Form 12 Financial Performance Measures - clean

The Health Center Program Application Forms

Financial Performance Measures - clean

Financial Performance Measures

OMB: 0915-0285

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


Financial 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, 2021)


Data Source & Methodology

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: Total Cost Per Total Patient (Costs)

Performance Measure

Ratio of total cost per patient served in the measurement calendar year

Numerator Description


Total accrued cost before donations and after allocation of overhead


Denominator Description



Total number of patients


Focus Area: Medical Cost Per Medical Visit (Costs)

Performance Measure

Ratio of total medical cost per medical visit in the measurement calendar year

Numerator Description


Total accrued medical staff and other medical cost after allocation of overhead, excluding medical lab and x-ray cost


Denominator Description



Medical visits, excluding nurse visits


Focus Area: BPHC Health Center Program Grant Cost Per Total Patient (Grant Costs)

Performance Measure

Ratio of total BPHC section 330 grant funds per patient served in the measurement calendar year

Numerator Description

BPHC section 330 grants drawn-down for the period from January 1 to December 31 of the measurement calendar year

Denominator Description

Total number of patients


Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1.5 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 14N136B, Rockville, Maryland, 20857 or [email protected].



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleClinical Performance Measures
AuthorBeth Hartmayer
File Modified0000-00-00
File Created2021-01-13

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