Form 1 Rural Health Care Services Outreach Program Measures

OMB Number: 0906-XXXX

Expiration date: XX/XX/201X

Public Burden Statement:  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.  The OMB control number for this project is 0906-XXXX.  Public reporting burden for this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10C-03I, Rockville, Maryland, 20857.

Rural Health Care Services Outreach (Outreach) Grant Program

Section I: ACCESS TO CARE (applicable to all Outreach grantees)

Table Instructions: This table collects information about an aggregate count of the number of people served through the program and the types of services that were provided during this budget period. Please report responses using a numeric figure. If the total number is zero (0), please put zero in the appropriate section. Do not leave any sections blank. There should not be an N/A (not applicable) response since all measures are applicable to all grantees.

Please refer to these detailed definitions and guidelines in providing your answers to the following measures:

Number of counties served in project and number of people in target population should be consistent with the figures your program reported in your grant application. The number of counties served should reflect your project’s service area.

Direct Services are defined as a documented interaction between a patient/client and a clinical or non-clinical health professional that has been funded with ORHP grant dollars. Examples of direct services include (but are not limited to) patient visits, counseling, and education.

For the purposes of this data collection activity, indirect services will be limited to:

1. billboards,

2. flyers,

3. health fairs,

4. mailings/newsletters, and

5. other mass media (radio, television, newspaper and social media)*

*For radio, television and newspaper please report estimated total circulation. For social media, please report reach (number of followers).

		Baseline	End of Budget Period
1	Number of counties served in project
2	Number of people in the target population (this is the number of people in your target population, but not the number of people who actually received your direct services)
3	Number of unique individuals who received direct services during this budget period Please report the number of unique (i.e. unduplicated count) patients/clients that received direct services from your organization
4	Number of individuals who received indirect services during this budget period Please report the total estimated number of individuals your organization reaches through the following indirect services: billboards, flyers, health fairs, mailings/newsletters, and other mass media (including social media). NOTE: You can add together estimated totals across the various indirect services you have completed. These estimates may be obtained from vendors, health fair organizers, etc. and added together to generate an estimated total number of persons reached.
5	Type of new and/or expanded services provided through this grant funding during this budget period Please check the box(es) that applies to your program
	Cardiovascular disease prevention
	Cardiovascular disease treatment and management
	Case management
	Dental/oral health education
	Dental/oral health treatment
	Diabetes prevention
	Diabetes treatment and management
	Emergency medical services
	Health education
	Maternal and child health
	Mental/behavioral health treatment and/or education
	Nutrition
	Obesity prevention
	Obesity treatment and management
	All other chronic disease prevention
	All other chronic disease treatment and management
	All other health promotion/disease prevention
	Primary care
	Substance abuse treatment and/or education
	Telehealth/telemedicine
	Transportation
	Workforce recruitment and/or retention
	All other new and/or expanded services Specify:

SECTION II: POPULATION DEMOGRAPHICS (applicable to all Outreach grantees)

Table Instructions: This table collects information about an aggregate count of the people served by race, ethnicity, age and insurance status. The total for each of the following questions should equal the total of the number of unique individuals who received only direct services reported in the previous section. Please do not leave any sections blank. There should not be a N/A (not applicable) response since all measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section (e.g., if the total number that is Hispanic or Latino is zero (0), enter zero in that section).

Number of people served through program by ethnicity (Hispanic or Latino/Not Hispanic or Latino) is defined as:

• Hispanic or Latino origin includes Mexican, Mexican American, Chicano, Puerto Rican, Cuban and other Hispanic, Latino or Spanish origin (i.e., Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, etc.)

		Baseline	End of Budget Period
6	Number of people served by ethnicity:
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown
	Total (automatically calculated)	Equal to the total of the number of unique individuals who received direct services	Equal to the total of the number of unique individuals who received direct services
7	Number of people served by race:
	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Other Pacific Islander
	White
	More than one race
	Unknown
	Total (automatically calculated)	Equal to the total of the number of unique individuals who received direct services	Equal to the total of the number of unique individuals who received direct services
8	Number of people served, by age group:
	Children (0-12)
	Adolescents (13-17)
	Adults (18-64)
	Elderly (65 and over)
	Unknown
	Total (automatically calculated)	Equal to the total of the number of unique individuals who received direct services	Equal to the total of the number of unique individuals who received direct services
9	Number of people by insurance status:
	Uninsured/self-pay
	Dual Eligible (covered by both Medicaid and Medicare)
	Medicaid/CHIP only
	Medicare only
	Other third party
	Unknown
	Total (automatically calculated)	Equal to the total of the number of unique individuals who received direct services	Equal to the total of the number of unique individuals who received direct services

SECTION III: STAFFING (applicable to all Outreach grantees)

Table Instructions: This table collects information about an aggregate number of clinical and non-clinical positions funded by this grant during this budget period. If you are not sure who is funded by this grant, please refer to the staffing plan and budget narrative that was submitted with your grant application. Please report a numeric figure. There should not be a N/A (not applicable) response since all measures are applicable to all grantees.

Please report each staff person who is funded by this program only once. If a staff person’s time is split between clinical and non-clinical activities, please include that staff person within the category that reflects the majority of their time.

Clinical staff includes, but is not limited to, physician (general or specialty), physician assistant, nurse, nurse practitioner, dentist, dental hygienist, psychiatrist, social worker, pharmacist, technician (medical, pharmacy, laboratory, etc.), therapist (behavioral, physical, occupational, speech, etc.), health educator, community health worker, promotora, case manager, interpreter/translator. Clinical staff are individuals that directly interact with patients/clinics.

Non-clinical staff includes management (CEO, CFO, CIO, etc.), support staff, fiscal and billing staff, information technology (IT). Non-clinical staff are individuals that do not directly interact with patients/clients.

		End of Budget Period
10	Number of positions funded by grant dollars during this budget period	Full-Time (1.0 FTE)	Part-Time (less than 1.0 FTE)
	Total number of new clinical staff
	Total number of new non-clinical staff

SECTION IV: CONSORTIUM/NETWORK (applicable to all Outreach grantees)

Table Instructions: This table collects information about an aggregate count of the types and number of consortium/network members. Consortium/network members are defined as members who have signed a Memorandum of Understanding or Memorandum of Agreement for this grant project. There should not be a N/A (not applicable) response since all measures are applicable to all grantees.

Please report information about collaboration among the consortium/network members. Refer to the activities listed in the project workplan for this budget period.

11	Identify the types and number of organizations in the consortium/network for your project:
		Type of Member Organizations in the Consortium/Network	End of Budget Period
	Non-Profit Organization	Area Health Education Center	Number
		Behavioral/Mental Health Organization
		Community College
		Community Health Center
		Critical Access Hospital
		Faith-based organization
		Free Clinic
		Health Department
		Hospice
		Hospital
		Migrant Health Center
		Private Practice
		Rural Health Clinic
		School District
		Social Services Organization
		University
		Other – Specify type
		TOTAL for non-profit organization	(Automatically calculated by system)
	For-Profit Organization	Critical Access Hospital
		Hospice
		Hospital
		Private Practice
		Rural Health Clinic
		Other – Specify Type
		TOTAL for-profit organization	(Automatically calculated by system)
12	Total number of NEW member organizations that joined the consortium/network and signed the MOU/A during this budget period:		Number
13	How many activities from the project workplan were initiated by at least two consortium/network members during this budget period?		Number
14	How many activities from the project workplan were completed by at least two consortium/network members during this budget period?		Number

SECTION V: SUSTAINABILITY (applicable to all Outreach grantees)

Table Instructions: This table collects information/data about the grant’s programmatic sustainability. There should not be a N/A (not applicable) response since all measures are applicable to all grantees.

In Year 3 of grant funding, grantees will need to report on the additional measures:

• Question #21 - The ratio impact for Economic Impact vs. HRSA Program Funding using HRSA’s Economic Impact Analysis Tool (http://www.raconline.org/econtool/)

• Question #22 - If your current consortium/network will sustain after the grant project period is over

• Question #23 - If any of the activities will sustain after the grant project period is over

		End of Budget Period
15	Annual program award Please report the annual program award based on box 12a of your Notice of Award (NOA).	Enter Dollar amount
16	Annual program revenue Please report the amount of annual program revenue made through the services offered through the program. Program revenue is defined as payments received for the services provided by the program that the grant supports. These services should be the same services outlined in your grant application work plan. Please do not include donations. If the total amount of annual revenue made is zero (0), please put zero in the appropriate section.	Enter Dollar amount
17	Additional funding already secured to assist in sustaining the project	Dollar amount
18	Sources of Sustainability Select the type(s) of sources of funding for sustainability. Please check all that apply.
	Program revenue
	In-kind Contributions (In-Kind contributions are defined as donations of anything other than money, including goods or services/time.)
	Membership fees/dues
	Fundraising/ Monetary donations
	Contractual Services
	Other grants
	Fees charged to individuals for services
	Reimbursement from third-party payers (e.g. private insurance, Medicare, Medicaid)
	Product sales
	Government (non-grant)
	Other – specify type
	None
19	Which of the following activities have you engaged in to enhance your sustained impact?  Check all that apply.	Selection list
	Local, State and Federal Policy changes
	Media Campaigns
	Community Engagement Activities
	Other – Specify activity
20	What is your ratio for Economic Impact vs. HRSA Program Funding? Use the HRSA’s Economic Impact Analysis Tool (http://www.raconline.org/econtool/) to identify your ratio.	Ratio
21	Will the consortium/network sustain?
22	Will any of the program’s activities be sustained after the project period?

SECTION VI: PROJECT SPECIFIC DOMAINS

HOME HEALTH (only applicable to projects that had home health activities that were funded by this grant)

Table Instructions: If your grant supported any home health activities that were implemented during this budget year, please discuss how you were able to measure “activities of daily living”. The term "activities of daily living," or ADLs, refers to common, everyday tasks (ex: eating, bathing, dressing, toileting, and transferring, performance) of which is required for personal self-care and independent living. If your grant did support home health activities, but you do not know the information, then select/enter DK (do not know). If your grant did not support any home health activities, then select/enter N/A(not applicable).

23	What tool did you use to measure “Activities of Daily Living”?	Enter Text
24	What was the average score/result based on the tool that was used?	Enter number

CARE COORDINATION (only applicable to projects that had care coordination activities funded by this grant)

Table Instructions: If your grant supported any care coordination activities, select the mechanisms/activities that were implemented during this budget year. Care coordination is defined as care that is coordinated across all elements of the broader healthcare system. If your grant did support care coordination activities, but you do not know the information, then select/enter DK (do not know). If your grant did not support any care coordination activities, then select/enter N/A (not applicable).

		Baseline	End of Budget Year
25	Which of the following care coordination mechanisms/activities have you implemented during this budget year? Select all that apply.
	Facilitate transitions across settings
	Linkage to community resources
	Patient support and engagement
	Case management
	Create care plans
	Medication management
	Other – specify
	Not applicable

INTEGRATION OF CARE (only applicable to projects that had integration of care activities funded by this grant)

Table Instructions: If your grant supported any integration of care activities, select the activities that were implemented during this budget year. Integration of care is defined as systematic coordination of general/primary care and other types of care (ex: behavioral health, substance abuse, mental health, oral health). If your grant did support integration of care activities, but you do not know the information, then select/enter DK (do not know). If your grant did not support any integration of care activities, then select/enter N/A (not applicable).

26	Which of the following care integration activities have you implemented during this budget period? Select all that apply	Baseline	End of Budget Period
	Care team expertise - develop a unified care plan that builds a team—with necessary members and functions—to care for a given patient.
	Clinical workflow - clinical protocols and workflows are clearly documented for integration of care
	Patient identification - establish systematic methods to identify individuals for integrated care
	Clinical outcomes – monitor patient’s clinical outcomes to assess impact of integration of care
	Other – specify
	Not applicable

WORKFORCE/ RECRUITMENT & RETENTION (only applicable to projects that focused on student/resident workforce recruitment and retention)

Table Instructions: This table collects information/data about student/resident workforce recruitment and/or retention activities during this budget period. Please refer to the detailed definitions and guidelines to provide responses for the following measures. Please report a numeric figure; if the total number is zero, please put zero (0) in the appropriate section. Do not leave any sections blank. If your grant did support workforce recruitment and/or retention activities, but you do not know the information, then select/enter DK (do not know). If your grant did not support any student/resident workforce recruitment and/or retention activities, then select/enter N/A (not applicable).

For the purposes of this data collection, “trainees” are persons who are working towards a professional degree.

Trainees (students and residents) are considered “New” if:

1. They have never engaged in a training/rotation within a rural community as a part of their certificate/degree/residency program and/or

2. They do not self-identify as “having lived”/ “living”/ “claiming residence” within a rural area.

Trainees (students and residents) are considered “Existing” if:

1. They have had prior exposure to rural areas by either engaging in a training/rotation within a rural area as a part of their certificate/degree/residency program prior to the respective budget year and/or

2. They self-identify as “having lived”/ “living”/ “claiming residence” within a rural area.

Please report the number of trainees by type that complete the trainings/rotations; this figure should not exceed the total number of all trainees recruited by type. Please also report the number of trainees by type that plan to practice in a rural area after completing their trainings/rotations. Of those trainees that completed their trainings/rotations, please specify the number that returned to formally practice in rural areas; for this measure, please report a numeric figure or indicate DK for “do not know”. For example, if zero (0) students completed their trainings/rotations and returned to formally practice in a rural area, please put zero (0) in the appropriate section. Do not leave any sections blank.

	STUDENTS			RESIDENTS
	Baseline	End of Budget Year		Baseline	End of Budget Year
Number of New
Number of Existing
TOTAL (Number (automatically calculated by the system)
Of the total number recruited, how many completed the training/rotation
Of the total number that complete the training/rotation, how many plan to practice in a rural area
Percentage trained that plan to practice in a rural area (automatically calculated by the system)
Of the total number that complete the training/rotation, how many returned to formally practice in rural areas
Percentage trained that return to formally practice in rural areas (automatically calculated by the system)

Trainee Primary Care Focus Area(s):	Number
Medical
Mental/Behavioral Health
Oral Health

Trainee Discipline Type(s): Note that psychiatrists are either allopathic (MD) or osteopathic (DO) physicians. Also, please specify the types of non-physician practitioners, nurses, and allied health professionals as appropriate. For example, physician assistants, nurse practitioners, certified nurse mid-wives, and certified registered nurse anesthesiologists are considered non-physician practitioners. Allied health professionals include dental hygienists, diagnostic medical sonographers, dietitians, medical technologists, occupational therapists, physical therapists, pharmacists, radiographers, respiratory therapists, community health workers, and speech language pathologists. If the targeted trainee does not fall under the listed categories, please refer to the detailed definition for Allied Health Professionals and specify the discipline(s) in the Allied Health Professionals category. Please check all that apply.	Number
Allied Health Professional– Please specify type(s)
Dentist
Non-physician practitioners – Please specify type(s)
Nurse – Please specify type(s)
Physician (DO)
Physician (MD)

	Baseline	End of Budget Period
Number of New Trainings/Rotations provided: Please report the number of trainings/rotations provided during the respective budget period as well as the number of training sites by type where the trainings/rotations were conducted. Please report a numeric figure. If the total number of trainings/rotations is zero (0), please put zero in the appropriate section. Do not leave any sections blank.
Number of Training Site(s) by Type:
Critical Access Hospital
Other Rural Hospital
Clinic
Rural Health Clinic
Community Health Center
Federally Qualified Health Center (FQHC)
Health Department
Indian Health Service (IHS) or Tribal Health Sites
Migrant Health Center (MHC)
Other Community Based Site – Please specify type(s)

COMMUNITY HEALTH PREVENTION, EDUCATION, AND PROMOTION (only applicable to projects that had community health prevention, education, and promotion activities funded by this grant)

Table Instructions: This table collects information/ data about the types of preventative services that were funded with this grant and the outputs for the respective preventative services. Preventive services consist of screening tests, counseling, immunizations or medications used to prevent disease, detect health problems early, or provide people with the information they need to make good decisions about their health. While preventive services are traditionally delivered in clinical settings, some can be delivered within communities, work sites, schools, residential treatment centers, or homes. If your grant did support community health prevention, education and promotion activities, but you do not know the information, then select/enter DK (do not know). If your grant did not support any community health prevention, education and/or promotion activities, then select/enter N/A (not applicable).

	Baseline	End of Budget Period
Total number of health screenings held in clinical and non-clinical settings
Total number of health screening participants
Of the total number of health screening participants, how many were referred to a health care provider?
Total number of health education/counseling activities (these are activities aimed at improving knowledge, attitudes, self-efficacy and individual capacity to change) held
Total number of participants who participated in health education/counseling activities

MENTAL/BEHAVIORAL HEALTH (only applicable to projects that had mental/behavioral health activities funded by this grant)

Table Instructions: This table collects information about an aggregate number of people receiving mental and/or behavioral health services among the unique individuals who received direct services. This number should not exceed the number of unique individuals receiving direct services. If you provided direct mental/behavioral health care, please answer clinical measure #3 (if applicable). This clinical measure is found under the “Clinical Measures” section. If your grant did support mental/behavioral health activities, but you do not know the information, then select/enter DK (do not know). If your grant did not support any mental/behavioral health activities, then select/enter N/A (not applicable).

	Baseline	End of Budget Period
Number of people receiving mental and/or behavioral health services (among the unique individuals receiving direct services).	Should not exceed the # of unique individuals receiving direct services	Should not exceed the # of unique individuals receiving direct services
Is your project working on integrating primary care and mental/behavioral health services? (y/n)

DENTAL/ORAL HEALTH (only applicable to projects that had oral health activities funded by this grant)

Table Instructions: Use this table to report the aggregate number(s) of persons receiving dental/oral health services among those unique individuals (e.g., an unduplicated count of persons) who received direct services. Aggregate number(s) should not exceed the number of unique individuals who received direct services. If you provided direct patient dental/oral health care, please answer clinical measure #2 (if applicable). This clinical measure is found under the “Clinical Measures” section. If your grant did support dental/oral health activities, but you do not know the information, then select/enter DK (do not know). If your grant did not support any dental/oral activities, then select/enter N/A (not applicable).

	Baseline	End of Budget Period
Number of people receiving dental / oral health services (among the unique individuals receiving direct services).	Should not exceed the # of unique individuals receiving direct services	Should not exceed the # of unique individuals receiving direct services
Is your project working on integrating primary care and dental/oral health services? (y/n)
Type(s) and quantity of dental/oral health services provided. Please report the number of persons who received specific dental/oral health services during this budget period. Report a numeric figure or indicate N/A for “not applicable” if your grant program did not fund this particular service.
	Baseline	End of Budget Period
Screenings / Exams
Sealants
Varnish
Oral Prophylaxis
Restorative
Extractions
Health education
Other (please specify)

CLINICAL MEASURES (only applicable to projects in which direct outpatient care was provided under this grant)

Table Instructions: This table collects information about measures of the clinical outcomes of certain direct outpatient care services provided to the unique individuals who received direct services funded by this grant during this budget period. The denominator for all measures should be based only on the population of unique persons (i.e., an unduplicated count of persons) who received direct services through this grant during this budget period.

If your grant did support direct outpatient care services, but you do not know the information for that particular clinical measure, then select/enter DK (do not know). If your grant did not support direct outpatient care services related to that particular clinical measure, then select/enter N/A (not applicable).

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Measure 1 – Hospitalization for Ambulatory Care Sensitive Condition – Diabetes Short Term Complications: The rate of admissions for a principal diagnosis of diabetes with short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 population, ages 18 years and older.

Measure 2 – Tooth loss: Percentage of adults with permanent tooth loss due to dental caries or periodontal disease.

Measure 3 - Screening for clinical depression: Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND a documented follow-up plan.

Measure 4 - Controlling high blood pressure: Percentage of adult patients, 18-85 years of age, who had a diagnosis of hypertension whose blood pressure was adequately controlled during the budget period.

Measure 5 – Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%): Percent of adult patients, 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c less than 8.0%.

Measure 6 - Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg): The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent blood pressure (BP) reading is <140/90 mm Hg during the budget period.

Measure 7 - Comprehensive Diabetes Care: LDL-C Control <100 mg/dL: Percent of adult patients, 18- 75 years of age with diabetes (type 1 or type 2) who had LDL-C less than 100 mg/dL.

Measure 8 - Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Percentage of patients 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of the following during the budget period:

- Body mass index (BMI) percentile documentation

- Counseling for nutrition

- Counseling for physical activity

Measure 9 - Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up: Percentage of patients aged 18 years and older with a documented BMI during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter.

	Clinical Measures	Numerator (Number)	Denominator (Number)	Percent/Rate (Automatically calculated by system)
1	AHRQ – Hospitalization for Ambulatory Care Sensitive Condition – Diabetes Short Term Complications: The rate of admissions for a principal diagnosis of diabetes with short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 population, ages 18 years and older.	Discharges for patients 18 years and older, with a principal ICD-9-CM diagnosis code for diabetes short term complications (ketoacidosis, hyperosmolarity, or coma)	Among the unique individuals who received the Outreach grant funded direct services, the number of people ages 18 years and older in the target service area
2	Healthy People 2020: Tooth loss Percentage of adults with permanent tooth loss due to dental caries or periodontal disease	Number of persons aged 45 to 64 years with a clinical confirmation of less than 28 natural teeth present (tooth loss due to caries or periodontal disease) exclusive of third molars.	Among the unique individuals who received the Outreach grant funded direct services, the number of persons aged 45 to 64 years with valid codes for 28 permanent teeth, exclusive of third molars
3	NQF 0418: Screening for clinical depression: Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented.	Patient’s screening for clinical depression using an age appropriate standardized tool AND follow-up plan is documented	Among the unique individuals who received the Outreach grant funded direct services, all patients aged 12 years and older
4	NQF 0018: Controlling High Blood Pressure: Percentage of adult patients, 18-85 years of age, who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year	The number of patients in the denominator whose most recent BP is adequately controlled during the budget period. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.	Among the unique individuals who received the Outreach grant funded direct services, patients 18-85 years of age by the end of the budget period who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the budget period.
5	NQF 0575: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%): Percent of adult patients, 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c less than 8.0%	Patients whose HbA1c level is <8.0% during the budget period.	Among the unique individuals who received the Outreach grant funded direct services, patients 18-75 years of age by the end of the budget period who had a diagnosis of diabetes (type 1 or type 2) during the budget period or the year prior to the budget period.
6	NQF 0061: Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg): The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent blood pressure (BP) reading is <140/90 mm Hg during the budget period.	Patients whose most recent BP reading is <140/90 mm Hg during the budget period.	Among the unique individuals who received the Outreach grant funded direct services, patients 18-75 years of age by the end of the budget period who had a diagnosis of diabetes (type 1 or type 2) during the budget period or the year prior to the budget period.
7	NQF 0064: Comprehensive Diabetes Care: LDL-C Control <100 mg/dL: Percent of adult patients, 18- 75 years of age with diabetes (type 1 or type 2) who had LDL-C less than 100 mg/dL	Patients whose most recent LDL-C test is <100 mg/dL during the budget period.	Among the unique individuals who received the Outreach grant funded direct services, patients 18-75 years of age by the end of the budget period who had a diagnosis of diabetes (type 1 or type 2) during the budget period or the year prior to the budget period
8	NQF 0024: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Percentage of patients 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of the following during the budget period: - Body mass index (BMI) percentile documentation - Counseling for nutrition - Counseling for physical activity	Body mass index (BMI) percentile documentation, counseling for nutrition and counseling for physical activity during the budget period.	Among the unique individuals who received the Outreach grant funded direct services, patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or OB-GYN.
9	NQF 0421: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up: Percentage of patients aged 18 years and older with a documented BMI during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter.	Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, follow-up is documented during the encounter or during the previous six months of the encounter with the BMI outside of normal parameters	Among the unique individuals who received the Outreach grant funded direct services, all patients aged 18 years and older

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