Performance Measures Instructions

Performance Measures Instructions

CLINICAL AND FINANCIAL PERFORMANCE MEASURES

The Clinical and Financial Performance Measures forms record the proposed project’s clinical and financial goals. The goals must be responsive to identified community health and organizational needs and correspond to proposed service delivery activities and organizational capacity discussed in the Project Narrative. Further detail is available at the Clinical and Financial Performance Measures Web site (refer to the UDS Manual for specific measurement details such as exclusionary criteria).

Required Clinical Performance Measures

1. Diabetes

2. Hypertension: Controlling High Blood Pressure

3. Cervical Cancer Screening

4. Prenatal care

5. Low Birth Weight

6. Childhood Immunization Status

7. Oral Health – Dental Sealants

8. Adolescent Weight Screening and Follow-Up

9. Adult Weight Screening and Follow-Up

10. Tobacco Use Screening and Cessation

11. Asthma: Use of Appropriate Medications

12. Coronary Artery Disease: Lipid Therapy

13. Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic

14. Colorectal Cancer Screening

15. HIV Linkage to Care

16. Depression Screening and Follow-Up

Required Financial Performance Measures

1. Total Cost per Patient

2. Medical Cost per Medical Visit

3. Health Center Program Grant Cost per Patient

Important Details about the Performance Measures Forms

• The Oral Health Clinical Performance Measure for sealants is currently only applicable to health centers that provide preventive dental services directly or by a formal arrangement in which the health center pays for the service (Form 5A, Columns I and II). A health center that only provides preventive dental services via a formal referral (Form 5A, Column III) may set the goal for the Oral Health performance measure as zero. If the goal for the Oral Health performance measure for sealants will be set to 0, at least one self-defined Oral Health performance measure must be tracked under the Additional Clinical Performance Measures section.

• Baselines for performance measures should be developed from data that are valid, reliable, and whenever possible, derived from currently established information management systems. If baselines are not yet available, enter 0 and provide a date by which baseline data will be available.

• Applicants applying for funds to serve special populations (i.e., migratory and seasonal agricultural workers, people experiencing homelessness, and/or residents of public housing), must include additional clinical performance measures that address the health care needs of these populations. Additional performance measures specific to special populations may not replace the required measures listed above. In providing additional performance measures specific to a special population, applicants must reference the target group in the performance measure. For example, if an applicant seeks funds to serve migratory and seasonal agricultural workers and their families, then the applicant must propose to measure “the percentage of migratory and seasonal agricultural workers and their families who…” rather than simply “the percentage of patients who…”

• Applicants that have identified unique issues (e.g., populations, age groups, health issues, risk management efforts) in the NEED section of the Project Narrative are encouraged to include additional related performance measures.

Additional Performance Measures

In addition to the required Clinical and Financial Performance Measures, applicants may identify other measures relevant to their target population and/or health center. Each additional measure must be defined by a numerator and denominator, and progress must be tracked over time. If a competing continuation applicant no longer tracks a previously self-defined measure in the Additional Performance Measures section, note this by marking the measure Not Applicable and including a justification in the Comments field as to why reporting is no longer possible and/or relevant.

Overview of the Performance Measures Form Fields

Pre-populated baseline data will be sourced from the 2015 UDS report for competing continuation applicants for measures that have not significantly changed.¹ For competing continuation applicants that did not submit a 2015 UDS report, such information will be pre-populated where possible from the latest SAC/NAP/BPR submission.

Table 2: Overview of Measures Form Fields

Field Name	Pre‑Populated	Editable	Notes
Focus Area	YES	NO	This field contains the content area description for each required performance measure. Applicants will specify focus areas when adding performance measures in the Additional Performance Measures section.
Performance Measure	YES	NO	This field defines each performance measure and is editable for performance measures in the Additional Performance Measures section. Edits must be explained in the Comments field.
Additional Performance Measures: Is this Performance Measure applicable to your organization?	NO	YES	This field is editable for previously self-defined performance measures. If “No” is selected, provide justification in the Comments field and the measure will no longer be tracked.
Target Goal Description	NO	YES	This field provides a description of the target goal.
Numerator Description	YES	NO	In the Clinical Performance Measures, the numerator is the number of patients that meet the criteria identified by the measure (e.g., patients in a specified age range that received a specified service). In the Financial Performance Measures, the numerator field is specific to the organizational measure. This field can be edited for any previously self-defined Additional Performance Measure. All edits require justification in the Comments field.
Denominator Description	YES	NO	In the Clinical Performance Measures, the denominator is all patients to whom the measure applies (e.g., patients in a specified age range, regardless of whether they received a specified service). In the Financial Performance Measures, the denominator field must be specific to the organizational measure. This field can be edited for any previously self-defined Additional Performance Measure. All edits require justification in the Comments field.
Baseline Data			The Baseline Data comprises the subfields below (i.e., Baseline Year, Measure Type, Numerator, and Denominator) that provide information regarding the initial threshold used to measure progress over the course of the project. Competing continuation applicants: These fields will be blank and editable for the updated Clinical Performance Measures, since no UDS data is available. Otherwise, data pre-populate from the 2015 UDS report and are not editable. For pre-populated, non-editable data, to report more current data, include information in the Comments field. New and competing supplement applicants: These fields will be blank and editable, For previously-self defined Additional Performance Measures, pre-populated information can be edited. Justification is required in the Comments field.
Baseline Year	Varies	Varies	The Baseline Year subfield identifies the initial data reference point. If it is blank and editable, provide the baseline reference year.
Measure Type	YES	NO	The Measure Type subfield provides the unit of measure (e.g., percentage, ratio).
Numerator	Varies	Varies	The Numerator subfield specifies a quantitative value in reference to the Numerator Description above.
Denominator	Varies	Varies	The Denominator subfield specifies a quantitative value in reference to the Denominator Description above.
Progress Field	NO	YES	Competing continuation applicants MUST use this field to provide information regarding progress for required measures since the application that initiated the budget period (e.g., FY 2016 Budget Period Progress Report (BPR)). State If progress cannot be reported due to the measure being updated. This field is not applicable for new and competing supplement applicants. Limit to 1,500 characters.
Projected Data	NO	YES	This field provides the goal to be met by December 31, 2018.
Data Source and Methodology	NO	YES	This field provides information about the data source used to develop each performance measures. Applicants are first required to identify a data source. For Clinical Performance Measures, select from EHR, Chart Audit, or Other (please specify). Applicants must then discuss the methodology used to collect and analyze data. Data must be valid, reliable, and derived from established information management systems. Limit to 500 characters.
Key Factors and Major Planned Actions			This field contains subfields that provide information regarding the factors that must be minimized or maximized to ensure goal achievement.
Key Factor Type	NO	YES	The Key Factor Type subfield requires applicants to select Contributing and/or Restricting factor categories. Applicants must specify at least one key factor of each type.
Key Factor Description	NO	YES	The Key Factor Description subfield provides a description of the factors predicted to contribute to and/or restrict progress toward stated goals.
Major Planned Action Description	NO	YES	The Major Planned Action Description subfield provides a description of the major actions planned for addressing key factors. Applicants must use this subfield to provide planned overarching action steps and strategies for achieving each performance measure. Limit to 1,500 characters.
Comments	NO	YES	Provide justifications required from changes made to other form fields as well as any additional information desired. Information exceeding the character limit should be placed in the EVALUATIVE MEASURES section of the Project Narrative. Limit to 1,500 characters.

Resources for the Development of Performance Measures

Competing continuation applicants are encouraged to use their UDS Health Center Trend Report and/or Summary Report available in EHB when considering how improvements to past performance can be achieved for performance measures that have not been updated. For help with accessing reports in EHB, contact the BPHC Helpline by submitting a request through the Web portal or call 877-974-2742. Applicants may also find it useful to do the following:

• Recognize that many UDS Clinical Performance Measures are aligned with the meaningful use measures.

• Examine the performance measures of other health centers that serve similar target populations.

• Consider state and national performance UDS benchmarks and comparison data (available at Health Center Data).

• Use the Healthy People 2020 goals as a guide when developing performance measures. Several of these objectives can be compared directly to UDS Clinical Performance. A table outlining the Healthy People 2020 objectives related to applicable performance measures is available at Healthy People 2020/Health Center Program Measures.

1 Refer to the 2016 Performance Measures Population Guide at the SAC Technical Assistance Web site.