| Patients by ZIP Code(PBZC) | |||||
| <BHCMIS ID - Grant Number: Health Center Name, City, State> | |||||
| ZIP Code (a) |
None/Uninsured (b) |
Medicaid / CHIP/ Other Public ( c ) | Medicare (d) |
Private ( e ) |
Total Patients (f) |
| <insert rows in case of more # of ZIP Codes> | |||||
| Other ZIP Codes | |||||
| Unknown Residence | |||||
| Total | 0 | 0 | 0 | 0 | 0 |
| Comments (Max 4000 characters) | |||||
| Table 3A: Patients by Age and by Sex Assigned at Birth | |||
| <BHCMIS ID - Grant Number: Health Center Name, City, State> | |||
| 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 | Ages 85 and over | ||
| 39 | Total Patients (Sum of Lines 1-38) | 0 | 0 |
| Comments (Max 4000 characters) | |||
| Table 3B: Demographic Characteristics | ||||||||||
| <BHCMIS ID - Grant Number: Health Center Name, City, State> | ||||||||||
| Patients by Race and Hispanic or Latino/a Ethnicity | ||||||||||
| Line | Patients by Race | Yes, Mexican, Mexican American, Chicano/o (a1) |
Yes, Puerto Rican (a2) |
Yes, Cuban (a3) |
Yes, Another Hispanic, Latino/a or Spanish origin (a4) |
Total Hispanic, Latino/a, or Spanish origin (a) (Sum Columns a1+a2+a3+a4) |
Not Hispanic, Latino/a, or Spanish origin (b) |
Unreported/ Choose Not to Disclose Ethnicity (c) |
Total (d) (Sum Columns a+b+c) |
|
| 1a | Asian Indian | |||||||||
| 1b | Chinese | |||||||||
| 1c | Filipino | |||||||||
| 1d | Japanese | |||||||||
| 1e | Korean | |||||||||
| 1f | Vietnamese | |||||||||
| 1g | Other Asian | |||||||||
| 1 | Total Asian (Sum Lines 1a+1b+1c+1d+1e+1f+1g) |
|||||||||
| 2a | Native Hawaiian |
|||||||||
| 2b | Other Pacific Islander | |||||||||
| 2c | Guamanian or Chamorro | |||||||||
| 2d | Samoan | |||||||||
| 2 | Total Native Hawaiian/Other Pacific Islander (Sum Lines 2a + 2b+2c+2d) |
|||||||||
| 3 | Black/African American | |||||||||
| 4 | American Indian/Alaska Native | |||||||||
| 5 | White | |||||||||
| 6 | More than one race | |||||||||
| 7 | Unreported/Choose not to disclose race | |||||||||
| 8 | Total Patients (Sum of Lines 1 + 2 + 3 to 7) |
|||||||||
| 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) | Patients by Gender Identity | Number (a) | ||||||
| 13 | Lesbian or Gay | Male | ||||||||
| 14 | Heterosexual (or straight) | Female | ||||||||
| 15 | Bisexual | Transgender Man/Transgender Male/Transmasculine | ||||||||
| 16 | Something else | Transgender Woman/Transgender Female/Transfeminine | ||||||||
| 17 | Don't know | Other | ||||||||
| 18 | Chose not to disclose | Chose not to disclose | ||||||||
| 18a | Unknown | Unknown | ||||||||
| 19 | Total Patients (Sum of Lines 13 to 18a) |
Total Patients (Sum of Lines 20 to 25a) |
||||||||
| Comments (Max 4000 characters) | ||||||||||
| Table 4: Selected Patient Characteristics | |||||||
| <BHCMIS ID - Grant Number: Health Center Name, City, State> | |||||||
| Line | Characteristic | Number of Patients (a) |
|||||
| Income as Percent of Poverty Guideline | |||||||
| 1 | 100% and below | ||||||
| 2 | 101 - 150% | ||||||
| 3 | 151 - 200% | ||||||
| 4 | Over 200% | ||||||
| 5 | Unknown | ||||||
| 6 | Total (Sum of Lines 1-5) | ||||||
| Primary 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 (Sum lines 8a+8b) | 0 | 0 | ||||
| 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 (Sum lines 10a+10b) | 0 | 0 | ||||
| 11 | Private Insurance | ||||||
| 12 | Total (Sum of Lines 7+8+9+10+11) | ||||||
| Managed Care Utilization | |||||||
| S.No | 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) | 0 | 0 | 0 | 0 | 0 | |
| S.No | 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 Service Site 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) | ||||||
| Comments (Max 4000 characters) | |||||||
| Table 6B: Quality of Care Measures | |||||||||||||||||||||||||
| <BHCMIS ID - Grant Number: Health Center Name, City, State> | |||||||||||||||||||||||||
| 0 | Prenatal Care Provided by Referral Only? (Indicate Yes or No) | ||||||||||||||||||||||||
| Section A—Age Categories for Prenatal 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) | ||||||||||||||||||||||||
| Section B—Early Entry into Prenatal Care | |||||||||||||||||||||||||
| Line | Early Entry into Prenatal Care | Patients Having First Visit with Health Center (a) |
Patients Having First Visit with Another Provider (b) | ||||||||||||||||||||||
| 7 | First Trimester | ||||||||||||||||||||||||
| 8 | Second Trimester | ||||||||||||||||||||||||
| 9 | Third Trimester | ||||||||||||||||||||||||
| Section C—Childhood Immunization Status | |||||||||||||||||||||||||
| Line | Childhood Immunization Status | Total Patients with 2nd Birthday (a) | Number of Records Reviewed (b) | Number of Patients Immunized (c) | |||||||||||||||||||||
| 10 | MEASURE: Percentage of children 2 years of age who received ageappropriate vaccines by their 2nd birthday |
||||||||||||||||||||||||
| Section D—Cervical and Breast Cancer Screening | |||||||||||||||||||||||||
| Line | Cervical Cancer Screening | Total Female Patients Aged 23 through 64 (a) |
Number of Records Reviewed (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 51 through 73 (a) |
Number of Records Reviewed (b) | Number of Patients with Mammogram (c) | |||||||||||||||||||||
| 11a | MEASURE: Percentage of women 51–73 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/Adolescents | Total Patients Aged 3 through 16 (a) | Number of Records Reviewed (b) | Number of Patients with Counseling and BMI Documented (c) | |||||||||||||||||||||
| 12 | MEASURE: Percentage of patients 3–16 years of age with a BMI percentile and counseling on nutrition and physical activity documented |
||||||||||||||||||||||||
| 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 of Records Reviewed (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 of Records Reviewed (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 during the measurement period, and (2) if identified to be a tobacco user received cessation counseling intervention |
||||||||||||||||||||||||
| Section H—Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | |||||||||||||||||||||||||
| Line | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | Total Patients High Risk of Cardiovascular Events (a) | Number of Records Reviewed (b) | Number of Patients with Acceptable Plan (c) | |||||||||||||||||||||
| 17a | MEASURE: Percentage of patients at high risk of cardiovascular events who were prescribed or were on statin therapy |
||||||||||||||||||||||||
| Section I—Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet | |||||||||||||||||||||||||
| Line | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet | Total Patients 18 and Older with IVD Diagnosis or AMI, CABG, or PCI Procedure (a) | Number of Records Reviewed (b) | Number of Patients with Documentation of Use of Aspirin or Other Antiplatelet (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 |
||||||||||||||||||||||||
| Section J—Colorectal Cancer Screening | |||||||||||||||||||||||||
| Line | Colorectal Cancer Screening | Total Patients Aged 50 through 74 (a) | Number of Records Reviewed (b) | Number of Patients with Appropriate Screening for Colorectal Cancer (c) | |||||||||||||||||||||
| 19 | MEASURE: Percentage of patients 50 through 74 years of age who had appropriate screening for colorectal cancer |
||||||||||||||||||||||||
| Section K—HIV Measures | |||||||||||||||||||||||||
| Line | HIV Linkage to Care | Total Patients First Diagnosed with HIV (a) | Number of Records Reviewed (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 personnel between December 1 of the prior year and November 30 of the measurement period 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) | Number of Records Reviewed (b) | Number of Patients Tested for HIV (c) | |||||||||||||||||||||
| 20a | MEASURE: Percentage of patients 15 through 65 years of age who were tested for HIV when within age range |
||||||||||||||||||||||||
| Section L—Depression Measures | |||||||||||||||||||||||||
| Line | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | Total Patients Aged 12 and Older (a) | Number of Records Reviewed (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 documente |
||||||||||||||||||||||||
| Line | Depression Remission at Twelve Months | Total Patients Aged 12 and Older with Major Depression or Dysthymia (a) | Number of Records Reviewed (b) | Number of Patients who Reached Remission (c) | |||||||||||||||||||||
| 21a | MEASURE: Percentage of patients 12 years of age and older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event |
||||||||||||||||||||||||
| Section M—Dental Sealants for Children between 6–9 Years | |||||||||||||||||||||||||
| Line | Dental Sealants for Children between 6-9 Years | Total Patients Aged 6 through 9 at Moderate to High Risk for Caries (a) | Number of Records Reviewed (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 |
||||||||||||||||||||||||
| Comments (Max 4000 characters) | |||||||||||||||||||||||||
| Section A: Deliveries and Birth Weight | |||||
| Line | Description | Patients (a) | |||
| 0 | HIV-Positive Pregnant Patients | <blank for demonstration> | |||
| 2 | Deliveries Performed by Health Center’s Providers | <blank for demonstration> | |||
| Line | Race and Ethnicity | Prenatal Care Patients Who Delivered During the Year | Live Births: | Live Births: | Live Births: |
| (1a) | <1500 grams | 1500–2499 grams | ≥2500 grams | ||
| (1b) | (1c) | (1d) | |||
| <section divider cell> | Mexican, Mexican American, Chicano/a | <section divider cell> | <section divider cell> | <section divider cell> | <section divider cell> |
| 1a1m | Asian Indian | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1a2m | Chinese | ||||
| 1a3m | Filipino | ||||
| 1a4m | Japanese | ||||
| 1a5m | Korean | ||||
| 1a6m | Vietnamese | ||||
| 1a7m | Other Asian | ||||
| 1b1m | Native Hawaiian | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1b2m | Other Pacific Islander | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1b3m | Guamanian or Chamorro | ||||
| 1b4m | Samoan | ||||
| 1cm | Black/African American | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1dm | American Indian/Alaska Native | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1em | White | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1fm | More than One Race | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1gm | Unreported/Chose Not to Disclose Race | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| subtotal | Subtotal Mexican, Mexican American, Chicano/a | <cell not reported> | <cell not reported> | <cell not reported> | <cell not reported> |
| <blank for demonstration> | Puerto Rican | <section divider cell> | <section divider cell> | <section divider cell> | <section divider cell> |
| 1a1p | Asian Indian | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1a2p | Chinese | ||||
| 1a3p | Filipino | ||||
| 1a4p | Japanese | ||||
| 1a5p | Korean | ||||
| 1a6p | Vietnamese | ||||
| 1a7p | Other Asian | ||||
| 1b1p | Native Hawaiian | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1b2p | Other Pacific Islander | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1b3p | Guamanian or Chamorro | ||||
| 1b4p | Samoan | ||||
| 1cp | Black/African American | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1dp | American Indian/Alaska Native | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1ep | White | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1fp | More than One Race | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1gp | Unreported/Chose Not to Disclose Race | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| Subtotal | Subtotal Puerto Rican | <cell not reported> | <cell not reported> | <cell not reported> | <cell not reported> |
| <blank for demonstration> | Cuban | <section divider cell> | <section divider cell> | <section divider cell> | <section divider cell> |
| 1a1c | Asian Indian | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1a2c | Chinese | ||||
| 1a3c | Filipino | ||||
| 1a4c | Japanese | ||||
| 1a5c | Korean | ||||
| 1a6c | Vietnamese | ||||
| 1a7c | Other Asian | ||||
| 1b1c | Native Hawaiian | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1b2c | Other Pacific Islander | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1b3c | Guamanian or Chamorro | ||||
| 1b4c | Samoan | ||||
| 1cc | Black/African American | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1dc | American Indian/Alaska Native | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1ec | White | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1fc | More than One Race | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1gc | Unreported/Chose Not to Disclose Race | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| Subtotal | Subtotal Cuban | <cell not reported> | <cell not reported> | <cell not reported> | <cell not reported> |
| <blank for demonstration> | Another Hispanic, Latino/a, or Spanish Origin | <section divider cell> | <section divider cell> | <section divider cell> | <section divider cell> |
| 1a1a | Asian Indian | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1a2a | Chinese | ||||
| 1a3a | Filipino | ||||
| 1a4a | Japanese | ||||
| 1a5a | Korean | ||||
| 1a6a | Vietnamese | ||||
| 1a7a | Other Asian | ||||
| 1b1a | Native Hawaiian | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1b2a | Other Pacific Islander | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1b3a | Guamanian or Chamorro | ||||
| 1b4a | Samoan | ||||
| 1ca | Black/African American | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1da | American Indian/Alaska Native | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1ea | White | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1fa | More than One Race | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 1ga | Unreported/Chose Not to Disclose Race | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| Subtotal | Subtotal Another Hispanic, Latino/a, or Spanish Origin | <cell not reported> | <cell not reported> | <cell not reported> | <cell not reported> |
| Subtotal | Subtotal Total Hispanic, Latino/a, or Spanish Origin | <cell not reported> | <cell not reported> | <cell not reported> | <cell not reported> |
| <blank for demonstration> | Not Hispanic, Latino/a, or Spanish Origin | <section divider cell> | <section divider cell> | <section divider cell> | <section divider cell> |
| 2a1 | Asian Indian | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 2a2 | Chinese | ||||
| 2a3 | Filipino | ||||
| 2a4 | Japanese | ||||
| 2a5 | Korean | ||||
| 2a6 | Vietnamese | ||||
| 2a7 | Other Asian | ||||
| 2b1 | Native Hawaiian | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 2b2 | Other Pacific Islander | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 2b3 | Guamanian or Chamorro | ||||
| 2b4 | Samoan | ||||
| 2c | Black/African American | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 2d | American Indian/Alaska Native | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 2e | White | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 2f | More than One Race | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| 2g | Unreported/Chose Not to Disclose Race | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| Subtotal | Subtotal Total Not Hispanic, Latino/a, or Spanish Origin | <cell not reported> | <cell not reported> | <cell not reported> | <cell not reported> |
| <blank for demonstration> | Unreported/Chose Not to Disclose Race and Ethnicity | <section divider cell> | <section divider cell> | <section divider cell> | <section divider cell> |
| h | Unreported/Chose Not to Disclose Race and Ethnicity | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> | <blank for demonstration> |
| i | Total | <cell not reported> | <cell not reported> | <cell not reported> | <cell not reported> |
| Table 8A: Financial Costs | ||||
| <BHCMIS ID - Grant Number: Health Center Name, City, State> | ||||
| 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 for Medical Care | ||||
| 1 | Medical Personnel | |||
| 2 | Lab and X-ray | |||
| 3 | Medical/Other Direct | |||
| 4 | Total Medical Care Services (Sum of Lines 1 through 3) |
|||
| Financial Costs for 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 Program Related 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 (Sum of Lines 11a-11h) | |||
| 12 | Other Program-Related Services (specify:___) | |||
| 12a | Quality Improvement | |||
| 13 | Total Enabling and Other Services (Sum of Lines 11, 12, and 12a) |
|||
| 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 Service Revenue | |||||||||||||||||||||||||
| <BHCMIS ID - Grant Number: Health Center Name, City, State> | |||||||||||||||||||||||||
| Line | Payer Category | Full Charges This Period (a) |
Amount Collected This Period (b) |
Retroactive Settlements, Receipts, and Paybacks (c) | Adjustments (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) | ||||||||||||||||||||||||
| 8c | Other Public, including COVID-19 Uninsured Program | ||||||||||||||||||||||||
| 9 | Total Other Public (Sum of Lines 7+8a+8b+8c) | ||||||||||||||||||||||||
| 10 | Private Non-Managed Care | ||||||||||||||||||||||||
| 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) | ||||||||||||||||||||||||
| Comments (Max 4000 characters) | |||||||||||||||||||||||||
| Table 9E: Other Revenues | |||
| <BHCMIS ID - Grant Number: Health Center Name, City, State> | |||
| 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 Service Site Capital Grants | ||
| 1l | Coronavirus Preparedness and Response Supplemental Appropriations Act (H8C) | ||
| 1m | Coronavirus Aid, Relief, and Economic Security Act (CARES) (H8D) | ||
| 1n | Expanding Capacity for Coronavirus Testing (ECT) (H8E and LAL ECT) | ||
| 1o | American Rescue Plan (ARP) (H8F, L2C, C8E) | ||
| 1p | Other COVID-19-Related Funding from BPHC (specify_______) | ||
| 1q | Total COVID-19 Supplemental (Sum of Lines 1l through 1p) | ||
| 1 | Total BPHC Grants (Sum of Lines 1g + 1k + 1q) | ||
| 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 | ||
| 3b | Provider Relief Fund (specify _______) | ||
| 5 | Total Other Federal Grants (Sum of Lines 2 through 3b) | ||
| 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) | 0 | |
| 10 | Other Revenue (non-patient service revenue not reported elsewhere) (specify____) | ||
| 11 | Total Revenue (Sum of Lines 1+5+9+10) | 0 | |
| Comments (Max 4000 characters) | |||
| Appendix E: Other Data Elements | |
| <BHCMIS ID - Grant Number: Health Center Name, City, State> | |
| 1. Medication-Assisted Treatment (MAT) for Opioid Use Disorder | |
| a. How many physicians, certified nurse practitioners, physician assistants, and certified nurse midwives, on-site or with whom the health center has contracts, have 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) (i.e., buprenorphine) for that indication during the calendar year? | |
| b. b. During the calendar year, how many patients received MAT for opioid use disorder from a physician, certified nurse practitioner, physician assistant, or certified nurse midwife with a DATA waiver working on behalf of the health center? | |
| 2. Telemedicine | |
| 2. Did your organization use telemedicine to provide remote (virtual) clinical care services? (Yes or No) | |
| If yes, who did you use telemedicine to communicate with? (Select all that apply.) a. Patients at remote locations from your organization (e.g., home telemedicine, satellite locations) b. Specialists outside your organization (e.g., specialists at referral centers) |
|
| If yes, what telehealth technologies did you use? (Select all that apply.) a. Real-time telehealth (e.g., live video conferencing) b. Store-and-forward medicine (e.g., secure email with photos or videos of patient examinations) c. Remote patient monitoring d. Mobile Health (mHealth) |
|
| If yes, what primary telemedicine services were used at your organization? (Select all that apply.) a. Primary care b. Oral health c. Behavioral health: Mental health d. Behavioral health: Substance use disorder e. Dermatology f. Chronic conditions g. Disaster management h. Consumer health education i. Provider-to-provider consultation j. Radiology k. Nutrition and dietary counseling l. Other (Please describe: __________________________) |
|
| If no, you did not have telemedicine services, please comment why. (Select all that apply.) a.. Have not considered/unfamiliar with telehealth service options b. Policy barriers (Select all that apply) i. Lack of or limited reimbursement ii. Credentialing, licensing, or privileging iii. Privacy and security iv. Other (Please describe: __________________) c. Inadequate broadband/telecommunication service (Select all that apply) i. Cost of service ii. Lack of infrastructure iii. Other (Please describe: __________________) d. Lack of funding for telehealth equipment e. Lack of training for telehealth services f. Not needed g. Other (Please describe: __________________) |
|
| 3. 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 (personnel, contracted personnel, or volunteers), regardless of the funding source that is supporting the assisters’ activities. Outreach and enrollment assists are defined as customizable education sessions about third-party primary care 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. |
|
| Appendix F: Workforce | ||
| <BHCMIS ID - Grant Number: Health Center Name, City, State> | ||
| 1. Does your health center provide any health professional education/training that is hands-on, practical, or clinical experience? | ||
| Indicate Yes or No | ||
| If yes, which category best describes your health center’s role in the health professional education/training process? (Select all that apply.) a. Sponsor b. Training site partner c. Other (please describe ________________) |
||
| 2. 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 calendar year. | ||
| Medical | a. Pre-Graduate/Certificate | b. Post-Graduate Training |
| 1. Physicians | ||
| a. Family Physicians | ||
| b. General Practitioners | ||
| c. Internists | ||
| d. Obstetrician/Gynecologists | ||
| e. Pediatricians | ||
| f. Other Specialty Physicians | ||
| 2. Nurse Practitioners | ||
| 3. Physician Assistants | ||
| 4. Certified Nurse Midwives | ||
| 5. Registered Nurses | ||
| 6. Licensed Practical Nurses/ Vocational Nurses | ||
| 7. Medical Assistants | ||
| Dental | a. Pre-Graduate/Certificate | b. Post-Graduate Training |
| 8. Dentists | ||
| 9. Dental Hygienists | ||
| 10. Dental Therapists | ||
| 10a. Dental Assistants | ||
| Mental Health and Substance Use Disorder | a. Pre-Graduate/Certificate | b. Post-Graduate Training |
| 11. Psychiatrists | ||
| 12. Clinical Psychologists | ||
| 13. Clinical Social Workers | ||
| 14. Professional Counselors | ||
| 15. Marriage and Family Therapists | ||
| 16. Psychiatric Nurse Specialists | ||
| 17. Mental Health Nurse Practitioners | ||
| 18. Mental Health Physician Assistants | ||
| 19. Substance Use Disorder Personnel | ||
| Vision | a. Pre-Graduate/Certificate | b. Post-Graduate Training |
| 20. Ophthalmologists | ||
| 21. Optometrists | ||
| Other Professionals | a. Pre-Graduate/Certificate | b. Post-Graduate Training |
| 22. Chiropractors | ||
| 23. Dieticians/Nutritionists | ||
| 24. Pharmacists | ||
| 25. Other (please describe ________) | ||
| 3. Provide the number of health center personnel serving as preceptors at your health center | ||
| 4. Provide the number of health center personnel (non-preceptors) supporting ongoing health center training programs | ||
| 5. How often does your health center conduct satisfaction surveys to providers (as identified in Appendix A, Listing of Personnel) working for the health center? (Select one.) | ||
| a. Monthly b. Quarterly c. Annually d. We DO NOT currently conduct provider satisfaction surveys e. Other (please describe _________) |
||
| 6. How often does your health center conduct satisfaction surveys for general personnel (as identified in Appendix A, Listing of Personnel) working for the health center (report provider surveys in question 5 only)? (Select one.) | ||
| a. Monthly b. Quarterly c. Annually d. We DO NOT currently conduct personnel satisfaction surveys e. Other (please describe _________) |
||
| Comments (Max 4000 characters) | ||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |