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Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/xxxx

Million Hearts™ Hypertension Control Champion Nomination
Public reporting burden of this collection of information is estimated at 30 minutes 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, NE, M/S D74, Atlanta, GA 30333, ATTN: PRA 0920-xxxx.

Private Organization Nomination

Federal Organization Nomination

Nominee: _________________________________________________________
Contact information (for individual submitting the nomination):
Name: ________________________________________________________________________
Address: _______________________________________________________________________
Phone: ________________________

E-mail: _______________________________________

Nominee information:
Name: ________________________________________________________________________
Business Address: ______________________________________________________________
Business Phone: _________________ Business E-mail: ____________________________
Check the box which best represents the nominee:







A healthcare system
A primary care practice/clinician
An obstetrics/gynecology practice/clinician
A family practice/clinician
An internal medicine practice/clinician



An osteopathic
practice/clinician



A cardiovascular care
practice/clinician



Other _________________

Nominee Reach and impact
Number of patients enrolled in your practice or health system: _____________________
Number of patients seen at least annually: ______________________________________
Number of adult patients (18 – 85 years old) seen at least annually: ______________________
Describe patient demographics that support the practice or health system’s care for a challenging
population:
• Geographic region served __________________________________________________
o Please select if this is:
 Urban
 Rural
 Both
• Percent of patients who belong to a racial/ethnic minority________________________
• Percent of patients whose primary language is not English ________________________
• Percent of patients who are eligible for Medicaid________________________________
• Other ___________________________________________________________________

CDC defines “hypertension control” as a blood pressure reading < 140 mmHg systolic and <90 mmHg diastolic
among hypertensive patients. There is no allowance for individuals on two or more medications.
How many adult patients in the total patient population seen annually are diagnosed with
hypertension?
________________
Million Hearts™ supports use of the National Quality Forum #0018 or other nationally recognized measures
for defining hypertension control (if other, please specify the measure used _________).
What is the Hypertension Control Rate for the practice or healthcare system’s adult hypertensive
population? __________________ Date collected ________________.
What was the Hypertension Control Rate for the practice or healthcare system’s adult hypertensive
population a year or more previous? ______________ Date collected: ___________
Do you report hypertension control rate to any other federal or regulatory agency?
o

Yes
Which one? __________

o

No

If you have a hypertension registry, please describe how it is developed and maintained. If you don’t
have a hypertension registry, please describe how the data were obtained.
_______________________________________________________________________________

Sustainable systems
Please check the button before each sustainable process for providing care in the clinic or healthcare
system that is used on a regular basis. Provide a brief description of as many “other” processes or
systems as applicable to your practice or health system. You may also add details to many of the systems
described below to support the nomination.
o
o
o
o
o
o
o
o
o
o

Electronic Medical Records (EMR): Registry Features
Electronic Medical Records (EMR): With clinical decision supports
Electronic Medical Records (EMR): With e-prescribing
Electronic Medical Records (EMR): With treatment/testing reminders
Electronic Medical Records (EMR): With patient summary reports
Team based care: nurse engagement
Team based care: nurse practitioner engagement
Team based care: pharmacist engagement
Team based care: patient navigator/care coordinator
Team based care: Other
o Please describe:
_______________________________________________________________________
_______________________________________________________________________

o

o

o

o

o

Provider Incentives: Financial
o Please describe:
_______________________________________________________________________
_______________________________________________________________________
Provider Incentives: Administrative
o Please describe:
_______________________________________________________________________
_______________________________________________________________________
Provider Incentives: Recognition
o Please describe:
_______________________________________________________________________
_______________________________________________________________________
Provider Incentives: Other
o Please describe:
_______________________________________________________________________
_______________________________________________________________________
Patient Incentives
o Please describe:
_______________________________________________________________________
_______________________________________________________________________

o
o
o
o

o

o

o

Non-electronic reminders or alerts for providers or patients
Free blood pressure checks
Provider dashboards
Home blood pressure monitoring support or equipment
o Please describe:
_______________________________________________________________________
_______________________________________________________________________
Medication adherence strategies
o Please describe:
_______________________________________________________________________
_______________________________________________________________________
Outreach to patients
o Please describe:
_______________________________________________________________________
_______________________________________________________________________
Other
o Please describe:
_______________________________________________________________________
_______________________________________________________________________

Is there anything else you would like to add to support the nomination?
__________________________________________________________________________________________
__________________________________________________________________________________________

Agreement to Participate

Please enter your name below to indicate that you, as the nominee, agree to the following.
If you are not the nominee, please enter your name below assuring that you have consulted with the
nominee, and the nominee agrees to the following:
All information provided is true and accurate to the best of your knowledge.
To participate in a data verification process if selected as a champion.
Consent to a background check if selected as a champion.
To be recognized by provider or practice name and location if selected, to participate in recognition
activities, and to share best practices for the development of publically available resources.
o To assume any and all risks and waive claims against the Federal Government and its related entities,
except in the case of willful misconduct, for any injury, death, damage, or loss of property, revenue, or
profits, whether direct, indirect, or consequential, arising from my participation in this prize contest,
whether the injury, death, damage, or loss arises through negligence or otherwise.
o To indemnify the Federal Government against third party claims for damages arising from or related
to competition activities.
______________________________________________
o
o
o
o

Submit Nomination
Thank you for participating.