Form 40 HCCN Progress Report (track changes)

OMB Number: 0915-0285360; Expiration Date XX3/XX31/20XX16
HCCN Progress Report Table
HEALTH CENTER CONTROLLED NETWORK NAME: Number of Health Centers (Baseline) Number of Health Centers (Current)DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and service Administration PROGRESS REPORT TABLE	Application Tracking Number	Grant Number

PARTICIPATING HEALTH CENTER
Health Center Name					System will pre-populate
Grant/Look alike NumberBHCMIS ID					System will pre-populate
Patient Details
Total Patients (UDS Definition)					System will pre-populate
Number of Patient Charts in EHR
Number of Sites (Baseline)
Number of Sites (Current)Number of Providers Receiving AIU/MU Payments
HP 2020 Measure	Not Met	Met	Exceeded			N/A	Comments (Maximum 1000 characters)
Access to Prenatal Care (First Prenatal Visit in 1st Trimester)Hypertension	[_]	[_]	[_]			[_]
Childhood Immunizations	[_]	[_]	[_]			[_]
Cervical Cancer ScreeningPrenatal Care	[_]	[_]	[_]			[_]
Colorectal Cancer Screening	[_]	[_]	[_]			[_]
Dental Sealants for Children	[_]	[_]	[_]			[_]
Low Birth Weight	[_]	[_]	[_]			[_]
Hypertension BP Control (BP < 140/90)	[_]	[_]	[_]			[_]
Diabetes Control (BP < 140/90)	[_]	[_]	[_]			[_]
Cervical Cancer	[_]	[_]	[_]			[_]
Tobacco Use	[_]	[_]	[_]			[_]
Tobacco Cessation	[_]	[_]	[_]			[_]
Other (e.g. asthma, tobacco use screening, tobacco cessationIf Other, then Specify):	[_]	[_]	[_]			[_]
PCMH Recognition
PCMH Recognition				[_]No Recognition [_]TJC [_]AAAHC [_]NCQA Level 1 [_]NCQA Level 2 [_]NCQA Level 3 [_]Other (If Other, then Specify):
Narrative
EHR AND HIT IMPLEMENTATION STATUS
1. Does the participating health center use an ONC- ATCB certified EHR (if implemented, what was date of implementation)?								[_] Yes [_] No
2. How many sites have the EHR system in use?

Narrative Sections:

PLANS FOR NEXT YEAR: EHR ADOPTION AND IMPLEMENTATION
PLANS FOR NEXT YEAR: MEANINGFUL USE
1. Have the eligible providers in participating health centers registered and attested/applied for EHR Incentive Program payments?	[_] Yes [_] No
2. Have the eligible providers in participating health centers received EHR Incentive Program payments?	[_] Yes [_] No
3. What is the number of eligible providers participating in MU payments?
4. What is the number of eligible providers in participating health centers?
DATA QUALITY AND REPORTING
1. Does the participating health center electronically extract data from an EHR to report all UDS Clinical Quality Measure data on all of their patients?	[_] Yes [_] No
2. Does the participating health center generate quality improvement reports at the site and clinical team levels?	[_] Yes [_] No
3. Does the participating health center integrate data from different service types and/or providers (e.g., behavioral health, oral health)?	[_] Yes [_] No
HEALTH INFORMATION EXCHANGE (HIE) AND POPULATION HEALTH MANAGEMENT
1. Does the participating health center improve care coordination through health information exchange with unaffiliated providers or entities?	[_] Yes [_] No
2. Does the participating health center use health information exchange to support population health management?	[_] Yes [_] No
PLANS FOR NEXT YEAR: QUALITY IMPROVEMENT
1. Does the participating health center improve the value, efficiency, and/or effectiveness of health center services?	[_] Yes [_] No
PROMISING PRACTICES
Narrative (voluntary):
THE HEALTH CENTER CONTROLLED NETWORK WILL COMPLETE THIS SECTION FOR THE ONE-TIME FINAL REPORT
CUSTOMER SATISFACTION: CHALLENGES AND BARRIERS: LESSONS LEARNED: CONTINGENCY PLANNING: PROMISING PRACTICES: ADDITIONAL COMMENTS:

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