Form 1 Clinical Performance Measures

OMB No.: 0915-0285     Expiration Date: 10/31/2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

CLINICAL PERFORMANCE MEASURES

FOR HRSA USE ONLY

Grant Number

Application Tracking Number

Project Period Date

Focus Area: Diabetes

Performance Measure: Percentage diabetic patients whose HbA1c levels are less than 7 percent, less than 8 percent, less than or equal to 9 percent, or greater than 9 percent.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Number of adult patients age 18 to 75 years with a diagnosis of Type 1 or Type 2 diabetes whose most recent HbA1c level during the measurement year is <7%, <8%, <=9%, or >9%, among those patients in the denominator.
Denominator Description	Number of adult patients age 18 to 75 years as of December 31 of the measurement year with a diagnosis of Type 1 or Type 2 diabetes, who have had a visit at least twice during the reporting year and do not meet any of the exclusion criteria.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Cardiovascular Disease

Performance Measure: Percentage of adult patients with diagnosed hypertension whose most recent blood pressure was less than 140/90.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Patients 18 to 85 years of age with a diagnosis of hypertension with most recent systolic blood pressure measurement < 140 mm Hg and diastolic blood pressure < 90 mm Hg.
Denominator Description	All patients 18 to 85 years of age as of December 31 of the measurement year with a diagnosis of hypertension and have been seen at least twice during the reporting year, and have a diagnosis of hypertension before June 30 of the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Cancer

Performance Measure: Percentage of women 21-64 years of age who received one or more tests to screen for cervical cancer.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Number of female patients 24–64 years of age receiving one or more Pap tests during the measurement year or during the two years prior to the measurement year, among those women included in the denominator.
Denominator Description	Number of female patients 24-64 years of age as of December 31 of the measurement year who were seen for a medical visit at least once during the measurement year and were first seen by the grantee before their 65th birthday.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Prenatal Health

Performance Measure: Percentage of pregnant women beginning prenatal care in first trimester.
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	All female patients who received perinatal care during the program year (regardless of when they began care) who initiated care in the first trimester either at the grantee’s service delivery location or with another provider.
Denominator Description	Number of female patients who received prenatal care during the program year (regardless of when they began care), either at the grantee’s service delivery location or with another provider. Initiation of care means the first visit with a clinical provider (MD, NP, CNM) where the initial physical exam was done and does not include a visit at which pregnancy was diagnosed or one where initial tests were done or vitamins were prescribed.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Perinatal Health

Performance Measure: Percentage of births less than 2,500 grams to health center patients.
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Women whose child weighed less than 2,500 grams during the measurement year, regardless of who did the delivery, among those women included in the denominator.
Denominator Description	Total births for all women who were seen for prenatal care during the measurement year regardless of who did the delivery.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Child Health

Performance Measure: Percentage of children with 2nd birthday during the measurement year with appropriate immunizations.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Number of children who received all of the following: 4 DTP/DTaP, 3 IPV, 1 MMR, 2 Hib*, 3 HepB, 1VZV (Varicella), 4 Pneumococcal conjugate, 2 HepA, 2 or 3 RV, and 2 influenza vaccines prior to or on their 2nd birthday whose second birthday occurred during the measurement year, among those children included in the denominator. *Note: While 2 Hib shots are required, HRSA recommends that 3 Hib shots be given per the CDC recommendation.
Denominator Description	Number of children with at least one medical visit during the reporting period, who had their second birthday during the reporting period, who did not have a contraindication for a specific vaccine. This includes only children who were seen for the first time in the clinic prior to their second birthday, regardless of whether or not they came to the clinic for vaccinations or well child care.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Behavioral Health

Performance Measure:
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Performance Measure Categories	[_] Mental Health [_] Substance Abuse Conditions [_] Other If ‘Other’, please specify: ___________
Target Goal Description
Numerator Description
Denominator Description
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Oral Health

Performance Measure:
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Performance Measure Categories	[_] Emergency Services [_] Oral Exams [_] Restorative Services [_] Oral Surgery [_] Rehabilitative Services [_] Prophylaxis - Adult or Child [_] Sealants [_] Fluoride Treatment - Adult or Child [_] Other If ‘Other’, please specify: ___________
Target Goal Description
Numerator Description
Denominator Description
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Weight Assessment and Counseling for Children and Adolescents

Performance Measure: Percentage of patients age 2 to 17 years who had a visit during the current year and who had Body Mass Index (BMI) Percentile documentation, counseling for nutrition, and counseling for physical activity during the measurement year.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Number of child and adolescent patients age 3 to 17 years who had Body Mass Index (BMI) Percentile documentation, counseling for nutrition, and counseling for physical activity during the measurement year, among those patients included in the denominator.
Denominator Description	Number of child and adolescent patients age 3 to 17 years as of December 31 of the measurement year, who have been seen in the clinic at least once during the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Adult Weight Screening and Follow-Up

Performance Measure: Percentage of patients age 18 years or older who had their Body Mass Index (BMI) calculated at the last visit or within the last six months and, if they were overweight or underweight, had a follow-up plan documented.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Number of adult patients age 18 years or older who had their Body Mass Index (BMI) calculated at the last visit or within the last six months and, if they were overweight or underweight, had a follow-up plan documented among those patients included in the denominator.
Denominator Description	Number of adult patients age 18 years or older as of December 31 of the measurement year, who have been seen in the clinic at least once during the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Tobacco Use Assessment and Counseling (Tobacco Use Assessment)

Performance Measure: Percentage of patients age 18 years and older who were queried about tobacco use one or more times within 24 months.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Number of patients age 18 years and older who were queried about tobacco use one or more times during their most recent visit or within 24 months of their most recent visit, among those patients included in the denominator.
Denominator Description	Number of patients age 18 years and older who had at least one medical visit during the measurement year and have been seen for at least two office visits ever.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Tobacco Use Assessment and Counseling (Tobacco Cessation Counseling)

Performance Measure: Percentage of patients age 18 years and older who are users of tobacco and who received (charted) advice to quit smoking or tobacco use.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Number of patients age 18 years and older who are users of tobacco and who received (charted) advice to quit smoking or tobacco use during their most recent visit or within 24 months of their most recent visit, among those patients included in the denominator.
Denominator Description	Number of patients age 18 years and older seen identified as users of tobacco during their most recent visit or within 24 months of their most recent visit and who had at least one medical visit during the current year and have been seen for at least two visits ever.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Asthma – Pharmacological Therapy

Performance Measure: Percentage of patients age 5 to 40 years with a diagnosis of persistent asthma (either mild, moderate, or severe) who were prescribed either the preferred long term control medication or an acceptable alternative pharmacological therapy during the current year.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Number of patients age 5 to 40 years included in the denominator with a diagnosis of persistent asthma (either mild, moderate, or severe) who were prescribed either the preferred long term control medication (inhaled corticosteroid) or an acceptable alternative pharmacological therapy (leukotriene modifiers, cromolyn sodium, nedocromil sodium, or sustained released methylxanthines) during the current year.
Denominator Description	Number of patients age 5 to 40 years with a diagnosis of persistent asthma (either mild, moderate, or severe) and who had at least one medical visit during the current year and have been seen for at least two visits ever.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Coronary Artery Disease (CAD): Lipid Therapy

Performance Measure: Percentage of patients age 18 years and older with a diagnosis of CAD prescribed a lipid lowering therapy (based on current ACC/AHA guidelines) during the measurement year.
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Number of patients age 18 years and older with a diagnosis of CAD prescribed a lipid lowering therapy (based on current ACC/AHA guidelines) during the measurement year, among those patients included in the denominator.
Denominator Description	Number of patients age 18 years and older as of December 31 of the measurement year with a diagnosis of CAD who have been seen in the clinic at least once during the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Ischemic Vascular Disease (IVD): Aspirin Therapy

Performance Measure: Percentage of patients age 18 years and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA), or who had a diagnosis of Ischemic Vascular Disease (IVD), and who had documentation of use of aspirin or another antithrombotic during the measurement year.
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Number of patients age 18 years and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA), or who had a diagnosis of Ischemic Vascular Disease (IVD), and who had documentation of use of aspirin or another antithrombotic during the measurement year, among those patients included in the denominator.
Denominator Description	Number of patients age 18 years and older as of December 31 of the measurement year who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA), or who had a diagnosis of Ischemic Vascular Disease (IVD), who have been seen in the clinic at least once during the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Colorectal Cancer Screening

Performance Measure: Percentage of patients age 50 to 75 years who had appropriate screening for colorectal cancer (includes colonoscopy <= 10 years, flexible sigmoidoscopy <= 5 years, or annual fecal occult blood test).
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Number of patients age 50 to 75 years who had appropriate screening for colorectal cancer (includes colonoscopy <= 10 years, flexible sigmoidoscopy <= 5 years, or annual fecal occult blood test), among those patients included in the denominator.
Denominator Description	Number of patients age 50 to 75 years as of December 31 of the measurement year, who have been seen in the clinic at least once during the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Other

Performance Measure:
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Performance Measure Categories (Applicable for Oral/Behavioral Focus Areas only)	[_] Mental Health [_] Substance Abuse Conditions [_] Emergency Services [_] Oral Exams [_] Restorative Services [_] Oral Surgery [_] Rehabilitative Services [_] Prophylaxis - Adult or Child [_] Sealants [_] Fluoride Treatment - Adult or Child [_] Other If ‘Other’, please specify: ___________
Target Goal Description
Numerator Description
Denominator Description
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ___________ Data Source and Methodology Description:
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

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