Nomination Form

Form Approved

OMB No. 0920-0976

Exp. date 7/31/2016

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 0920-0976.

Contact information (for individual submitting the nomination):

Name: ________________________________________________________________________

Business Address: _______________________________________________________________

City: ______________________ State: __________ Zip Code: ______________

Business Phone:____________________ Business E-mail: _______________________________

Nominee information: Please provide the following information for the provider or practice being entered into the Challenge.

Practice Name (if the practice is the nominee): ________________________________________________________________________

Provider Name (if the provider is the nominee):

________________________________________________________________________

Business Address: ______________________________________________________________

Business Phone: _________________ Business E-mail: ____________________________

Check the box which best represents the nominee:

• A healthcare system

• A single clinician or group practice or clinic

Check the box which best represents the nominee’s practice:

• Obstetrics/gynecology

• Family practice

• Internal medicine

• Osteopathy

• Cardiovascular care

• Other ________________________

Population served

Number of patients enrolled in the practice or health system: _____________________

Describe patient demographics that support the practice or health system’s care for a population with a high prevalence of hypertension:

• Geographic region served: __________________________________________________

  • Is this urban, rural, or 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 enrolled in Medicaid: ________________________

• Percent of patients who have no health insurance: ________________________

• Other ___________________________________________________________________

Hypertension Control

Nominees are asked to provide two hypertension control rates: a current rate for a 12-month period and a previous rate for a 12 month period a year or more before.

CDC supports the definition of “hypertension control” as patients aged 18 through 85 years who had a diagnosis of hypertension and whose blood pressure was adequately controlled ( <140 mmHg systolic and <90 mmHg diastolic).

For the current Hypertension Control Rate:

What is the reporting period (e.g., 1/1/2014 to 12/31/2014)? ________________.

For the current reporting period, the nominee used which of the following clinical quality measure to define hypertension control. Please check the appropriate box below and provide the requested information:

• National Quality Forum (NQF) 0018 guidelines Describe the exclusions the nominee includes (e.g., pregnant women, patients with end-stage renal disease). __________________________________________________________________________

• CMS Physician Quality Reporting System (PQRS) 236 guidelines. Describe the exclusions the nominee includes (e.g., pregnant women, patients with end-stage renal disease).______________________________________________________________

• CMS 165v3 guidelines. Describe the exclusions the nominee includes (e.g., pregnant women, patients with end-stage renal disease).___________________________________________________________________

• NCQA HealthCare Effectiveness Information Set (HEDIS). Describe the exclusions the nominee includes (e.g., pregnant women, patients with end-stage renal disease).____________________________________________________________________

• HRSA Uniform Data System (UDS). Describe the exclusions the nominee includes (e.g., pregnant women, patients with end-stage renal disease).__________________________________________________________________

• Other. Describe how the nominee calculates the measure; including who is included in the denominator and what is considered adequate control.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

In the following table, report, by age group, the number of adult patients that: 1) were seen at least once during the reporting period; 2) among those treated, were diagnosed with hypertension; and 3) among those diagnosed with hypertension, were included in the hypertension control rate denominator [were not listed above as being in an excluded category (e.g., pregnant women, patients with end-stage renal disease)]?

Age Group	Number of patients seen during the entire reporting period	Number of patients who were diagnosed with hypertension during the entire reporting period	Number of patients with hypertension who were included in the hypertension control rate denominator*
Aged 18-44 years
Aged 45-64 years
Aged 65-74 years
Aged 75-85 years
Total: Aged 18-85 years

*Depending on what methodology the nominee uses to calculate their hypertension control rate, this will represent the number of hypertensive patients who were seen during the entire reporting period or just the first six months of the reporting period.

What was the Hypertension Control Rate for the practice or healthcare system’s adult hypertensive population during this reporting period? __________________

For the previous period Hypertension Control Rate:

For the previous reporting period, did the nominee use the same clinical quality measure guidelines as the current reporting period?

• Yes.

• No.

If not, which clinical quality measure guideline was used?______________________________

Using the same steps, what was the Hypertension Control Rate for the practice or healthcare system’s adult hypertensive population during previous reporting period? ______________

Reporting period (e.g., 1/1/2013 to 12/31/2013): ___________

Do you report hypertension control rate to any other federal or regulatory agency?

• Yes. Which one? _________________

• No.

Were the data obtained from an electronic health record system? ________.

If not, how were the data obtained? ________________________________________________

Clinical system supports

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.

• Written treatment protocols

• 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

Please describe: ______________________________________________________________
___________________________________________________________________________

• Provider Dashboards

• Provider Incentives: Financial

Please describe: ______________________________________________________________
___________________________________________________________________________

• Provider Incentives: Administrative

Please describe: ______________________________________________________________
___________________________________________________________________________

• Provider Incentives: Recognition

Please describe: ______________________________________________________________
___________________________________________________________________________

• Provider Incentives: Other

Please describe: ______________________________________________________________
___________________________________________________________________________

• Patient Incentives

Please describe: ______________________________________________________________
___________________________________________________________________________

• Non-electronic reminders or alerts for providers or patients

• Free blood pressure checks

• Home blood pressure monitoring support or equipment

• Please describe: ______________________________________________________________
  _________________________________________________________________________

Please describe: ______________________________________________________________
___________________________________________________________________________

• Medication adherence strategies

Please describe: ______________________________________________________________
___________________________________________________________________________

• Outreach to patients

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 candidate for champion.

• Consent to a background check if selected as a candidate for champion.

• To be recognized by provider or practice name and location if selected as a champion, to participate in recognition activities, and to share best practices for the development of publically available resources.

• 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.

• To indemnify the Federal Government against third party claims for damages arising from or related to competition activities.”

___________________________________________________________________

__________________________________________________________________

Thank you for participating.