7E Clinical Performance Measures edits

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Clinical 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	Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : Data Source and Methodology Description:
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: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
	Performance Measure		Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c greater than 9.0% during the measurement period.
	Numerator Description		Patients whose most recent HbA1c level performed during the measurement period is > 9.0% or who had no test conducted during the measurement period
	Denominator Description		Only patients 18-75 years of age with a diagnosis of Type 1 or Type 2 diabetes should be included in the denominator of this measure; patients with a diagnosis of secondary diabetes due to another condition should not be included
	Focus Area: Controlling High Blood Pressure
	Performance Measure		Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (less than 140/90mmHg) during the measurement period.
	Numerator Description		Patients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period.
	Denominator Description		Patients 18-85 years of age who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period with a medical visit during the measurement period, excluding patients with evidence of end stage renal disease (ESRD), dialysis, or renal transplant before or during the measurement period; patients who were pregnant during the measurement period; or patients who were in hospice care during the measurement period
	Focus Area: Cervical Cancer Screening
	Performance Measure		Percentage of women 21-64 years of age, who were screened for cervical cancer using either of the following criteria: 1) Women age 21-64 who had cervical cytology performed every three years, or 2) Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every five years
	Numerator Description		Women with one or more screenings for cervical cancer, defined by any one of the following: 1) Cervical cytology performed during the measurement period, or the two years prior to the measurement period, for women who are at least 21 years old at the time of the test, or 2) Cervical cytology/human papillomavirus (HPV) co-testing performed during the measurement period, or the four years prior to the measurement period, for women who are at least 30 years old at the time of the test
	Denominator Description		Women 23-64 years of age with a medical visit during the measurement period, excluding women who had a hysterectomy with no residual cervix, or a congenital absence of cervix, or patients who were in hospice care during the measurement period
	Focus Area: Early Entry into Prenatal Care
	Performance Measure	Percentage of prenatal care patients who entered prenatal care during their first trimester.
	Numerator Description	Women beginning prenatal care at the health center or a referral provider, or with another prenatal provider during their first trimester
	Denominator Description	Women seen for prenatal care during the measurement period.
	Focus Area: Low Birth Weight
	Performance Measure	Percentage of babies of health center prenatal care patients born whose birth weight was below normal (less than 2,500 grams).
	Numerator Description	Babies born with a birth weight of under 2,500 grams.
	Denominator Description	Babies born during the measurement period to prenatal care patients, excluding stillbirths and miscarriages
	Focus Area: Childhood Immunization Status
	Performance Measure	Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.
	Numerator Description	Children who have evidence showing they received recommended vaccines, had documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine by their second birthday.
	Denominator Description	Children who turn 2 years of age during the measurement period and who had a medical visit during the measurement period, excluding patients who were in hospice care during the measurement period
Focus Area: Dental Sealants for Children between 6-9 Years
Performance Measure		Percentage of children, 6-9 years of age, at moderate to high risk for caries who received a sealant on a permanent first molar during the measurement period.
Numerator Description		Children who received a sealant on a permanent first molar tooth during measurement period.
Denominator Description		Children 6- 9 years of age who had an oral assessment or comprehensive or periodic oral evaluation dental visit, and are at moderate to high risk for cares,excepting children for whom all first permanent molars are non-sealable.
	Focus Area: Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
	Performance Measure	Percentage of patients 3-17 years of age who had a medical visit and evidence of height, weight, and BMI percentile documentation, and who had documentation of (1) counseling for nutrition, and (2) counseling for physical activity during the measurement period
	Numerator Description	Patients who had their BMI percentile (not just BMI or height and weight) documented during the measurement period, and who had documentation of (1) counseling for nutrition and (2) counseling for physical activity during the measurement period
	Denominator Description	Patients 3 - 17 years of age with at least one medical visit during the measurement period, excluding patients with a diagnosis of pregnancy or in hospice care during the measurement period
	Focus Area: Body Mass Index (BMI) Screening and Follow-Up Plan
	Performance Measure	Percentage of patients 18 years of age and older with a BMI documented during the most recent visit or within the previous 12 months to that visit, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the visit or during the previous 12 months of that visit
	Numerator Description	Patients with a documented BMI during the most recent visit or during the previous twelve months of that visit, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the visit or during the previous 12 months of the current visit. Normal Parameters: Age 18 years and older with a BMI greater than or equal to 18.5 and less than 25 kg/m2
	Denominator Description	Patients age 18 years of age and older with at least one medical visit during the measurement period, excluding patients who are: pregnant; receiving palliative care; who refuse measurement of height and/or weight or follow-up; patients with a documented medical reason during the visit or within 12 months of the visit; or patients in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
	Focus Area: Tobacco Use: Screening and Cessation Intervention
	Performance Measure	Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation intervention, if identified as a tobacco user.
	Numerator Description	Patients who were screened for tobacco use at least once within 24 months before the end of the measurement period AND who received tobacco cessation intervention if identified as a tobacco user.
	Denominator Description	All patients aged 18 years and older seen for at least two visits or at least one preventive medical visit during the measurement period, excluding documentation of medical reason(s) for not screening for tobacco use OR for not providing tobacco cessation intervention for patients identified as tobacco users
	Focus Area: Use of Appropriate Medications for Asthma
	Performance Measure	Percentage of patients 5-64 years of age with a diagnosis of persistent asthma and who were appropriately prescribed medication during the measurement period.
	Numerator Description	Patients who were ordered at least one prescription for a preferred therapy during the measurement period.
	Denominator Description	Patients 5-64 years of age with persistent asthma and who had at least one medical visit during the measurement period, excluding patients with a diagnosis of emphysema, COPD, obstructive chronic bronchitis, cystic fibrosis, or acute respiratory failure that overlaps the measurement period
	Focus Area: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
	Performance Measure	Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: Adults aged >= 21 years who were previously diagnosed with, or currently have, an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR Adults aged >= 21 years who have ever had a fasting, or direct low-density lipoprotein cholesterol (LDL-C) level, >= 190 mg/dL or were previously diagnosed with, or currently have an active diagnosis of familial or pure hypercholesterolemia; OR Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL
	Numerator Description	Patients who are actively using or who receive an order (prescription) for statin therapy at any point during the measurement period.
	Denominator Description	All patients who meet one or more of the following criteria (considered at high risk for cardiovascular events, under ACC/AHA guidelines): 1) Patients aged >= 21 years at the beginning of the measurement period with clinical ASCVD diagnosis. 2) Patients aged >= 21 years at the beginning of the measurement period who have ever had a fasting, or direct laboratory result of LDL-C, >=190 mg/dL or were previously diagnosed with, or currently have, an active diagnosis of familial or pure hypercholesterolemia. 3) Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with an LDL-C result of 70-189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period. Except Patients who are pregnant, breastfeeding, have a diagnosis of rhabdomyolysis, adverse effect, allergy, or intolerance to statin medication; have active liver disease of hepatic disease or insufficiency, have end stage renal disease, most recent fasting or direct LDL-C laboratory test result < 70 mg/dL and are not taking statin therapy, or receiving palliative care
	Focus Area: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
	Performance Measure	Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and had documentation of use of aspirin or another antiplatelet during the measurement period
	Numerator Description	Patients who had an active medication of aspirin or another antiplatelet during the measurement period
	Denominator Description	Patients 18 years of age and older with a medical visit during the measurement period who had an AMI, CABG, or PCI during the 12 months prior to the measurement year or who had a diagnosis of IVD overlapping the measurement period, excluding patients who had documentation of use of anticoagulant medications overlapping the measurement period, and patients who were in hospice care during the measurement period
	Focus Area: Colorectal Cancer Screening
	Performance Measure	Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.
	Numerator Description	Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria: Fecal occult blood test (FOBT) during the measurement period; Fecal immunochemical test (FIT)-DNA during the measurement period or the two years prior to the measurement period; Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period; CT colonography during the measurement period or the four years prior to the measurement period; or Colonoscopy during the measurement period or the nine years prior to the measurement period
	Denominator Description	Patients 50-75 years of age with a medical visit during the measurement period, excluding patients with a diagnosis or past history of total colectomy or colorectal cancer, or patients who were in hospice care during the measurement period
	Focus Area: HIV Linkage to Care
	Performance Measure	Percentage of patients newly diagnosed with HIV who were seen for follow-up treatment within 90 days of diagnosis
	Numerator Description	Newly diagnosed HIV patients that received treatment within 90 days of diagnosis, including patients who were newly diagnosed by health center providers, and: Had a medical visit with a health center provider who initiates treatment for HIV, or Had a visit with a referral resource who initiates
	Denominator Description	Patients first diagnosed with HIV by the health center between October 1 of the prior year through September 30 of the current measurement year, and who had at least one medical visit during the measurement period or prior year
Focus Area: Screening for Depression and Follow-Up Plan
Performance Measure		Percentage of patients 12 years and older screened for depression on the date of the visit using an age appropriate standardized depression screening tool AND if the screening is positive, a follow-up plan is documented on the date of the positive screening.
Numerator Description		Patients screened for depression on the date of the medical visit using an age appropriate standardized tool AND if positive, a follow-up plan is documented on the date of the positive screening.
Denominator Description		Patients 12 years of age and older with at least one medical visit during the measurement period, excluding patients with an active diagnosis of depression or bipolar disorder; patients who refuse to participate; patients who are in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health status; or situations where the patient's functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools

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