Form 2 Grant Report - 2020 UDS Tables Redline

2020 HRSA Uniform Data System (UDS)

2020 UDS Tables_redline

Uniform Data System

OMB: 0915-0193

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Download: docx | pdf

OMB No. 0915-0193

Expires: XX/XX/20XX













Shape1

Table: Patients by ZIP Code

Reporting Period: January 1, 2019, through December 31, 2019




ZIP Code (a)


None/ Uninsured (b)


Medicaid/ CHIP/Other Public (c)


Medicare (d)


Private (e)


Total Patients (f)

[Blank for demonstration]






[Blank for demonstration]






Other ZIP Codes






Unknown Residence






Total






Shape2 Note: This is a representation of the form. The actual online input process looks significantly different and the printed output from the EHBs may be modified.

Shape3 Table 3A: Patients by Age and by Sex Assigned at Birth

Reporting Period: January 1, 2019, through December 31, 2019



Line

Age Groups

Male Patients

(a)

Female Patients

(b)

1

Under age 1



2

Age 1



3

Age 2



4

Age 3



5

Age 4



6

Age 5



7

Age 6



8

Age 7



9

Age 8



10

Age 9



11

Age 10



12

Age 11



13

Age 12



14

Age 13



15

Age 14



16

Age 15



17

Age 16



18

Age 17



19

Age 18



20

Age 19



21

Age 20



22

Age 21



23

Age 22



24

Age 23



25

Age 24



26

Ages 25–29



27

Ages 30–34



28

Ages 35–39



29

Ages 40–44



30

Ages 45–49



31

Ages 50–54



32

Ages 55–59



33

Ages 60–64



34

Ages 65–69



35

Ages 70–74



36

Ages 75–79



37

Ages 80–84



38

Age 85 and over



39

Total Patients

(Sum of Lines 1-38)



Table 3B: Demographic Characteristics

Reporting Period: January 1, 2019, through December 31, 2019

Shape4 Shape5 Patients by Race and Hispanic or Latino Ethnicity



Line


Patients by Race

Hispanic/ Latino (a)

Non- Hispanic/ Latino

(b)

Unreported/Refused to Report Ethnicity

(c)

Total (d)

(Sum Columns a+b+c)

1

Asian





2a

Native Hawaiian





2b

Other Pacific Islander






2

Total Native Hawaiian/Other Pacific Islander

(Sum Lines 2a + 2b)





3

Black/African American





4

American Indian/Alaska Native





5

White





6

More than one race





7

Unreported/Refused to report race





8

Total Patients

(Sum of Lines 1 + 2 + 3 to 7)






Line

Patients Best Served in a Language Other than English

Number (a)

12

Patients Best Served in a Language Other than English




Line


Patients by Sexual Orientation


Number (a)



Line


Patients by Gender Identity


Number (a)

13

Lesbian or Gay


20

Male


14

Straight (not lesbian or gay)


21

Female


15

Bisexual


22

Transgender Male/Female-to- Male


16

Something else


23

Transgender Female/Male-to-

Female


17

Don’t know


24

Other


18

Chose not to disclose


25

Chose not to disclose


19

Total Patients

(Sum of Lines 13 to 18)


26

Total Patients

(Sum of Lines 20 to 25)










Table 4: Selected Patient Characteristics

Reporting Period: January 1, 2019, through December 31, 2019


Line

Income as Percent of Poverty Guideline

Number of Patients

(a)

1

100% and below


2

101–150%


3

151–200%


4

Over 200%


5

Unknown


6

TOTAL (Sum of Lines 1–5)



Line

Principal Third-Party Medical Insurance

0-17 years old

(a)

18 and older

(b)

7

None/Uninsured



8a

Medicaid (Title XIX)



8b

CHIP Medicaid



8

Total Medicaid (Line 8a + 8b)



9a

Dually Eligible (Medicare and Medicaid)



9

Medicare (Inclusive of dually eligible and other Title

XVIII beneficiaries)



10a

Other Public Insurance (Non-CHIP) (specify)



10b

Other Public Insurance CHIP



10

Total Public Insurance (Line 10a + 10b)



11

Private Insurance



12

TOTAL (Sum of Lines 7 + 8 + 9 +10 +11)







Line



Managed Care Utilization



Medicaid (a)



Medicare (b)

Other Public Including Non- Medicaid CHIP

(c)



Private (d)



TOTAL

(e)

13a

Capitated Member Months






13b

Fee-for-service Member Months






13c

Total Member Months

(Sum of Lines 13a + 13b)





















Shape7 Table 4: Selected Patient Characteristics (continued)

Reporting Period: January 1, 2019, through December 31, 2019

Shape8

Line

Special Populations

Number of Patients

(a)

14

Migratory (330g awardees only)


15

Seasonal (330g awardees only)


16

Total Agricultural Workers or Dependents

(All health centers report this line)


17

Homeless Shelter (330h awardees only)


18

Transitional (330h awardees only)


19

Doubling Up (330h awardees only)


20

Street (330h awardees only)


21a

Permanent Supportive Housing (330h awardees only)


21

Other (330h awardees only)


22

Unknown (330h awardees only)


23

Total Homeless (All health centers report this line)


24

Total School-Based Health Center Patients

(All health centers report this line)


25

Total Veterans (All health centers report this line)


26

Total Patients Served at a Health Center Located In or Immediately

Accessible to a Public Housing Site

(All health centers report this line)










































Table 5: Staffing and Utilization

Reporting Period: January 1, 2019, through December 31, 2019

Shape9 Shape10

Line

Personnel by Major Service Category

FTEs (a)

Clinic Visits (b)

Virtual Visits (b2)

Patients (c)

1

Family Physicians





2

General Practitioners





3

Internists





4

Obstetrician/Gynecologists





5

Pediatricians





7

Other Specialty Physicians





8

Total Physicians (Lines 1–7)





9a

Nurse Practitioners





9b

Physician Assistants





10

Certified Nurse Midwives





10a

Total NPs, PAs, and CNMs (Lines 9a–10)





11

Nurses





12

Other Medical Personnel





13

Laboratory Personnel





14

X-ray Personnel





15

Total Medical (Lines 8 + 10a through 14)





16

Dentists





17

Dental Hygienists





17a

Dental Therapists





18

Other Dental Personnel





19

Total Dental Services (Lines 16–18)





20a

Psychiatrists





20a1

Licensed Clinical Psychologists





20a2

Licensed Clinical Social Workers





20b

Other Licensed Mental Health Providers





20c

Other Mental Health Staff





20

Total Mental Health (Lines 20a–c)





21

Substance Use Disorder Services





22

Other Professional Services (specify )





Shape11 Shape12 Table 5: Staffing and Utilization (continued)

Reporting Period: January 1, 2019, through December 31, 2019

Line

Personnel by Major Service Category

FTEs (a)

Clinic Visits (b)

Virtual Visits (b2)

Patients (c)

22a

Ophthalmologists





22b

Optometrists





22c

Other Vision Care Staff





22d

Total Vision Services (Lines 22a–c)





23

Pharmacy Personnel





24

Case Managers





25

Patient/Community Education Specialists





26

Outreach Workers





27

Transportation Staff





27a

Eligibility Assistance Workers





27b

Interpretation Staff





27c

Community Health Workers





28

Other Enabling Services (specify )





29

Total Enabling Services (Lines 24–28)





29a

Other Programs/Services (specify )





29b

Quality Improvement Staff





30a

Management and Support Staff





30b

Fiscal and Billing Staff





30c

IT Staff





31

Facility Staff





32

Patient Support Staff





33

Total Facility and Non-Clinical Support Staff

(Lines 30a–32)





34

Grand Total (Lines 15+19+20+21+22+22d+23+29+29a+29b+33)





Shape13 Table 5: Selected Service Detail Addendum

Reporting Period: January 1, 2019, through December 31, 2019

Line

Personnel by Major Service Category: Mental Health Service Detail

Personnel (a1)

Clinic Visits (b)

Virtual Visits (b2)

Patients (c)

20a01

Physicians (other than Psychiatrists)





20a02

Nurse Practitioners





20a03

Physician Assistants





20a04

Certified Nurse Midwives





Line

Personnel by Major Service Category: Substance Use Disorder Detail

Personnel (a1)

Clinic Visits (b)

Virtual Visits (b2)

Patients (c)

21a

Physicians (other than Psychiatrists)





21b

Nurse Practitioners (Medical)





21c

Physician Assistants





21d

Certified Nurse Midwives





21e

Psychiatrists





21f

Licensed Clinical Psychologists





21g

Licensed Clinical Social Workers





21h

Other Licensed Mental Health Providers





Table 6A: Selected Diagnoses and Services Rendered

Reporting Period: January 1, 2019, through December 31, 2019


Shape14 Shape15


Line


Diagnostic Category


Applicable ICD-10-CM Code

Number of Visits by Diagnosis Regardless of

Primacy (a)

Number of Patients with Diagnosis (b)

Selected Infectious and Parasitic Diseases

1-2

Symptomatic/Asymptomatic human immunodeficiency virus

(HIV)

B20, B97.35, O98.7-, Z21



2a

Pre-Exposure Prophylaxis (PrEP) Prescription


Through possible exposure risk at encounters:

Z20.2, Z11.4, Z11.3, Z20.6, Z72.5, Z72.51, Z72.52, Z72.53, Z11.59, Z20.5, Z71.7, F19.20, Z70.1, Z20.82, Z77.21, Z77.9, W46, W46.0, W46.1

Through possible counseling during initiation or continuation:

(CPT codes) 99201-99205, 99211-99215, 99401-99404, 99411, 99412

Through possible lab codes during initiation or surveillance:

(CPT codes) 86689, 86701-86703, 87534-87539, 87389-87391, G0432, G0433, G0435

Z01.812, Z51.81, Z79.899, Z86.59, Z87.898, F11.20, F11.21, F11.10, F11.90

Through codes associated with possible PrEP prescribing:

Z79.899 and (RXNorm codes) Truvada 495430, Descovy 1747692, TDF 322248, FTC 276237, TAF 1721604



3

Tuberculosis

A15- through A19-, O98.0-



4

Sexually transmitted infections

A50- through A64- (exclude A63.0)



4a

Hepatitis B

B16.0 through B16.2, B16.9, B17.0, B18.0, B18.1, B19.10,

B19.11, O98.4-



4b

Hepatitis C

B17.10, B17.11, B18.2, B19.20, B19.21



Selected Diseases of the Respiratory System

5

Asthma

J45-



6

Chronic lower respiratory diseases

J40- through J44-, J47-



Selected Other Medical Conditions

7

Abnormal breast findings,

C50.01-, C50.11-, C50.21-,




female

C50.31-, C50.41-, C50.51-,



C50.61-, C50.81-, C50.91-,



C79.81, D05-, D48.6-, D49.3, N60-



, N63-, R92-

8

Abnormal cervical findings

C53-, C79.82, D06-, R87.61-, R87.629, R87.810, R87.820




Table 6A: Selected Diagnoses


























Selected Diseases of the Respiratory System




















































Selected Other Medical





















Shape16 Shape17


Line


Diagnostic Category


Applicable ICD-10-CM Code

Number of Visits by Diagnosis Regardless of

Primacy (a)

Number of Patients with Diagnosis (b)

9

Diabetes mellitus

E08- through E13-, O24- (exclude O24.41-)



10

Heart disease (selected)

I01-, I02- (exclude I02.9), I20- through I25-, I27-, I28-, I30-

through I52-



11

Hypertension

I10- through I16-, O10-, O11-



12

Contact dermatitis and other eczema

L23- through L25-, L30- (exclude L30.1, L30.3, L30.4, L30.5), L58-



13

Dehydration

E86-



14

Exposure to heat or cold

T33-, T34-, T67-, T68-, T69-, W92-, W93-



14a

Overweight and obesity

E66-, Z68- (exclude Z68.1, Z68.20

through Z68.24, Z68.51, Z68.52)



Selected Childhood

Conditions (limited to ages 0 through 17)

15

Otitis media and Eustachian

tube disorders

H65- through H69-



16

Selected perinatal/neonatal medical conditions

A33-, P19-, P22- through P29-

(exclude P29.3), P35- through P96- (exclude P54-, P91.6-, P92-, P96.81), R78.81, R78.89



17

Lack of expected normal physiological development (such as delayed milestone, failure to gain weight, failure to thrive); nutritional deficiencies in children only. Does not include sexual or mental

development.

E40- through E46-, E50- through E63-, P92-, R62- (exclude R62.7), R63.3



Selected Mental Health Conditions and Substance Use Disorders

18

Alcohol-related disorders

F10-, G62.1, O99.31-



19

Other substance-related disorders (excluding tobacco

use disorders)

F11- through F19- (exclude F17-), G62.0, O99.32-



19a

Tobacco use disorder

F17-, O99.33-



20a

Depression and other mood disorders

F30- through F39-



20b

Anxiety disorders, including

post-traumatic stress disorder (PTSD)

F06.4, F40- through F42-, F43.0, F43.1-, F93.0



20c

Attention deficit and disruptive behavior disorders

F90- through F91-




Selected Childhood Conditions






















































































Selected Mental Health and Substance Abuse Conditions

Shape18


Line


Diagnostic Category


Applicable ICD-10-CM Code

Number of Visits by Diagnosis Regardless of

Primacy (a)

Number of Patients with Diagnosis (b)

20d

Other mental disorders, excluding drug or alcohol dependence

F01- through F09- (exclude F06.4), F20- through F29-, F43- through F48- (exclude F43.0- and F43.1-), F50- through F99- (exclude F55-, F84.2, F90-, F91-, F93.0, F98-),

O99.34-, R45.1, R45.2, R45.5,

R45.6, R45.7, R45.81, R45.82, R48.0



20e

Human Trafficking

T74.5- through T74.6-, T76.5-

through T76.6-, Z04.8-, Z62.813, Z91.42



20f

Intimate Partner Violence

T74.11, T74.21, T74.31, Z69.11,

Y07.0



Shape19

Line

Service Category

Applicable ICD-10-CM Code or CPT-4/II Code

Number of Visits (a)

Number of Patients (b)

Selected Diagnostic Tests/

Screening/Preventive Services

21

HIV test

CPT-4: 86689, 86701 through

86703, 87389 through 87391,

87534 through 87539, 87806



21a

Hepatitis B test

CPT-4: 86704 through 86707,

87340, 87341, 87350



21b

Hepatitis C test

CPT-4: 86803, 86804, 87520

through 87522



22

Mammogram

CPT-4: 77065, 77066, 77067

OR



ICD-10: Z12.31

23

Pap test

CPT-4: 88141 through 88153,

88155, 88164 through 88167,

88174, 88175 OR

ICD-10: Z01.41-, Z01.42, Z12.4

(exclude Z01.411 and Z01.419)



24

Selected immunizations: hepatitis A; haemophilus influenzae B (HiB); pneumococcal, diphtheria, tetanus, pertussis (DTaP) (DTP) (DT); mumps, measles, rubella (MMR); poliovirus; varicella; hepatitis B

CPT-4: 90632, 90633, 90634,

90636, 90643, 90644, 90645,

90646, 90647, 90648,

90669, 90670, 90696, 90697,

90698, 90700, 90701, 90702,

90703, 90704, 90705, 90706,

90707, 90708, 90710, 90712,

90713, 90714, 90715, 90716,

90718, 90720, 90721, 90723,

90730, 90731, 90732, 90740,

90743, 90744, 90745, 90746,

90747, 90748



24a

Seasonal flu vaccine

CPT-4: 90630, 90653 through

90657, 90658, 90661, 90662,

90672, 90673, 90674, 90682,

90685 through 90689, 90749,

90756



25

Contraceptive management

ICD-10: Z30-



26

Health supervision of infant or child (ages 0 through 11)

CPT-4: 99381 through 99383,

99391 through 99393

ICD-10: Z00.1-



26a

Childhood lead test screening (9 to 72 months)

ICD-10: Z13.88

CPT-4: 83655



26b

Screening, Brief Intervention, and Referral to Treatment

(SBIRT)

CPT-4: 99408, 99409

HCPCS: G0396, G0397, G0443, H0050



26c

Smoke and tobacco use cessation counseling

CPT-4: 99406, 99407 OR

HCPCS: S9075 OR

CPT-II: 4000F, 4001F, 4004F



26d

Comprehensive and intermediate eye exams

CPT-4: 92002, 92004, 92012,

92014




Table 6A: Selected Services Rendered


Selected Diagnostic








Shape20


Line

Service Category

Applicable ADA Code

Number of Visits (a)

Number of Patients (b)

Selected Dental Services

27

Emergency services

ADA: D0140, D9110



28

Oral exams

ADA: D0120, DO145, D0150, D0160, D0170, D0171, D0180



29

Prophylaxis–adult or child

ADA: D1110, D1120



30

Sealants

ADA: D1351



31

Fluoride treatment–adult or child

ADA: D1206, D1208

CPT-4: 99188



32

Restorative services

ADA: D21xx through D29xx



33

Oral surgery (extractions and other surgical procedures)

ADA: D7xxx



34

Rehabilitative services (Endo, Perio, Prostho, Ortho)

ADA: D3xxx, D4xxx, D5xxx, D6xxx, D8xxx



Shape21 Sources of Codes:

  • ICD-10-CM (2019)–National Center for Health Statistics (NCHS)

  • CPT (2019)–American Medical Association (AMA)

  • Code on Dental Procedures and Nomenclature CDT Code (2019)–Dental Procedure Codes. American Dental Association (ADA)


Note: “X” in a code denotes any number including the absence of a number in that place. Dashes (–) in a code indicate that additional characters are required. ICD-10-CM codes all have at least four digits. These codes are not intended to reflect if a code is billable or not. Instead, they are used to point out that other codes in the series are to be considered.

Shape22 Shape23 Table 6B: Quality of Care Measures

Reporting Period: January 1, 2019, through December 31, 2019



0

Prenatal Care Provided by Referral Only (Check if Yes)


Shape24 Section A – Age Categories for Prenatal Care Patients: Demographic Characteristics of Prenatal Care Patients


Line

Age

Number of Patients (a)

1

Less than 15 years


2

Ages 15-19


3

Ages 20-24


4

Ages 25-44


5

Ages 45 and over


6

Total Patients (Sum of Lines 1-5)




Line

Early Entry into Prenatal Care

Women Having First Visit with Health Center (a)

Women Having First Visit with Another Provider (b)

7

First Trimester



8

Second Trimester



9

Third Trimester






Line


Childhood Immunization Status

Total Patients with 2nd Birthday (a)

Number Charts Sampled or EHR Total (b)

Number of Patients Immunized (c)

10

MEASURE: Percentage of children 2 years of age who received age appropriate vaccines by their 2nd

birthday







Line


Cervical Cancer Screening

Total Female Patients

Aged 23 through 64 (a)

Number Charts Sampled or EHR Total (b)


Number of Patients Tested (c)

11

MEASURE: Percentage of women 23-

64 years of age who were screened for cervical cancer





Line


Breast Cancer Screening

Total Female Patients

Aged 50 through 74 (a)

Number Charts Sampled or EHR total (b)


Number of Patients with Mammogram (c)


11a

MEASURE: Percentage of women 50- 74 years of age who had a mammogram to screen for breast

cancer




Section E - Weight Assessment and Counseling for Nutrition and Physical Activity of Children and Adolescents



Line

Weight Assessment and Counseling

for Nutrition and Physical Activity for Children and Adolescents

Total Patients Aged 3 through 17 (a)

Number Charts

Sampled or EHR Total (b)

Number of Patients

with Counseling and BMI Documented (c)

12

MEASURE: Percentage of patients 3– 17 years of age with a BMI percentile and counseling on nutrition and

physical activity documented




Shape25 Section F – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan




Line


Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan


Total Patients Aged 18 and Older (a)


Number Charts Sampled or EHR Total (b)

Number of Patients with BMI Charted and Follow-Up Plan Documented as

Appropriate (c)

13

MEASURE: Percentage of patients 18 years of age and older with (1) BMI documented and (2) follow-up plan

documented if BMI is outside normal parameters




Section G – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention




Line


Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention


Total Patients Aged 18 and Older (a)


Number Charts Sampled or EHR Total (b)

Number of Patients Assessed for Tobacco Use and Provided Intervention if a

Tobacco User (c)

14a

MEASURE: Percentage of patients aged 18 years of age and older who (1) were screened for tobacco use one or more times within 24 months, and (2) if identified to be a tobacco user received cessation counseling

intervention




Shape26 Section H – Use of Appropriate Medications for Asthma



Line

Use of Appropriate Medications for Asthma

Total Patients Aged 5 through 64 with Persistent Asthma

(a)

Number Charts Sampled or EHR Total (b)

Number of Patients with Acceptable Plan (c)


16

MEASURE: Percentage of patients 5 through 64 years of age identified as having persistent asthma and were

appropriately ordered medication




Shape27 Section I - Statin Therapy for the Prevention and Treatment of Cardiovascular Disease




Line


Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Total Patients Aged 21 and Older at High Risk of Cardiovascular

Events (a)


Number Charts Sampled or EHR Total (b)


Number of Patients Prescribed or On Statin Therapy (c)


17a

MEASURE: Percentage of patients 21 years of age and older at high risk of cardiovascular events who were

prescribed or were on statin therapy








Line


Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet

Total Patients Aged 18 and Older with IVD Diagnosis or AMI, CABG, or PCI

Procedure (a)


Number Charts Sampled or EHR Total (b)

Number of Patients with Documentation of Aspirin or Other Antiplatelet Therapy

(c)



18

MEASURE: Percentage of patients 18 years of age and older with a diagnosis of IVD or AMI, CABG, or PCI procedure with aspirin or another

antiplatelet







Line


Colorectal Cancer Screening


Total Patients Aged 50 through 75 (a)

Number Charts Sampled or EHR Total (b)

Number of Patients with Appropriate Screening for

Colorectal Cancer(c)


19

MEASURE: Percentage of patients 50 through 75 years of age who had appropriate screening for colorectal

cancer




Shape28 Shape29 Shape30 Section L - HIV MeasuresLinkage to Care



Line


HIV Linkage to Care

Total Patients First Diagnosed with HIV (a)

Number Charts Sampled or EHR Total (b)

Number of Patients Seen Within 30 Days of First Diagnosis of

HIV (c)




20

MEASURE: Percentage of patients whose first ever HIV diagnosis was made by health center staff between October 1 of the prior year and September 30 of the measurement year and who were seen for follow-up

treatment within 30 days of that first- ever diagnosis





Line


HIV Screening

Total Patients Aged 15 through 65

(a)

Charts Sampled or EHR Total

(b)

Number of Patients Tested for HIV

(c)


20a

MEASURE: Percentage of patients

15-65 years of age who have been tested for HIV within that age range




Shape31 Section M – Preventive Care and Screening: Screening for Depression and Follow-Up PlanDepression Measures




Line


Preventive Care and Screening: Screening for Depression and Follow-Up Plan



Total Patients Aged 12 and Older (a)


Number Charts Sampled or EHR Total (b)

Number of Patients Screened for Depression and Follow-Up Plan Documented as

Appropriate (c)



21

MEASURE: Percentage of patients 12 years of age and older who were (1) screened for depression with a standardized tool and, if screening was positive, (2) had a follow-up plan

documented






Line



Depression Remission at 12 Months

Total Patients Aged 18 and Older with Major Depression or Dysthymia

(a)


Charts Sampled or EHR Total (b)

Number of Patients who Reached Remission

(c)



21a

MEASURE: Percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/-

60 days) after an index event

[blank for]

[blank for demonstration]

[blank for demonstration]

Section N – Dental Sealants for Children between 6–9 Years

Shape32 Shape33

Line

Dental Sealants for Children between 6–9 Years

Total Patients Aged 6 through 9 at Moderate to High Risk for Caries (a)

Number Charts Sampled or EHR Total (b)

Number of Patients with Sealants to First

Molars (c)

22

MEASURE: Percentage of children 6 through 9 years of age at moderate to high risk of caries who received a sealant on a first

permanent molar










Table 7: Health Outcomes and Disparities

Reporting Period: January 1, 2019, through December 31, 2019

Shape34



Line



Race and Ethnicity

Prenatal Care Patients Who Delivered During the Year

(1a)

Live Births:

<1500

grams (1b)

Live Births: 1500–2499

grams (1c)

Live Births:

2500

grams (1d)

Hispanic/Latino

1a

Asian





1b1

Native Hawaiian





1b2

Other Pacific Islander





1c

Black/African American





1d

American Indian/Alaska Native





1e

White





1f

More than One Race





1g

Unreported/Refused to Report Race






Subtotal Hispanic/Latino


Non-Hispanic/Latino

2a

Asian





2b1

Native Hawaiian





2b2

Other Pacific Islander





2c

Black/African American





2d

American Indian/Alaska Native





2e

White





2f

More than One Race





2g

Unreported/Refused to Report Race






Subtotal Non-Hispanic/Latino


Unreported/Refused to Report Race & Ethnicity

h

Unreported/Refused to Report Race and

Ethnicity





i

Total






Section A: Deliveries and Birth Weight

Line

Description

Patients (a)

0

HIV-Positive Pregnant Women


2

Deliveries Performed by Health Center’s Providers







Shape35 <section divider cell>






























































































subtotal






<






























































































Shape36 subtotal





<blank for demonstrati >

Shape37


Line


Race and Ethnicity

Total Patients 18 through 85 Years of Age with Hypertension

(2a)

Number Charts Sampled or EHR Total

(2b)

Patients with Hypertension Controlled

(2c)

Hispanic/Latino

1a

Asian




1b1

Native Hawaiian




1b2

Other Pacific Islander




1c

Black/African American




1d

American Indian/Alaska Native




1e

White




1f

More than One Race




1g

Unreported/Refused to Report Race





Subtotal Hispanic/Latino


Non-Hispanic/Latino

2a

Asian




2b1

Native Hawaiian




2b2

Other Pacific Islander




2c

Black/African American




2d

American Indian/Alaska Native




2e

White




2f

More than One Race




2g

Unreported/Refused to Report Race





Subtotal Non-Hispanic/Latino


Unreported/Refused to Report Race and Ethnicity

h

Unreported/Refused to Report Race and Ethnicity




i

Total





Section B: Controlling High Blood Pressure

















Shape38 subtotal





<blank for demonstration>


















































































































Shape39 subtotal





<blank for demonstration>

Shape40 Shape41


Line


Race and Ethnicity

Total Patients 18 through 75 Years of Age with Diabetes

(3a)

Number Charts Sampled or EHR Total

(3b)

Patients with HbA1c

>9% or No Test During Year

(3f)


Hispanic/Latino




1a

Asian




1b1

Native Hawaiian




1b2

Other Pacific Islander




1c

Black/African American




1d

American Indian/Alaska Native




1e

White




1f

More than One Race




1g

Unreported/Refused to Report Race




Subtotal

Subtotal Hispanic/Latino



Non-Hispanic/Latino




2a

Asian




2b1

Native Hawaiian




2b2

Other Pacific Islander




2c

Black/African American




2d

American Indian/Alaska Native




2e

White




2f

More than One Race




2g

Unreported/Refused to Report Race




Subtotal

Subtotal Non-

Hispanic/Latino



Unreported/Refused to Report Race and Ethnicity




h

Unreported/Refused to Report Race and Ethnicity




i

Total





Section C: Diabetes: Hemoglobin A1c Poor Control































Shape42 <blank for demonstration>





























































































































































































































Table 8A: Financial Costs

Reporting Period: January 1, 2019, through December 31, 2019


















Shape43



Line



Cost Center



Accrued Cost (a)

Allocation of Facility and Non- Clinical Support Services (b)

Total Cost After Allocation of Facility and Non- Clinical Support

Services (c)

Financial Costs of Medical Care

1

Medical Staff




2

Lab and X-ray




3

Medical/Other Direct




4

Total Medical Care Services

(Sum of Lines 1 through 3)





Financial Costs of Other Clinical Services




5

Dental




6

Mental Health




7

Substance Use Disorder




8a

Pharmacy not including pharmaceuticals




8b

Pharmaceuticals




9

Other Professional (Specify: )




9a

Vision




10

Total Other Clinical Services

(Sum of Lines 5 through 9a)




Financial Costs of Enabling and Other Services

11a

Case Management




11b

Transportation




11c

Outreach




11d

Patient and Community Education




11e

Eligibility Assistance




11f

Interpretation Services




11g

Other Enabling Services (Specify: )




11h

Community Health Workers




11

Total Enabling Services Cost

(Sum of Lines 11a through 11h)




12

Other Related Services (Specify: )




12a

Quality Improvement




13

Total Enabling and Other Services

(Sum of Lines 11, 12, and 12a)





[section divide]









































































Shape44 [blank for section divide]




















Shape45

Line

Cost Center

Accrued Cost (a)

Allocation of Facility and Non- Clinical Support Services (b)

Total Cost After Allocation of Facility and Non- Clinical Support

Services (c)

Facility and Non-Clinical Support Services and Totals

14

Facility




15

Non-Clinical Support Services




16

Total Facility and Non-Clinical Support

Services

(Sum of Lines 14 and 15)




17

Total Accrued Costs

(Sum of Lines 4 + 10 + 13 + 16)




18

Value of Donated Facilities, Services, and Supplies (specify: )




19

Total with Donations

(Sum of Lines 17 and 18)




Table 9D: Patient Related Revenue

Shape46 Reporting Period: January 1, 2019, through December 31, 2019





Line




Payer Category



Full Charges This Period (a)



Amount Collected This Period (b)

Retroactive S

tlements, Receip

s, and Paybacks

c)




Allowances (d)




Sliding Fee Discounts (e)



Bad Debt Write Off (f)


Collection of Reconciliation/ Wrap-Around Current Year (c1)


Collection of Reconciliation/ Wrap-Around Previous Years (c2)


Collection of Other Payments: P4P, Risk Pools, etc.

(c3)



Penalty/ Payback (c4)

1

Medicaid Non-Managed Care










2a

Medicaid Managed Care (capitated)










2b

Medicaid Managed Care (fee- for-service)











3

Total Medicaid

(Sum of Lines 1 + 2a + 2b)










4

Medicare Non-Managed Care










5a

Medicare Managed Care (capitated)










5b

Medicare Managed Care (fee- for-service)










6

Total Medicare

(Sum of Lines 4 + 5a + 5b)











7

Other Public, including Non- Medicaid CHIP, Non-Managed

Care











8a

Other Public, including Non- Medicaid CHIP, Managed Care

(capitated)











8b

Other Public, including Non- Medicaid CHIP, Managed Care (fee-for-service)











9

Total Other Public

(Sum of Lines 7 + 8a + 8b)










10

Private Non-Managed Care













Line




Payer Category



Full Charges This Period (a)



Amount Collected This Period (b)

Retroactive S

tlements, Receip

s, and Paybacks

c)




Allowances (d)




Sliding Fee Discounts (e)



Bad Debt Write Off (f)


Collection of Reconciliation/ Wrap-Around Current Year (c1)


Collection of Reconciliation/ Wrap-Around Previous Years (c2)


Collection of Other Payments: P4P, Risk Pools, etc.

(c3)



Penalty/ Payback (c4)

11a

Private Managed Care (capitated)










11b

Private Managed Care (fee-for- service)










12

Total Private

(Sum of Lines 10 + 11a + 11b)










13

Self-pay











14

TOTAL

(Sum of Lines 3 + 6 + 9 + 12 +

13)










Shape48


Table 9E: Other Revenues

Shape49 Shape50 Reporting Period: January 1, 2019, through December 31, 2019


Line

Source

Amount (a)


BPHC Grants (Enter Amount Drawn Down – Consistent with PMS 272)


1a

Migrant Health Center


1b

Community Health Center


1c

Health Care for the Homeless


1e

Public Housing Primary Care


1g

Total Health Center (Sum Lines 1a through 1e)


1k

Capital Development Grants, including School-Based Health Center Capital Grants


1

Total BPHC Grants

(Sum of Lines 1g + 1k)



Other Federal Grants


2

Ryan White Part C HIV Early Intervention


3

Other Federal Grants (specify: )


3a

Medicare and Medicaid EHR Incentive Payments for Eligible Providers


5

Total Other Federal Grants

(Sum of Lines 2–3a)



Non-Federal Grants or Contracts


6

State Government Grants and Contracts (specify: )


6a

State/Local Indigent Care Programs (specify: )


7

Local Government Grants and Contracts (specify: )


8

Foundation/Private Grants and Contracts (specify: )


9

Total Non-Federal Grants and Contracts

(Sum of Lines 6 + 6A + 7 + 8)


10

Other Revenue (non-patient related revenue not reported elsewhere) (specify: )


11

Total Revenue (Sum of Lines 1 + 5 + 9 + 10)




























Appendix D: Health Center Health Information Technology (HIT) Capabilities

Instructions

The HIT Capabilities Form includes a series of questions on HIT capabilities, including EHR interoperability and eligibility for Meaningful Use. The HIT Form must be completed and submitted as part of the UDS submission. The form includes questions about the health center’s implementation of an EHR, certification of systems, and how widely adopted the system is throughout the health center and its providers.

Questions

Shape52 The following questions appear in the EHBs. Complete them before you file the UDS Report. Instructions for the HIT questions are on-screen in EHBs as you complete the form. Respond to each question based on your health center status as of December 31.

  1. Does your center currently have an Electronic Health Record (EHR) system installed and in use?

    1. Yes, installed at all sites and used by all providers

    2. Yes, but only installed at some sites or used by some providers

    3. No

If the health center installed it, indicate if it was in use by December 31, by:

  1. Installed at all sites and used by all providers: For the purposes of this response, “providers” mean all medical providers, including physicians, nurse practitioners, physician assistants, and certified nurse midwives. Although some or all of the dental, mental health, or other providers may also be using the system, as may medical support staff, this is not required to choose response a. For the purposes of this response, “all sites” means all permanent sites where medical providers serve health center medical patients and does not include administrative-only locations, hospitals or nursing homes, mobile vans, or sites used on a seasonal or temporary basis. You may check this option even if a few, newly hired, untrained employees are the only ones not using the system.

  2. Installed at some sites or used by some providers: Select option b if one or more permanent sites did not have the EHR installed, or in use (even if this is planned), or if one or more medical providers (as defined above) do not yet use the system. When determining if all providers have access to the system, the health center should also consider part-time and locum providers who serve clinic patients. Do not select this option if the only medical providers who did not have access were those who were newly hired and still being trained on the system.

  3. Select “no” if no EHR was in use on December 31 even if you had the system installed and training had started.

This question seeks to determine whether the health center installed an EHR by December 31 and, if so, which product is in use, how broad is access to the system, and what features are available and in use. Do not include PMS or other billing systems even though they can often produce much of the UDS data. If the health center purchased an EHR, but has not yet placed it into use, answer “no.”




28

Shape53 If a system is in use (i.e., if a or b has been selected above), indicate it has been certified by the Office of the National Coordinator - Authorized Testing and Certification Bodies.

1a. Is your system certified by the Office of the National Coordinator for Health IT (ONC) Health IT Certification Program?

    1. Yes

    2. No

Shape54 Health centers are to indicate in the blanks the vendor, product name, version number, and ONC-certified health IT product list number. (More information is available at https://chpl.healthit.gov/#/search). If you have more than one EHR (if, for example, you acquired another practice with its own EHR), report the EHR that will be the successor system.

1a1. Vendor

1a2. Product Name 1a3. Version Number

1a4. ONC-certified Health IT Product List Number

1b. Did you switch to your current EHR from a previous system this year?

  1. Yes

  2. No

If “yes, but only at some sites or for some providers” is selected above, a box expands for health centers to identify how many sites have the EHR in use and how many (medical) providers are using it. Please enter the number of sites (as defined above) where the EHR is in use and the number of providers who use the system (at any site). Include part-time and locum medical providers who serve clinic patients. Count a provider who has separate login identities at more than one site as just one provider.

1c. Do you use more than one EHR or data system across your organization?

If yes, what is the reason?

    1. Second EHR/data system is used during transition to primary EHR

    2. Second EHR/data system is specific to one service type (e.g. dental, behavioral health)

    3. Second EHR/data system is used at specific sites with no plan to transition

    4. Shape55 Other (please specify)

How many sites have the EHR system in use?

1d. Is your EHR up to date with the latest software and system patches?How many providers use the EHR system?

1e. When do you plan? to install the EHR system?





29

Shape56 Shape57 With reference to your EHR, BPHC would like to know if your system has each of the specified capabilities that relate to the CMS Meaningful Use criteria for EHRs and if you are using them (more information on Meaningful Use). For each capability, indicate:

a. Yes if your system has this capability and it is being used by your center; b. No if your system does not have the capability or it is not being used; or

  1. Not sure if you do not know if the capability is built in and/or do not know if your center is using it.

Shape58 Select “a” (has the capability and it is being used) if the software can perform the function and some or all of your medical providers are using it. It is not necessary for all providers to be using a specific capability in order to select “a.”

Select “b” or “c” if the capability is not present in the software, if the capability is present but still unused, or if it is not currently in use by any medical providers at your center. Select “b” or “c” only if none of the providers use the function.

  1. Does your center send prescriptions to the pharmacy electronically? (Do not include faxing.) a. Yes

    1. No

    2. Not sure

  1. Does your center use computerized, clinical decision support, such as alerts for drug allergies, checks for drug-drug interactions, reminders for preventive screening tests, or other similar functions?

    1. Yes b. No

c. Not sure

  1. Which ith which of the following key providers/health care settings does your center electronically exchange clinical information with? (Select all that apply)

    1. Hospitals/Emergency rooms

    2. Specialty clinicians

    3. Other primary care providers d. Labs or imaging

c.e. Health information exchange (HIE)

d.f. None of the above

e.g.Other (please describe )

  1. Does your center engage patients through health IT in any of the following ways? (Select all that apply)

    1. Patient portals


30

    1. Kiosks

    2. Secure messaging

    3. Other (please describe )

    4. No, we do not engage patients using HIT

  1. Question removed.

  2. How do you collect data for UDS clinical reporting (Tables 6B and 7)?

    1. Shape59 We use the EHR to extract automated reports

    2. We use the EHR but only to access individual patient charts

    3. We use the EHR in combination with another data analytic system

    4. We do not use the EHR

  3. Question removed.

  4. Question removed.

  5. How does your health center utilize HIT and EHR data beyond direct patient care? (Select all that apply)

    1. Quality improvement

    2. Population health management

    3. Program evaluation

    4. Research

    5. Other (please describe )

    6. We do not utilize HIT or EHR data beyond direct patient care

  6. Does your health center collect data on individual patients’ social risk factors, outside of the data reportable in the UDS?

    1. Yes

    2. No, but we are in planning stages to collect this information

    3. No, we are not planning to collect this information
















31

  1. Shape60 Shape61 Which standardized assessment(s) to collect information on the social determinants of health or social risk factors, if any, do you use? (Select all that apply)

    1. Accountable Health Communities Screening Tools

    2. Upstream Risks Screening Tool and Guide

    3. iHELP

    4. Recommend Social and Behavioral Domains for EHRs

    5. Shape62 Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

    6. Well Child Care, Evaluation, Community Resources, Advocacy Referral, Education (WE CARE)

    7. WellRx

g.h.Health Leads Screening Toolkit

h.i. Other (please describe )

j. We do not use a standardized screener



12a. Please provide the total number of patients that screened positive for the following:

  1. Food insecurity

  2. Housing insecurity

  3. Financial strain

  4. Lack of transportation/access to public transportation



12b. If you do not use a standardized assessment to collect this information, please comment why (Select all that apply)

  1. Have not considered/unfamiliar with assessments

  2. Lack of funding for addressing these unmet social needs of patients c. Lack of training for staff to discuss these issues with patients

d. Inability to include in patient intake and clinical workflow e. Not needed

f. Other (Please specify: )


  1. Does your center integrate a statewide Prescription Drug Monitoring Program (PDMP) database into the health information systems such as Health Information Exchanges,




32

Shape64 electronic health record (EHR) systems, and/or pharmacy dispensing software (PDS) to streamline provider access to controlled substance prescriptions?

    1. Yes b. No

c. Not sure



Shape65












33


Appendix E: Other Data Elements Instructions

Health centers are becoming increasingly diverse

Shape66 and comprehensive in the care and services provided. These questions capture the changing landscape of healthcare centers to include expanded services and delivery systems.

Questions

Report on these data elements as part of your UDS submission. Topics include medication- assisted treatment (MAT), telehealth, and outreach and enrollment assistance. Respond to each question based on your health center status as of December 31.

  1. Medication-Assisted Treatment (MAT) for Opioid Use Disorder

    1. How many physicians, certified nurse practitioners, and physician assistants,1

on-site or with whom the health center has contracts, have obtained a Drug Addiction Treatment Act of 2000 (DATA) waiver to treat opioid use disorder with medications specifically approved by the U.S. Food and Drug Administration (FDA) for that indication?

    1. How many patients received medication- assisted treatment for opioid use disorder from a physician, certified nurse practitioner, or physician assistant, with a DATA waiver working on behalf of the health center?













Shape67

1 With the enactment of the Comprehensive Addiction and Recovery Act of 2016, Public Law 114-198, opioid treatment prescribing privileges have


  1. Did your organization use telemedicine to provide remote clinical care services?

(The term “telehealth” includes “telemedicine” services but encompasses a broader scope of remote healthcare services. Telemedicine is specific to remote clinical services whereas telehealth may include remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services.)

    1. Yes

2a1. Who did you use telemedicine to communicate with? (Select all that apply)

      1. Patients at remote locations from your organization (e.g., home telehealth, satellite locations)

      2. Specialists outside your organization (e.g., specialists at referral centers)

2a2. What telehealth technologies did you use? (Select all that apply)

  1. Real-time telehealth (e.g., live videoconferencing)

  2. Store-and-forward telehealth (e.g., secure email with photos or videos of patient examinations)

  3. Remote patient monitoring

  4. Mobile Health (mHealth)











been extended beyond physicians to include certain qualifying nurse practitioners (NPs) and physician assistants (PAs).


34

2a3. What primary telemedicine services were used at your organization? (Select all that apply)

  1. Primary care

  2. Oral health

  3. Behavioral health: Mental health

  4. Shape68 Behavioral health: Substance use disorder

  5. Dermatology

  6. Chronic conditions

  7. Disaster management

  8. Consumer health education

  9. Provider-to-provider consultation

  10. Radiology

  11. Nutrition and dietary counseling

  12. Other (Please specify:

)

  1. No. If you did not have telemedicine services, please comment why (Select all that apply).

    1. Have not considered/unfamiliar with telehealth service options

    2. Policy barriers (Select all that apply) i.Lack of or limited reimbursement ii.Credentialing, licensing, or

privileging iii.Privacy and security

iv.Other (Please specify:

)

    1. Inadequate broadband/ telecommunication service (Select all that apply)

      1. Cost of service ii.Lack of infrastructure iii.Other (Please specify:

)

    1. Lack of funding for telehealth equipment

    2. Lack of training for telehealth services

    3. Not needed

    4. Other (Please specify:

)

  1. Provide the number of all assists provided during the past year by all trained assisters (e.g., certified application counselor or equivalent) working on behalf of the health center (employees, contractors, or volunteers), regardless of the funding source that is supporting the assisters’ activities. Outreach and enrollment assists are defined as customizable education sessions about affordable health insurance coverage options (one-on-one or small group) and any other assistance provided by a health center assister to facilitate enrollment.

Enter number of assists

Note: Assists do not count as visits on the UDS tables.













35

Appendix F: Workforce Instructions

It is important to understand the current state of health center workforce training and different

staffing models to better support recruitment and retention of health center professionals. This section includes a series of questions on health center workforce.

Shape69 Questions

Report on these data elements as part of your UDS submission. Topics include health professional education/training and satisfaction surveys. Respond to each question based on your health center status as of December 31.

  1. Does your health center provide health professional education/training? Health professional education/training does not include continuing education units.

    1. Yes

    2. No

1a. If yes, which category best describes your health center’s role in the health professional education/training process?

  1. Sponsor2

  2. Training site partner3

  3. Other (please describe )

  1. Please indicate the range of health professional education/training offered at your health center and how many individuals you have trained in each category within the last year.



a. Pre-Graduate/Certificate

b. Post-Graduate Training

Medical

[blank]

[blank]

1. Physicians

[blank for demonstration]

[blank for demonstration]

a. Family Physicians

[blank for demonstration]

[blank for demonstration]

b. General Practitioners

[blank for demonstration]

[blank for demonstration]

c. Internists

[blank for demonstration]

[blank for demonstration]

d. Obstetrician/Gynecologists

[blank for demonstration]

[blank for demonstration]

e. Pediatricians

[blank for demonstration]

[blank for demonstration]

f. Other Specialty Physicians

[blank for demonstration]

[blank for demonstration]

2. Nurse Practitioners

[blank for demonstration]

[blank for demonstration]

3. Physician Assistants

[blank for demonstration]

[blank for demonstration]

4. Certified Nurse Midwives

[blank for demonstration]

[blank for demonstration]

5. Registered Nurses

[blank for demonstration]

[blank for demonstration]

6. Licensed Practical Nurses/ Vocational Nurses

[blank for demonstration]

[blank for demonstration]

7. Medical Assistants

[blank for demonstration]

[blank for demonstration]

Dental

[blank]

[blank]

Shape70

  1. A sponsor hosts a comprehensive health profession education and/or training program, the implementation of which may require partnerships with other entities that deliver focused, time-limited education and/or training (e.g., a teaching health center with a family medicine residency program).

  2. A training site partner delivers focused, time-limited education and/or training to learners in support of a comprehensive curriculum hosted by another health profession education provider (e.g., month-long primary care dentistry experience for dental students).

36



a. Pre-Graduate/Certificate

b. Post-Graduate Training

8. Dentists

[blank for demonstration]

[blank for demonstration]

9. Dental Hygienists

[blank for demonstration]

[blank for demonstration]

10. Dental Therapists

[blank for demonstration]

[blank for demonstration]

Mental Health and Substance Use Disorder

[blank]

[blank]

11. Psychiatrists

[blank for demonstration]

[blank for demonstration]

12. Clinical Psychologists

[blank for demonstration]

[blank for demonstration]

13. Clinical Social Workers

[blank for demonstration]

[blank for demonstration]

14. Professional Counselors

[blank for demonstration]

[blank for demonstration]

15. Marriage and Family Therapists

[blank for demonstration]

[blank for demonstration]

16. Psychiatric Nurse Specialists

[blank for demonstration]

[blank for demonstration]

17. Mental Health Nurse Practitioners

[blank for demonstration]

[blank for demonstration]

18. Mental Health Physician Assistants

[blank for demonstration]

[blank for demonstration]

19. Substance Use Disorder Personnel

[blank for demonstration]

[blank for demonstration]

Vision

[blank]

[blank]

20. Ophthalmologists

[blank for demonstration]

[blank for demonstration]

21. Optometrists

[blank for demonstration]

[blank for demonstration]

Other Professionals

[blank]

[blank]

22. Chiropractors

[blank for demonstration]

[blank for demonstration]

23. Dieticians/Nutritionists

[blank for demonstration]

[blank for demonstration]

24. Pharmacists

[blank for demonstration]

[blank for demonstration]

25. Other (please specify )

[blank for demonstration]

[blank for demonstration]


  1. Shape71 Provide the number of health center staff serving as preceptors at your health center

  2. Provide the number of health center staff (non-preceptors) supporting health center training programs

  3. How often does your health center implement satisfaction surveys for providers?

    1. Monthly

    2. Quarterly

    3. Annually

    4. We do not currently conduct provider satisfaction surveys

    5. Other (please describe )

  4. How often does your health center implement satisfaction surveys for general staff?

    1. Monthly

    2. Quarterly

    3. Annually

    4. We do not currently conduct staff satisfaction surveys

    5. Other (please describe )



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 0915-0193. Public reporting burden for this collection of information is estimated to average xx 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 14N136B, Rockville, Maryland, 20857.

37












Shape72












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