## **Office of Rural Health Policy Network Development Grantees**

**Rural Health Network Self-Assessment Tool**

**Developed by: Georgia Health Policy Center, Andrew Young School of
Policy Studies, Georgia State University**

## 

## **Network**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Location**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Person completing
self-assessment**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Role on the
network**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Date**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## 

## 

## The following information will be used to assess the needs for technical assistance of your network. For every network there must be ***three*** Self-Assessments completed, one by each of the following individuals: 1) the Executive Director/Network Coordinator; 2) a member of the Governing Board/Advisory Group (preferable the chairperson); and 3) a major stakeholder in the community. 

## 

## Please use the following scale to answer the self-assessment:

## 

## **1=Strongly Disagree 2=Disagree 3=Neutral 4=Agree 5=Strongly Agree NA=Non-applicable**

The completed self-assessments must be returned to the respective
Technical Assistance Team Leader (TATL). A telephone consultation with
the Network Director will follow the self-assessment to discuss critical
areas of need and obtain additional background information. A customized
technical assistance plan will be developed between the TATL and the
Network Director based on the network's goals, needs, and priorities.

Please refer to your TATL if you have any questions or comments during
the completion of this self-assessment.

+-----------------------------------------------------------+----------+
| **Key to Success: Effective Leadership**                  | ###      |
|                                                           |          |
|                                                           | ##       |
|                                                           | # Answer |
+-----------------------------------------------------------+----------+
| **Network Board Leadership**                              |          |
+-----------------------------------------------------------+----------+
| The network has a formalized board                        | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| Board members understand and support the mission and      | 1 2 3 4  |
| vision of the network                                     | 5 NA     |
+-----------------------------------------------------------+----------+
| The board appropriately represents the diversity within   | 1 2 3 4  |
| the community                                             | 5 NA     |
+-----------------------------------------------------------+----------+
| The officers of the board have strong leadership skills   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The board has an entrepreneurial vision                   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| Board members participate in periodic strategic planning  | 1 2 3 4  |
| retreats                                                  | 5 NA     |
+-----------------------------------------------------------+----------+
| The board uses consensus building in decision-making      | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The board applies principles of conflict resolution when  | 1 2 3 4  |
| needed                                                    | 5 NA     |
+-----------------------------------------------------------+----------+
| The board has a strong connection with the community      | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| Board members are politically savvy                       | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The board participates in continuing education programs   | 1 2 3 4  |
| and/or board development activities                       | 5 NA     |
+-----------------------------------------------------------+----------+
| The network is viewed as an independent entity, separate  | 1 2 3 4  |
| from the organizations represented by the Board members   | 5 NA     |
+-----------------------------------------------------------+----------+
| Other                                                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| Other                                                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| **Clinical Leadership**                                   |          |
+-----------------------------------------------------------+----------+
| The network has a health focus                            | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| Community physicians understand and support the mission,  | 1 2 3 4  |
| vision, and goals of the network                          | 5 NA     |
+-----------------------------------------------------------+----------+
| Community physicians are actively involved in the network | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| There is a physician "champion" within the network and an | 1 2 3 4  |
| external (community) champion                             | 5 NA     |
+-----------------------------------------------------------+----------+
| Physicians are actively involved in the development of    | 1 2 3 4  |
| the network's clinical programs                           | 5 NA     |
+-----------------------------------------------------------+----------+
| Physicians involved in the network actively recruit peer  | 1 2 3 4  |
| physicians                                                | 5 NA     |
+-----------------------------------------------------------+----------+
| There is strong physician volunteerism in the network     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| Other                                                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| Other                                                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| **Managerial Leadership**                                 |          |
+-----------------------------------------------------------+----------+
| The network management understands and supports the       | 1 2 3 4  |
| mission and vision of the project                         | 5 NA     |
+-----------------------------------------------------------+----------+
| The network management has strong leadership skills       | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network management has an entrepreneurial vision      | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network management has exceptional communication      | 1 2 3 4  |
| skills                                                    | 5 NA     |
+-----------------------------------------------------------+----------+
| The network management uses consensus building in         | 1 2 3 4  |
| decision-making                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network management applies principles of conflict     | 1 2 3 4  |
| resolution when needed                                    | 5 NA     |
+-----------------------------------------------------------+----------+
| The network management has a strong connection with the   | 1 2 3 4  |
| community                                                 | 5 NA     |
+-----------------------------------------------------------+----------+

+-----------------------------------------------------------+----------+
| The network management is politically savvy               | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| **Key to success: Network programs driven by needs and    |          |
| assets**                                                  |          |
+-----------------------------------------------------------+----------+
| The network's vision and strategic activities are based   |          |
| on data and information about:                            |          |
+-----------------------------------------------------------+----------+
| -   Demographics                                          | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Population health indicators                          | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Human Services                                        | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Member financial needs                                | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Community perceptions of the current system and       | 1 2 3 4  |
|     health needs                                          | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Community and health system assets                    | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Other                                                 | 1 2 3 4  |
|     (specify)\_\_\_\_\_\_\_\_\_\                          | 5 NA     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
+-----------------------------------------------------------+----------+
| -   The network has conducted an assessment of the        | 1 2 3 4  |
|     population health needs in the communities served by  | 5 NA     |
|     it                                                    |          |
+-----------------------------------------------------------+----------+
| -   The network has conducted an assessment of the health | 1 2 3 4  |
|     system needs in the communities served by it          | 5 NA     |
+-----------------------------------------------------------+----------+
| **Key to success: Win/win partnerships**                  |          |
+-----------------------------------------------------------+----------+
| Community health organizations are represented in the     | 1 2 3 4  |
| network                                                   | 5 NA     |
+-----------------------------------------------------------+----------+
| Social service agencies are represented in the network    | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| There is a high level of collaboration, trust, and        | 1 2 3 4  |
| openness among the network partners                       | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has partnerships with organizations in urban  | 1 2 3 4  |
| settings                                                  | 5 NA     |
+-----------------------------------------------------------+----------+
| The urban partners support the local rural health system  | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network coordinates with regional systems of care for | 1 2 3 4  |
| services not offered locally                              | 5 NA     |
+-----------------------------------------------------------+----------+
| There is balance in exercise of control and power in the  | 1 2 3 4  |
| network                                                   | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has formed new partnerships since its         | 1 2 3 4  |
| inception                                                 | 5 NA     |
+-----------------------------------------------------------+----------+
| Each partner in the network invests equal amount of time  | 1 2 3 4  |
| and resources                                             | 5 NA     |
+-----------------------------------------------------------+----------+
| **Key to success: Integrated delivery system driven by a  |          |
| culture of whole patient care**                           |          |
+-----------------------------------------------------------+----------+
| The network board is driven by a desire to:               |          |
+-----------------------------------------------------------+----------+
| -   Improve the viability of member organizations         | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Improve population health status                      | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Improve access to needed services                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Improve efficiency of health care services            | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Reduce costs of care                                  | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Improve care of vulnerable populations (i.e.,         | 1 2 3 4  |
|     elderly, uninsured, children, migrant populations)    | 5 NA     |
+-----------------------------------------------------------+----------+
| The network is responsible for the ***provision*** of     | 1 2 3 4  |
| patient care services                                     | 5 NA     |
| Which\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\  |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
+-----------------------------------------------------------+----------+
| The network is responsible for the ***coordination*** of  | 1 2 3 4  |
| patient care services                                     | 5 NA     |
| Which\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\  |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
+-----------------------------------------------------------+----------+
| ##                                                        |          |
|                                                           |          |
| ## These service                                          |          |
| s are offered by the network or by members of the network |          |
+-----------------------------------------------------------+----------+
| -   Prevention                                            | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Primary Care                                          | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Public Health services                                | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Oral Health                                           | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Specialty physician care                              | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Hospital-based services                               | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Tertiary hospital care                                | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Behavioral Health/Substance Abuse                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Pharmaceutical access (especially to low-cost drug    | 1 2 3 4  |
|     programs)                                             | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Social Services                                       | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Home health                                           | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Faith-based services                                  | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Emergency and Non-emergency transportation            | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Long-term care                                        | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| #                                                         |          |
|                                                           |          |
| # Key to success: Stakeholder support and participation   |          |
+-----------------------------------------------------------+----------+
| There is awareness of the programs offered by the network |          |
| by:                                                       |          |
+-----------------------------------------------------------+----------+
| -   Community leaders                                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Community providers                                   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Potential consumers                                   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Community at large                                    | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| Input into the network's activities is provided by        |          |
+-----------------------------------------------------------+----------+
| -   Community leaders                                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Community providers                                   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Potential consumers                                   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Community at large                                    | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| ## Time for network activities is volunteered by          |          |
+-----------------------------------------------------------+----------+
| -   Community leaders                                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Community providers                                   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Potential consumers                                   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Community at large                                    | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| ##                                                        |          |
|                                                           |          |
| ## There is                                               |          |
|  financial and/or in-kind contributions to the network by |          |
+-----------------------------------------------------------+----------+
| -   Community leaders                                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Community providers                                   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Potential consumers                                   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Community at large                                    | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| #                                                         |          |
|                                                           |          |
| # Key to success: Effective communication and advocacy    |          |
+-----------------------------------------------------------+----------+
| The network markets its services to partner institutions  | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network provides outreach services to potential       | 1 2 3 4  |
| consumers                                                 | 5 NA     |
+-----------------------------------------------------------+----------+
| ##                                                        |          |
|                                                           |          |
| ## Th                                                     |          |
| e network leaders have developed awareness campaigns to:  |          |
+-----------------------------------------------------------+----------+
| -   Maintain the community abreast of successes and       | 1 2 3 4  |
|     challenges                                            | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Leverage additional community support                 | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Obtain and provide feedback to the community          | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network leaders have been involved in advocacy        |          |
| efforts to:                                               |          |
+-----------------------------------------------------------+----------+
| -   Educate state legislators and gain support to the     | 1 2 3 4  |
|     network activities                                    | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Communicate with policy makers                        | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network leaders have been involved in advocacy        | 1 2 3 4  |
| efforts at the national level                             | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has participated in community-based research  | 1 2 3 4  |
| studies                                                   | 5 NA     |
+-----------------------------------------------------------+----------+
| **Key to success: Infrastructure to support mission**     |          |
+-----------------------------------------------------------+----------+
| The network has sufficient staff                          | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has qualified and competent staff             | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has cultural competence characteristics for   | 1 2 3 4  |
| continuous quality improvement                            | 5 NA     |
+-----------------------------------------------------------+----------+
| There is a culture within the network of innovation and   | 1 2 3 4  |
| creativity                                                | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has access to a specific information system   | 1 2 3 4  |
| to manage eligibility, enrollment, and referral of        | 5 NA     |
| patients                                                  |          |
+-----------------------------------------------------------+----------+
| The network has a strong business plan                    | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network leaders review the business plan and update   | 1 2 3 4  |
| it periodically                                           | 5 NA     |
+-----------------------------------------------------------+----------+

+-----------------------------------------------------------+----------+
| **Key to success: Financial resources for long-term       |          |
| viability**                                               |          |
+-----------------------------------------------------------+----------+
| The network has a business focus                          | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| ##                                                        |          |
|                                                           |          |
| ## The                                                    |          |
| network provides these business services to its partners: |          |
+-----------------------------------------------------------+----------+
| -   Advocacy                                              | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Benchmarking                                          | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Claims management                                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Coding consultation                                   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Collections                                           | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Contract review                                       | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Education                                             | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   EMS enhancements                                      | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Flexible benefits contracting                         | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Grants                                                | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Group purchasing                                      | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Human services consulting or training                 | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Information clearinghouse                             | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Insurance (i.e. facility, equipment, malpractice)     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Legal consultation                                    | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Nurse call system                                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Occupational health                                   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Patient satisfaction survey                           | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Peer review                                           | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Physician recruitment and retention                   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Physician CME                                         | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   PR/Marketing communications                           | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Quality indicators program                            | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Risk services                                         | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Self-insured employee benefits                        | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Staffing pools                                        | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Telemedicine                                          | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Transportation services                               | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Trustee education                                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Web page development                                  | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network's budget was developed with the input of its  | 1 2 3 4  |
| members                                                   | 5 NA     |
+-----------------------------------------------------------+----------+
| Sources of network revenue are diverse                    | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| Sources of network revenue are sustainable                | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| Network's revenue is sufficient to finance operations and | 1 2 3 4  |
| capital development                                       | 5 NA     |
+-----------------------------------------------------------+----------+
| All members contribute resources (time or money) to       | 1 2 3 4  |
| network support                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has a long range funding strategy             | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| Network value is quantified and reported regularly to     | 1 2 3 4  |
| members                                                   | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has defined financial performance measures    | 1 2 3 4  |
| and benchmarks                                            | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has developed other business lines and/or     | 1 2 3 4  |
| entrepreneurial initiatives.                              | 5 NA     |
| Which\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                  |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
+-----------------------------------------------------------+----------+
| The network receives in-kind contributions from community | 1 2 3 4  |
| members                                                   | 5 NA     |
+-----------------------------------------------------------+----------+
| The network currently receives state grants               | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network currently receives other federal grants       | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network obtains revenue from member contributions     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network obtains revenue from enrollee contributions   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network currently receives funds from private         | 1 2 3 4  |
| foundations                                               | 5 NA     |
+-----------------------------------------------------------+----------+
| **Key to success: Evaluation of activity and impact**     |          |
+-----------------------------------------------------------+----------+
| The network has a formal evaluation plan                  | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network leaders periodically evaluate the             | 1 2 3 4  |
| effectiveness of the network's activities                 | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has a clear method for data collection and    | 1 2 3 4  |
| analysis                                                  | 5 NA     |
+-----------------------------------------------------------+----------+
| The network measures/intends to measure changes in:       | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Access to care                                        | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Health care cost                                      | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Health status                                         | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Quality of life                                       | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| -   Leverage of funds                                     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has conducted provider satisfaction surveys   | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has conducted patient satisfaction surveys    | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| #                                                         |          |
|                                                           |          |
| # Key t                                                   |          |
| o success: External facilitation and technical assistance |          |
+-----------------------------------------------------------+----------+
| The network received specialized consultation,            | 1 2 3 4  |
| facilitation, and/or technical assistance during the      | 5 NA     |
| planning phase.                                           |          |
| Which\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_     |          |
+-----------------------------------------------------------+----------+
| The network received specialized consultation,            | 1 2 3 4  |
| facilitation, and/or technical assistance during the      | 5 NA     |
| implementation phase.                                     |          |
| Which\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                 |          |
+-----------------------------------------------------------+----------+
| The network has received technical assistance for         | 1 2 3 4  |
| expansion and/or replication of services                  | 5 NA     |
+-----------------------------------------------------------+----------+
| The network receives technical assistance to review best  | 1 2 3 4  |
| practices                                                 | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has contracted with an external evaluator     | 1 2 3 4  |
|                                                           | 5 NA     |
+-----------------------------------------------------------+----------+
| The network has received external assistance in mediation | 1 2 3 4  |
| and/or conflict resolution                                | 5 NA     |
+-----------------------------------------------------------+----------+
| The network members have engaged in peer learning         | 1 2 3 4  |
| activities                                                | 5 NA     |
+-----------------------------------------------------------+----------+
| The specialized consultation, facilitation, and/or        | 1 2 3 4  |
| technical assistance the network received was appropriate | 5 NA     |
+-----------------------------------------------------------+----------+

Please rate your organization's desire to receive the following
technical assistance on the following scale:

**1 = None, 2 = Low, 3 = Medium, 4 = High, 5 = Very High**

+----------------------------------------------------------+-----------+
| Partnership Facilitation                                 | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Resource Identification                                  | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Community Needs Assessment                               | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Sustainability/Business Planning                         | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Marketing/Outreach Planning                              | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Clinical Workgroup Facilitation/Physician Engagement     | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Assistance with Staff Acquisition/training               | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Evaluation-Planning/Analysis                             | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Strategic Planning Facilitation                          | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Education re: Best Practices/Models                      | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Assistance with Organizational Development               | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Facilitation of County-level (or multi-county/parish)    | 1 2 3 4 5 |
| integration                                              |           |
+----------------------------------------------------------+-----------+
| Provision of data to determine need/feasibility          | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Replication                                              | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Cultural competency training                             | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Clinical consultation for care management and other      | 1 2 3 4 5 |
| programs                                                 |           |
+----------------------------------------------------------+-----------+
| Information system development                           | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| ##                                                       | 1 2 3 4 5 |
|                                                          |           |
| ## Building state                                        |           |
| policy momentum for community health systems development |           |
+----------------------------------------------------------+-----------+
| Fostering peer learning both at the coalition and state  | 1 2 3 4 5 |
| level.                                                   |           |
+----------------------------------------------------------+-----------+
| Managing staff turnover while maintaining momentum for   | 1 2 3 4 5 |
| the project.                                             |           |
+----------------------------------------------------------+-----------+
| Fostering collaboration with related (federal, state,    | 1 2 3 4 5 |
| local and foundation funded) community health system     |           |
| development efforts.                                     |           |
+----------------------------------------------------------+-----------+
| Assistance with legal issues (by-laws, incorporation,    | 1 2 3 4 5 |
| not-for-profit status).                                  |           |
+----------------------------------------------------------+-----------+
| Conflict resolution.                                     | 1 2 3 4 5 |
+----------------------------------------------------------+-----------+
| Assistance with evaluating staffing needs to support     | 1 2 3 4 5 |
| program activities.                                      |           |
+----------------------------------------------------------+-----------+

List your network's top three priorities for technical assistance:

1.  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2.  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3.  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_