State and Community Awardee Performance Measure Reportin

Process Evaluation of "Teenage Pregnancy Prevention: Integrating Services, Programs, and Strategies through Community-Wide Initiatives"

Att 6 State and Community Awardee Performance Measure Reporting Tool.Revised

State and Community Awardee Performance Measure Reporting Tool

OMB: 0920-0952

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Form Approved

OMB No. 0920-xxxx

Exp. xx/xx/xxxx









State and Community Awardee Performance Measure Reporting Tool




















Public reporting burden of this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx).


Grantee: _________________________

Please complete these performance measures to CDC once per year as part of your Annual Progress Report due December 31 of each year (reporting period October 1-September 30). Under the evidence based program performance measures, please report letters d through h separately for each implementation partner and program (you may combine information for different facilitators). Under the clinical performance measures, please report letters a through f separately for each clinical partner.


  1. Evidence-Based Program Performance Measures


  1. Implementation Partners


# of implementation partners to date


# of new implementation partners obtained during this reporting period


# of implementation partners retained during this reporting period





  1. Facilitators


# of facilitators/teachers newly trained on any program during this reporting period


# of facilitators/teachers with follow up training on any program during this reporting period



  1. Program youth served1 and retained2 in all evidence-based interventions during this reporting period


 

Characteristics of Program Youth3

Males

Females

# served

# retained

# served

# retained

Age (one response per participant)

 

 

 

 

10 years or younger

 

 

 

 

11-12 years

 

 

 

 

13-14 years

 

 

 

 

15-16 years

 

 

 

 

17-18 years

 

 

 

 

19 years or older

 

 

 

 

Grade (one response per participant)

 

 

 

 

6th grade or lower

 

 

 

 

7-8th grade

 

 

 

 

9-10th grade

 

 

 

 

11-12th grade

 

 

 

 

GED program

 

 

 

 

Technical/vocational training

 

 

 

 

College (any year)

 

 

 

 

Not currently in school

 

 

 

 

Ethnicity (one response per participant)

 

 

 

 

Hispanic or Latino

 

 

 

 

Not Hispanic or Latino

 

 

 

 

Unknown/unreported

 

 

 

 

Race (one response per participant)

 

 

 

 

American Indian or Alaska Native

 

 

 

 

Asian

 

 

 

 

Black or African American

 

 

 

 

Native Hawaiian or Other Pacific Islander

 

 

 

 

White

 

 

 

 

Other

 

 

 

 

More than one race

 

 

 

 

Unknown/unreported

 

 

 

 

Primary language spoken at home (one response per participant)

 

 

 

 

English

 

 

 

 

Spanish

 

 

 

 

Chinese

 

 

 

 

Other

 

 

 

 

Special populations (one response per participant)

 

 

 

 

None





Pregnant or parenting teens

 

 

 

 

Youth in foster care

 

 

 

 

Homeless youth

 

 

 

 

Youth in the juvenile justice system

 

 

 

 

Other (describe____________________)

 

 

 

 

Total






*Please report sections d through h separately for each implementation partner and program (you may combine information for different facilitators)*


Implementation Partner 1:_______________________________________


Program 1:_____________________________________________


  1. Evidence-based intervention sessions4


Setting(s)5

 

# of cycles6 implemented this reporting period

 

Fidelity: mean % of activities implemented as planned


Mean % of activities implemented as planned for sessions observed


Mean overall quality rating of observed sessions





  1. Evidence based intervention adaptations


Adaptations this reporting period7

Planned8

Unplanned9


Shape1

Shape2


Shape3

Shape4


Shape5

Shape6


  1. Program youth targeted


Total number of targeted youth in this setting10, during this reporting period:_____________________

Total number of targeted males in this setting, during this reporting period:_____________________

Total number of targeted females in this setting, during this reporting period:____________________


  1. Youth served and retained


Total number of youth served during this reporting period:___________________

Total number of youth retained during this reporting period:_________________

Percent of youth retained during this reporting period:______________________




  1. Youth Outcomes for Evidence-Based Interventions


# of pre-tests completed

 

# post-tests completed

 

# of youth who completed both a pre- and post-test

 

% of youth who completed both a pre- and post-test

 

Youth satisfaction post- test score (mean %)

 

% of participants with 75% or better attendance

 

Mean attendance rate (%) among youth who completed both pre- and post-tests11


Median attendance rate (%) among youth who completed both pre- and post-tests



*Reminder: Include only pre-test information on youth behaviors*


Youth Behaviors12 among all youth who completed a pre-test

Males

Females

Pre-Test Response

Pre-Test Response

N

%

N

%

Youth who have ever had sex





Youth who had sex in the past 3 months (sexually active)





Sexually active youth who used hormonal contraception, an IUD, or a condom at last sex






Knowledge, attitudes, and intentions of targeted outcomes for youth with matched pre- and post-tests13

Participant

Comparison or control group14

T-test15 score comparing participants and control groups

Mean

pre-test

response score

Mean post-test

response score

Mean difference between pre- and post-test scores

Mean

pre-test

response score

Mean post-test

response score

Mean difference between pre- and post-test scores



















































  1. Other Clients Served by Evidence-Based Programs


Program Name


Mean # of Program Services Received by Parents/Guardians

 

Median # of Program Services Received by Parents/Guardians

 

Mean # of Program Services Received by Other Clients Served (Siblings, other Family Members, Etc.)

 

Median # of Program Services Received by Other Clients Served (Siblings, other Family Members, Etc.)

 

 

 Client Type

# served

# retained16

Parents/Guardians

 

 

Other Clients Served (Siblings, other Family Members, Etc.)

 

 

Total






  1. Clinical Component Performance Measures


Total Number of clinical partners:________________________________


Clinical Partner 1: ________________________________________


  1. Linkages and Referrals


Please indicate the total number of formal and informal linkages17,18 to date that your health center has developed with organizations, providers, programs, and/or institutions for the purposes of increasing access to and utilization of contraceptive or reproductive health services among adolescents, the number of new formal and informal linkages obtained during this reporting period, and the percent of formal and informal linkages that were obtained during this reporting period (Denominator = total number of formal or informal linkages to date). By “formal linkages” we mean written agreements to work with these providers or organizations to enhance access to contraceptive or reproductive health services that your health center provides; by “informal linkages” we mean no written agreement exists.


# of Formal Linkages

to date

# of New Formal Linkages obtained this reporting period




# of Informal Linkages

to date

# of New Informal Linkages obtained this reporting period




Please indicate the total number of youth referred by organizations/providers with whom you have formal or informal linkages and the total number of youth referrals that resulted in the receipt of care.


Total number of youth referred (optional, depending on data availability): __________________________

Total number of youth referrals that resulted in the receipt of care: _______________________



  1. Billable Source by Revenue for adolescent patients between the ages of 12-19 years


Please indicate both the percentage of revenue by source that the health center receives for adolescent visits at which contraceptive or reproductive health services19 are provided (Denominator = total number of unduplicated adolescent visits), and the number of visits at which contraceptive or reproductive health services are provided, per revenue source.


%

# of Visits

Source of Revenue



Medicaid Fee for Service



Medicaid Family Planning Waiver



Medicaid Managed Care



Commercial Insurance



Sliding Fee Scale (Patient pays for a portion of the charges out-of-pocket)



Full Pay (Patient pays for the full cost of service out-of-pocket)



No pay (services are covered by grants, e.g., Title X, Title V, 330, Private Foundation, etc)



Uninsured (health center absorbs costs of services)



Other (Please describe):


  1. Training on Adolescent Development


Please indicate the number and percentage of ALL health center staff (e.g., all clinical and non-clinical staff who have direct contact with adolescent clients) who have received training in Stages of Adolescent Development during the past two years: ____________________


  1. Continuous Quality Improvement (CQI) efforts and processes


Does the health center

Yes

No

Have a set of performance measures that are collected on a regular basis (e.g., quarterly, monthly) for monitoring the use of health care services for adolescents?



Have a set of performance measures that are collected on a regular basis (e.g., quarterly, monthly) for monitoring the delivery of contraceptive, reproductive, or sexual health care services for adolescents?







  1. Clinical Best Practices20



Promoting “Teen Friendly” Services:

Health Care Delivery System, Contraceptive and Reproductive Health Best Practices

Total number of best practices implemented to date

Number of new best practices implemented during the past reporting cycle

Subset 1: Contraceptive Access (7)



Subset 2: Quick Start Method for Initiation of Hormonal Contraception and IUD (4)



Subset 3: Emergency Contraception (3)



Subset 4: Cervical Cancer Screening (1)



Subset 5: STD and HIV Testing (6)



Subset 6: Cost, Confidentiality and Consent (2)



Subset 7: Infrastructure (3)



Subset 8: Environment (5)



Total (31)







  1. Use of health care services by adolescents


The following data may be collected via billing records, EMRs, and other methods. It is recommended that you collect these data for each month.


FEMALE Adolescent Clients (Unduplicated) and Visits by Race/Ethnicity, Age Group, and Reporting Period


FEMALES

# Adolescent Clients

(Unduplicated)

# Adolescent Visits21

# Adolescent Visits in which

Contraceptive, Reproductive, or Sexual Health Services are Provided22

Hispanic/Latino(a) – All Races23




12-14 years




15-17 years




18-19 years




Total




Black or African American (Non-Hispanic)




12-14 years




15-17 years




18-19 years




Total




White (Non-Hispanic)




12-14 years




15-17 years




18-19 years




Total




Other (Non-Hispanic)




12-14 years




15-17 years




18-19 years




Total




Unknown Race and Ethnicity




12-14 years




15-17 years




18-19 years




Total




All Races and Ethnicities




12-14 years




15-17 years




18-19 years




Total




Table 2. MALE Adolescent Clients (Unduplicated) and Visits by Race/Ethnicity, Age Group, for each Reporting Period24


MALES

# Adolescent Clients

(Unduplicated)

# Adolescent Visits25

# Adolescent Visits in which

Contraceptive, Reproductive or Sexual Health Services are Provided26

Hispanic/Latino(a) – All Races27




12-14 years




15-17 years




18-19 years




Total




Black or African American (Non-Hispanic)




12-14 years




15-17 years




18-19 years




Total




White (Non-Hispanic)




12-14 years




15-17 years




18-19 years




Total




Other (Non-Hispanic)




12-14 years




15-17 years




18-19 years




Total




Unknown Race and Ethnicity




12-14 years




15-17 years




18-19 years




Total




All Races and Ethnicities




12-14 years




15-17 years




18-19 years




Total






Table 3. FEMALE Adolescent Clients (Unduplicated) and Number Provided (i.e., dispensed on-site or by prescription) Contraception by Age Group, for each Reporting Period28


FEMALES

# Adolescent Clients (Unduplicated)

All Unduplicated Clients (Total)


12-14 years


15-17 years


18-19 years


Total


Provided Hormonal Contraception29 (not including IUDs or Implants)


12-14 years


15-17 years


18-19 years


Total


Provided the Pill


12-14 years


15-17 years


18-19 years


Total


Provided Injectable Contraception (e.g., Depo Provera)


12-14 years


15-17 years


18-19 years


Total


Provided IUD


12-14 years


15-17 years


18-19 years


Total


Provided Contraceptive Implants (e.g., Implanon)


12-14 years


15-17 years


18-19 years


Total


Provided Emergency Contraception (EC)30


12-14 years


15-17 years


18-19 years


Total


% Contraceptive Coverage31


12-14 years


15-17 years


18-19 years


Total


% LARC Coverage32


12-14 years


15-17 years


18-19 years


Total







Table 4. FEMALE Adolescent Clients (Unduplicated) and Number Provided (i.e., dispensed on-site or by prescription) Contraception by Race/Ethnicity Group, for each Reporting Period33


FEMALES

# Adolescent Clients (Unduplicated)

All Unduplicated Clients (Total)


Hispanic/Latina (all races)


Black or African American (non-Hispanic)


White (non-Hispanic)


Other (non-Hispanic)


Unknown/unreported


Total


Provided Hormonal Contraception34 (not including IUDs or Implants)


Hispanic/Latina (all races)


Black or African American (non-Hispanic)


White (non-Hispanic)


Other (non-Hispanic)


Unknown/unreported


Total


Provided the Pill


Hispanic/Latina (all races)


Black or African American (non-Hispanic)


White (non-Hispanic)


Other (non-Hispanic)


Unknown/unreported


Total


Provided Injectable Contraception (e.g., Depo Provera)


Hispanic/Latina (all races)


Black or African American (non-Hispanic)


White (non-Hispanic)


Other (non-Hispanic)


Unknown/unreported


Total


Provided IUD


Hispanic/Latina (all races)


Black or African American (non-Hispanic)


White (non-Hispanic)


Other (non-Hispanic)


Unknown/unreported


Total


Provided Contraceptive Implants (e.g., Implanon)


Hispanic/Latina (all races)


Black or African American (non-Hispanic)


White (non-Hispanic)


Other (non-Hispanic)


Unknown/unreported


Total


Provided Emergency Contraception (EC)35


Hispanic/Latina (all races)


Black or African American (non-Hispanic)


White (non-Hispanic)


Other (non-Hispanic)


Unknown/unreported


Total


% Contraceptive Coverage36


Hispanic/Latina (all races)


Black or African American (non-Hispanic)


White (non-Hispanic)


Other (non-Hispanic)


Unknown/unreported


Total


% LARC Coverage37


Hispanic/Latina (all races)


Black or African American (non-Hispanic)


White (non-Hispanic)


Other (non-Hispanic)


Unknown/unreported


Total





  1. Community Mobilization and Sustainability Performance Measures


  1. Core Partner Leadership Team


Total # of Core Leadership Team Meetings Convened

 


# of Core Leadership Team Members who Attend at least 75% of Team Meetings

 


Significant Action Items38

Completed

 

1

 

 

2

 

 

3

 

 

4

 

 

5

 

 


  1. Community Action Team Participation


Total # of Community Action Team Meetings Convened

 

# of Community Action Team Members who Attend at least 75% of Team Meetings

 

Significant Action Items39

Completed

1

 

2

 

3

 

4

 

5

 


  1. Youth Leadership Team


Total # of Youth Leadership Team Meetings Convened

 

# of Youth Leadership Team Members who Attend at least 75% of Team Meetings

 

Significant Action Items40

Completed

1

 

2

 

3

 

4

 

5

 




  1. Stakeholder Education Performance Measures


Total number of stakeholder education strategies guided by best practices implemented to date: ______________

Number of new stakeholder education strategies guided by best practices implemented during the past reporting cycle:_____________



  1. Working with Diverse Communities Performance Measures


Working with Diverse Communities strategies guided by best practice41

Total number of strategies guided by best practices implemented to date

Number of new strategies guided by best practices implemented during the past reporting cycle

Subset 1: Engage diverse youth (7)



Subset 2: Utilize participatory approaches for community mobilization to include diverse youth (8)



Subset 3: Engage a diverse group of community partners to participate in teen pregnancy prevention efforts (3)



Subset 4: Support implementation partners’ programmatic practices (8)



Subset 5: Support clinical partners to develop culturally competent clinical services (7)



Subset 6: Support community outreach practices (4)



Total (37)






  1. Dissemination



  1. Manuscripts


How many manuscripts related to this project have been accepted for publication or published during the past reporting cycle? _________________

How many manuscripts related to this project have been published to date? ______________


Please list the references for any published manuscripts.





  1. Presentations


How many presentations have you made at each of the following levels during the past reporting cycle:

National or regional? ___

Please list titles of all presentations and venue (e.g., conference or organization to which the presentation was made).




State? ____

Please list titles of all presentations and venue (e.g., conference or organization to which the presentation was made).



1 Number of youth who attended at least one session

2 Number of youth who attended at least 75% of sessions

3 Characteristics may be obtained from attendance records or pre-/post-tests

4 Session refers to one meeting for an evidence based intervention. We are interested in the number of sessions as opposed to modules or lessons because many partners have made adaptations so that one lesson may be split across two different sessions/meetings.

5 Settings could include a school, church, youth development program, recreation center, clinic, etc. If a partner is implementing the same program in different settings, consider reporting information for sections c through h separately for each setting.

6 Cycle refers to a complete offering of an evidence based intervention

7 Adaptations could include add-on lessons/modules, etc.

8 Planned adaptations received prior CDC approval before the start of implementation.

9 Unplanned adaptations did not receive CDC approval before the start of implementation.

10 For example, if implementing a program among 9th graders in a particular school, the targeted number of youth in the setting would be all 9th graders in the school.

11 If it is not possible to match attendance rates to pre-/post-test data, a question on attendance may be added to the post test

12 Include behavioral data for as many youth served as possible; time periods (e.g., past 3 months) may not be exact

13 May be reported as individual items or as a composite score. If composite scores are reported, please provide the individual survey questions and the scale.

14 Include scores for comparison group(s) when available. Comparisons could be made with separate youth or youth could serve as their own comparison.

15 Matched pairs t-test

16 If there are multiple sessions

17 Linkage: A formal partnership between community organizations, agencies, or other institutions (which may include but are not limited to health centers, schools, and churches). The partnership is formalized through a written agreement (e.g., a MOU) that clearly defines how partners will share resources and services related to teen pregnancy prevention.

Referral: An informal mechanism or medium that directs clients to care. Referral sources can include friends, family members, Internet sources, schools, as well as linkage partner organizations/agencies/institutions.

18 Please include linkages created during this project as well as linkages created before the start of this project.

19 Includes adolescent visits at which contraceptive or reproductive health services are provided, regardless of the primary reason for the visit.

20 Best practice refers to strategies and activities that have been evaluated and demonstrate effectiveness at promoting sexual health for adolescents. The clinical best practices focus on systems related to access, processes for the delivery of care, utilization of evidence-based clinical recommendations, cost, confidentiality, supportive infrastructure, and the health care delivery environment. Where gaps exist, as identified through assessment activities, improvement efforts should focus on strategies to ensure that the set of “best practices” are adopted and implemented over the course of the project.


21 Any visit where an adolescent is seen by a healthcare team member – not only visits designated as reproductive/sexual health visits.

22 Includes any health center visit where contraceptive , reproductive, or sexual health services are provided to the adolescent patient, regardless of the primary reason for the visit.

23 Count data for all clients that indicated Hispanic/Latino(a) ethnicity, regardless of race

24 Data should be pulled for unduplicated adolescents by hormonal contraception or IUD adopted or continued, at the time of exit from their last encounter (visit) to the health center in the given reporting period. If the client reports using more than one method of birth control, report the most effective one as the primary method (e.g., if a client is given the patch and emergency contraception as a backup method, only include information on the patch).

25 Any visit during which an adolescent is seen by a healthcare team member – not only visits designated as reproductive/sexual health visits.

26 Includes any health center visit at which contraceptive, reproductive, or sexual health services are provided to the adolescent patient, regardless of the primary reason for the visit.

27 Count data for all clients that indicated Hispanic/Latino(a) ethnicity, regardless of race

28 Data should be pulled for unduplicated adolescents by hormonal contraception or IUD adopted or continued, at the time of exit from their last encounter (visit) to the health center in the given reporting period. If the client reports using more than one method of birth control, report the most effective one as the primary method (e.g., if a client is given the patch and emergency contraception as a backup method, only include information on the patch).

29 Hormonal contraception here includes the pill, patch, ring, and injectable contraception

30 Including the provision of EC as a backup method along with another contraceptive method

31 Calculated as the proportion of all unduplicated adolescent female clients provided hormonal contraception, contraceptive implants, or IUD.

32 Calculated as the proportion of all unduplicated adolescent female clients provided contraceptive implants, or IUD.

33 Data should be pulled for unduplicated adolescents by hormonal contraception or IUD adopted or continued, at the time of exit from their last encounter (visit) to the health center in the given reporting period. If the client reports using more than one method of birth control, report the most effective one as the primary method (e.g., if a client is given the patch and emergency contraception as a backup method, only include information on the patch).

34 Hormonal contraception here includes the pill, patch, ring, and injectable contraception

35 Including the provision of EC as a backup method along with another contraceptive method

36 Calculated as the proportion of all unduplicated adolescent female clients provided hormonal contraception, contraceptive implants, or IUD.

37 Calculated as the proportion of all unduplicated adolescent female clients provided contraceptive implants, or IUD.

38 Significant items include the large or key action items that the group would like to accomplish each year. We anticipate that each group would have no more than 5 significant action items per year.

39 Significant items include the large or key action items that the group would like to accomplish each year. We anticipate that each group would have no more than 5 significant action items per year.

40 Significant items include the large or key action items that the group would like to accomplish each year. We anticipate that each group would have no more than 5 significant action items per year.

41 Best practice refers to strategies and activities that have been evaluated and demonstrate effectiveness at promoting sexual health for adolescents. Strategies that do not have strong evidence of effectiveness (e.g., less rigorous evaluation) are considered strategies guided by best practices (e.g., lessons learned). The WDC strategies guided by best practice focus on identifying and developing a plan for serving diverse, hard-to-reach, marginalized, or vulnerable youth with teen pregnancy prevention programs and services (e.g., African American and Latino youth, youth in foster care, youth in the juvenile justice system, GLTBQ youth, and pregnant and parenting teens); conducting activities to educate community partners on the link between social determinants and teen pregnancy (e.g., workshops, webinars); and training clinical and program partners to provide teen-friendly, culturally competent services and programs.

44


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