If your hospital has already completed ALL investments listed on the SHIP purchasing menu, your hospital may identify an alternative piece of equipment and/or service ONLY IF: a) the purchase will optimally affect your hospital's transformation into an accountable care organization, increase value-based purchasing objectives and/or aid in the adoption of ICD-10; and b) your hospital receives pre-approval from both your state SHIP Coordinator and the appropriate FORHP project coordinator.
2019-2020 SHIP PROJECT REIMBURSEMENT REQUEST

Following the instructions/priorities above, please select the activity(ies) that were part of the SHIP project. Provide the amount of total expenditures for each category. The total requested budget amount shall not exceed $10,376.

Allowable Expenditures: SHIP funds must be spent in the prioritized manner as exhibited above.

Non-Allowable Expenditures:
- To provide healthcare services or salaries of hospital personnel;
- To purchase ambulances and any other vehicles or major communications equipment;
- To purchase real property;
- To conduct any activity regarding a certificate if needed; and
- To fund any travel or food expenses
2019-20 Completed Value-Based Purchasing (VBP) SHIP Activities:

A. Quality reporting data collection/related trainingB. HCAHPS data collection process/related trainingC. Efficiency or quality improvement training/project in support of VBP initiativesD. Provider-Based Clinic Quality Measures EducationE. Alternative Payment Model and Merit-Based Incentive Payment training/education
Expenditure for VBP Project(s):*
($0 - $10,376)
VBP %
2019-20 Completed Accountable Care Organization (ACO) or Shared Savings (SS) SHIP Activities:

A. Computerized provider order entry implementation and/or trainingB. Pharmacy services implementationC. Disease registry training and/or software/hardwareD. Efficiency or quality improvement training/project in support of ACO or shared savings related initiativesE. Systems performance trainingF. Telemedicine or mobile health equipment installation/useG. Community paramedicine training and/or equipment installation/useH. Health Information Technology Training for Value and ACOs
Expenditure for ACO or SS Project(s):*
($0 - $10,376)
ACO or SS %
2019-20 Completed Payment Bundling (PB) or Prospective Payment System (PPS) SHIP Activities:

A. ICD-10 softwareB. ICD-10 trainingC. Efficiency or quality improvement training/project in support of PB orPPS related initiativesD. S-10 Cost Reporting training/projectE. Price Transparency training
Expenditure for PB or PPS Project(s):*
($0 - $10,376)
PB or PPS %
2019-20 SHIP PROJECT TOTAL REIMBURSEMENT REQUEST:
Maximum Amount - $10,376
TOTAL REIMBURSEMENT SHALL NOT EXCEED $10,376
The hospital is allowed to change SHIP funding categories/activities as long as the SHIP priorities are followed. Did funding categories/activities change from the original application?

YESNO
Briefly describe funding activity changes.
Example: Added VBP-B HCAHPS data collection
Upload SHIP Project Invoices in .pdf format *

Browse Files
Maximum file size for each file is 100MB Cancelof
Upload Cancelled Checks or Proof of Payment in pdf format*

Browse Files
Maximum file size for each file is 100MB Cancelof
Upload 1 - 2 photos (.jpeg or image files) for your completed SHIP project. Label the file with hospital name and SHIP grant contract number. Ex.: Jones County Hospital 2019SHP115 photo 1

Browse Files

Cancelof
SECTION F: SHIP Grant and Funding Information
Did the hospital expend 90% ($10,376 X 90%=$9,338) of the SHIP funds for the 2019-2020 SHIP project?*

YESNO
If the Texas SHIP program has any unobligated funds remaining from the 2019-20 funding year, what type of training, workshops, hardware, or software would be beneficial for your hospital?*
Please provide any recommendations you have for improving the SHIP program. Are there changes to the SHIP program that you would recommend to the Federal Office of Rural Health Policy or the Texas State Office of Rural Health?*
I, {name}, certify that the information within this application is correct and accurate.
Type the full name of person submitting this application:*
Signature of Person Submitting Project Completion Report: (use mouse)*
Should be Empty:

2019 - 2020 Small Rural Hospital Improvement Grant Program (SHIP) Project Completion Report Form

SECTION A: HOSPITAL INFORMATION

SECTION B: CONTACT INFORMATION - CEO/Administrator

SECTION C: CONTACT INFORMATION - SHIP Project Director

SECTION D: 2019-20 SHIP PROJECT STATUS & EVALUATION

SECTION E: SHIP PROJECT REIMBURSEMENT REQUEST:

SECTION F: SHIP Grant and Funding Information