Form 0920-1156 Annual Health Center Perfornce Meure Repting Tool

Form Approved

OMB No. 0920-1156

Exp. xx/xx/xxxx

Annual Health Center Performance Measure Reporting Tool

Public reporting burden of this collection of information is estimated to average 6 hours per response including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-1156).

Health Center Information

Health Center Name: _________________________ Date Completed:________________

Practice Setting Description (e.g., pediatrics, family planning): ____________________

Health Center/Practice Setting ID:____________

Reporting Period: Fiscal Year__________ (e.g., Fiscal Year 2016 is October 2015 to September 2016)

Please complete the following questions for each participating practice settings within your health center. Most items request information for the fourth quarter of the last fiscal year (i.e., July to September) and for the last fiscal year. See the appendix titled ‘Additional Guidance’ at the end of this document for more information on completing Tables 2 and 3.

Operational Changes and Project Activities

1. Please describe operational changes or other activities (e.g., training, quality improvement team meetings) undertaken as part of this project that occurred during the fourth quarter.

Health Care Service Use by 15 to 19 year olds

Table 1. Adolescent Clients, Ages 15-19, by Race/Ethnicity (Unduplicated) Receiving Any Service within the Identified Practice Setting

	Number of Adolescent Clients (Unduplicated) Ages 15 to 19 years old
	Female		Male
	Fourth Quarter	Fiscal Year	Fourth Quarter	Fiscal Year
Hispanic/Latino – All Races1
Black or African American (Non-Hispanic)
White (Non-Hispanic)
Other (Non-Hispanic)
Total

1a. Please describe any increases or decreases in funding or other resources (e.g., staffing) for any type of clinical care (not just sexual and reproductive health care) for 15 to 19 year olds in the past fiscal year and indicate how this effected your practice setting’s ability to serve teens.

Table 2. Receipt of Reproductive or Sexual Health Services by Clients, Ages 15-19 (Unduplicated). See appendix at the end of this document for additional guidance on completing this table.

	Number of Female Clients Ages 15 to 19 Years who Received the Specified Service		Number of Male Clients Ages 15 to 19 Years who Received the Specified Service
	Fourth Quarter	Fiscal Year	Fourth Quarter	Fiscal Year
Received any reproductive or sexual health service
Received STD screening/ counseling/treatment and/or HIV testing/counseling
Screened to determine if sexually active
Sexual health assessment conducted

Table 3 Female Clients, Ages 15-19 Years Old, (Unduplicated) Adopting or Continuing Use of Moderately or Highly Effective Contraception, by Race/Ethnicity

See appendix at the end of this document for additional guidance on completing this table.

	Number of 15-19 Year Old Clients who Adopted or Continued Use (Unduplicated)
Pill, Patch, Ring, or Injectable Contraception (e.g., Depo Provera)	Fourth Quarter	Fiscal Year
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
IUD (e.g., Mirena or Paragard)
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
Contraceptive Implants (e.g., Nexplanon)
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total

Table 3a. Past Quarter Percent Adopting or Continuing Contraception and Percent Adopting or Continuing LARC for Female Clients, Ages 15-19 Years Old (When entering data into web interface, these rates will auto-populate based on data already entered.)

	% Adopted or Continued Contraception2	% Adopted or Continued LARC3
15-19 year old clients

Table 3b. Past Fiscal Year Quarter Percent Adopting or Continuing Contraception and Percent Adopting or Continuing LARC for Female Clients, Ages 15-19, by Race/Ethnicity (When entering data into web interface, these rates will auto-populate based on data already entered.)

	% Adopted or Continued Contraception2	% Adopted or Continued LARC3
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total

Table 4. Confidence in Data Reported.

After reviewing the data collected in Tables 1 through 3, please indicate your level of confidence in the accuracy of each type of data retrieved from your health center’s electronic medical record. Please reflect on the extent to which the data reflects your team’s understanding of the sexual and reproductive health services being provided in your practice setting.

	No Confidence	Low Confidence	Moderate Confidence	High Confidence
Number of clients, ages 15-19
Received any reproductive or sexual health service
Received STD screening/ counseling/treatment and/or HIV testing/counseling
Screened to determine if sexually active
Sexual health assessment conducted
Adopted or Continued Pill, Patch, Ring, or Injectable Contraception (e.g., Depo Provera)
Adopted or Continued IUD (e.g., Mirena or Paragard)
Adopted or Continued Contraceptive Implants (e.g., Nexplanon)

Table 5a. Female Clients, Ages 15-19 Years Old, Provided Contraceptive Implant (e.g., Nexplanon) on the Same Day Requested

Check here if your practice setting does not provide contraceptive implants to 15-19 year old clients or does not provide them on the same day requested and go to Table 5b.

The following data should be collected by reviewing the charts of the last ten 15-19 year olds provided a contraceptive implant during the fiscal year to determine if those clients received the contraceptive implant on the same day that they requested it.

Of the charts reviewed, number of 15-19 year olds provided contraceptive implants (e.g., Nexplanon) on the same day requested
Number of charts reviewed (Typically ten, unless fewer than ten 15-19 year old clients received a contraceptive implant in the last year.)

Table 5b. Female Clients, Ages 15-19 Years Old, Provided IUD (e.g., Mirena or Paragard) on the Same Day Requested

Check here if your practice setting does not provide IUDs to 15-19 year old clients or does not provide them on the same day requested and go to Table 6.

The following data should be collected by reviewing the charts of the last five 15-19 year olds provided an IUD during the fiscal year to determine if those clients received the IUD on the same day that they requested it.

Of the charts reviewed, number of 15-19 year olds provided IUD (e.g., Mirena or Paragard) on the same day requested
Number of charts reviewed (Typically five, unless fewer than five 15-19 year old clients received an IUD)

Linkages

Table 6. Formal and Informal Linkages

Please indicate the total number of formal linkages that your health center has developed with organizations, providers, programs, and/or institutions for the purposes of increasing access to and utilization of contraceptive or reproductive health services among adolescents, as well as the number of new formal and informal linkages obtained during this reporting period). By “formal linkages” we mean written agreements to work with these providers or organizations to enhance access to contraceptive or reproductive health services that your health center provides; by “informal linkages” we mean no written agreement exists.

	# of Formal Linkages to date	# of New Formal Linkages obtained this past fiscal year	# of Informal Linkages to date	# of New Informal Linkages obtained this past fiscal year
Health Center and Health Center
Health Center and Youth Serving Organization
Health Center and other organization (Please specify: ___________________ ___________________ ___________________)

Appendix: Additional Guidance

Table 2 Variables

Received any reproductive or sexual health service

Include the following services:

Provision/Surveillance/Maintenance of contraceptive methods (same codes as for Table 3, see below)

STD screening/STD treatment/STD counseling/HIV testing /HIV counseling

Pregnancy Testing

Gynecological Exam/Pap Smear

HIV Counseling

Counseling on Sexual Attitude, Behavior and Orientation

STD Prevention Education/Counseling

Provided Emergency Contraception

Provided Condoms-Male and Female

Screened to determine if sexually active and sexual health assessment conducted

Accurately collecting this information will require that additional fields are added to health center partners’ EMRs. Standard, existing codes do not adequately assess for these activities. We recognize that not all health centers are able to modify their EMR. They will not be expected to report this data.

Table 3 Variables

Please de-duplicate data, so that you only report on one form of contraception per patient. If a patient is provided a service related to more than one form of contraception during a reporting period, please only consider the most recent. The one exception is that patients provided a contraceptive implant who later receive oral contraception for management of side effects associated with the implant should be counted as an implant user.

Pill, Patch, Ring, or Injectable Contraception (e.g., Depo Provera)

Number of 15-19 year old female clients who adopted or continued use of pill should be determined using codes for 1) initial prescription and 2) surveillance/prescription refill/management. Adopted or continued use of patch should be determined using codes for prescription. Adopted or continued use of ring should be determined using codes for 1) prescription and 2) surveillance/maintenance. Adopted or continued use of injectable contraception should be determined using codes for 1) initial dose and 2) surveillance/subsequent dose/management.

IUD (e.g., Mirena or ParaGard)

Number of 15-19 year old female clients who adopted or continued use of an IUD should be determined by examining codes for 1) insertion of the IUD, 2) surveillance/management of the IUD, 3) removal and reinsertion of the IUD, and 4) IUD present.

Contraceptive Implants (e.g., Nexplanon)

Number of 15-19 year old female clients who adopted or continued use of a contraceptive implant should be determined by examining codes for 1) insertion/reinsertion of the implant, 2) surveillance/management of the implant, and 3) implant present.

1 Count data for all clients that indicated Hispanic/Latino(a) ethnicity, regardless of race

2 Calculated as the proportion of all unduplicated 15-19 year old female clients who adopted or continued hormonal contraception, contraceptive implants, or IUD out of all 15-19 year old female clients (use data from Table 1 for number of female clients).

3 Calculated as the proportion of all unduplicated 15-19 year old female clients who adopted or continued contraceptive implants or IUD out of al 15-19 year old female clients.

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