17 Clinical Performance Measures Final

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Clinical Performance Measures PERFORMANCE MEASURES		FOR HRSA USE ONLY
		Grant Number	Application Tracking Number
Focus Area: Prepopulated according to chart below
Performance Measure	Prepopulated according to chart below
Target Goal Description
Numerator Description	Prepopulated according to chart below
Denominator Description	Prepopulated according to chart below
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Progress Field (for Service Area Competition and non-competing continuation applications)
Projected Goal (by December 31, 2018)
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 Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments

	Focus Area: Diabetes: Hemoglobin A1c Poor Control
	Performance Measure		Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c greater than 9.0% during the measurement period.
	Numerator Description		Patients whose most recent HbA1c level (performed during the measurement period) is greater than 9.0%.
	Denominator Description		Patients 18-75 years of age with diabetes with a visit during the measurement period.
	Focus Area: Hypertension: Controlling High Blood Pressure
	Performance Measure		Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (less than 140/90mmHg) during the measurement period.
	Numerator Description		Patients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period.
	Denominator Description		Patients 18-85 years of age who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period, excluding patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period.
	Focus Area: Cervical Cancer Screening
	Performance Measure		Percentage of women 21-64 years of age, who received one or more Pap tests to screen for cervical cancer.
	Numerator Description		Women with one or more Pap tests during the measurement period or the two years prior to the measurement period.
	Denominator Description		Women 23-64 years of age with a visit during the measurement period, excluding women who had a hysterectomy with no residual cervix.
	Focus Area: Access to Prenatal Care
	Performance Measure	Percentage of prenatal care patients who entered treatment during their first trimester.
	Numerator Description	Women entering prenatal care at the health center or with the referred provider during their first trimester.
	Denominator Description	Women seen for prenatal care during the year.
	Focus Area: Low Birth Weight
	Performance Measure	Percentage of patients born to health center patients whose birth weight was below normal (less than 2,500 grams).
	Numerator Description	Children born with a birth weight of under 2,500 grams.
	Denominator Description	Live births during the measurement year for women who received prenatal care from the health center or by a referral provider.
	Focus Area: Childhood Immunization Status
	Performance Measure	Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.
	Numerator Description	Children who have evidence showing they received recommended vaccines, had documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine by their second birthday.
	Denominator Description	Children who turn 2 years of age during the measurement period and who have a visit during the measurement period.
Focus Area: Dental Sealants
Performance Measure		Percentage of children, age 6 through 9 years, at moderate to high risk for caries who received a sealant on a permanent first molar during the measurement period.
Numerator Description		Patients who received a sealant on a permanent first molar tooth in the measurement year.
Denominator Description		Dental patients aged 6- 9 who had an oral assessment or comprehensive or periodic oral evaluation visit during the measurement year and documented as having moderate to high risk for caries, excepting children for whom all first permanent molars are non-sealable.
	Focus Area: Weight Assessment and Counseling for Children and Adolescents
	Performance Measure	Percentage of patients aged 3 -17 years of age who had evidence of BMI percentile documentation and who had documentation of counseling for nutrition and who had documentation of counseling for physical activity during the measurement year.
	Numerator Description	Number of patients in the denominator who had their BMI percentile (not just BMI or height and weight) documented during the measurement year and who had documentation of counseling for nutrition and who had documentation of counseling for physical activity during the measurement year.
	Denominator Description	Number of patients who were 3 years of age through adolescents who were aged 17 at some point during the measurement year, who had at least one medical visit during the reporting year, and were seen by the health center for the first time prior to their 18th birthday.
	Focus Area: Adult Weight Screening and Follow-Up
	Performance Measure	Percentage of patients aged 18 years and older with a BMI documented 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 current encounter. Normal parameters: Age 18 - 64 years BMI => 18.5 and < 25 kg/m², and Age 65 years and older BMI => 23 and < 30 kg/m².
	Numerator Description	Number of patients in the denominator who had their BMI (not just height and weight) documented during their most recent visit or within 6 months of the most recent visit and if the most recent BMI is outside of normal parameters, a follow-up plan is documented.
	Denominator Description	Number of patients who were 18 years of age or older during the measurement year, who had at least one medical visit during the reporting year.
	Focus Area: Tobacco Use Screening and Cessation Intervention
	Performance Measure	Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
	Numerator Description	Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user.
	Denominator Description	All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period, excluding patients whose medical record reflects documentation of medical reason(s) for not screening for tobacco use.
	Focus Area: Asthma: Use of Appropriate Medications
	Performance Measure	Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period.
	Numerator Description	Patients who were dispensed at least one prescription for a preferred therapy during the measurement period.
	Denominator Description	Patients 5-64 years of age with persistent asthma and a visit during the measurement period, excluding patients with emphysema, COPD, cystic fibrosis, or acute respiratory failure during or prior to the measurement period.
	Focus Area: Coronary Artery Disease (CAD): Lipid Therapy
	Performance Measure	Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) who were prescribed a lipid-lowering therapy.
	Numerator Description	Number of patients who received a prescription for or were provided or were taking lipid lowering medications.
	Denominator Description	Number of patients who were seen during the measurement year after their 18th birthday, who had at least one medical visit during the measurement year, at least two medical visits ever, and who had an active diagnosis of coronary artery disease (CAD) including any diagnosis for myocardial infarction (MI) or who had had cardiac surgery in the past, excluding patients whose last LDL lab test during the measurement year was less than 130 mg/dL, individuals with an allergy to or a history of adverse outcomes from or intolerance to LDL lowering medications.
	Focus Area: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
	Performance Measure	Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period.
	Numerator Description	Patients who have documentation of use of aspirin or another antithrombotic during the measurement period.
	Denominator Description	Patients 18 years of age and older with a visit during the measurement period, and an active diagnosis of ischemic vascular disease (IVD) or who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period.
	Focus Area: Colorectal Cancer Screening
	Performance Measure	Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.
	Numerator Description	Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria: fecal occult blood test (FOBT) during the measurement period; flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period; or colonoscopy during the measurement period or the nine years prior to the measurement period.
	Denominator Description	Patients 50-75 years of age with a visit during the measurement period, excluding patients with a diagnosis or past history of total colectomy or colorectal cancer.
	Focus Area: HIV Linkage to Care
	Performance Measure	Percentage of newly diagnosed HIV patients who had a medical visit for HIV care within 90 days of first-ever HIV diagnosis.
	Numerator Description	Patients who had a medical visit for HIV care within 90 days of first-ever HIV diagnosis.
	Denominator Description	Patients first diagnosed with HIV by the health center between October 1 of the prior year through September 30 of the current measurement year.
Focus Area: Depression Screening and Follow-Up
Performance Measure		Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.
Numerator Description		Patients screened for clinical depression on the date of the encounter using an age appropriate standardized tool AND if positive, a follow-up plan is documented on the date of the positive screen.
Denominator Description		All patients aged 12 years and older before the beginning of the measurement period with at least one eligible encounter during the measurement period, excluding patients with an active diagnosis for depression or a diagnosis of bipolar disorder, or patient refuses to participate, or medical reason(s), such as patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health status or situations where the patient's functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools.

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 0915-0285. Public reporting burden for this collection of information is estimated to average 3.5 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 14N-39 Rockville, Maryland, 20857.