3a NHHCIA NCC Clinical Performance Measures

Clinical Performance Measures, Required and Optional Sample

Progress toward all six required performance measure goals must be tracked over the course of the 3-year period of performance. Starting with the Required Clinical Performance Measures Forms submitted with the FY 2021 limited competition application, add two new rows (as seen in red in the table below) to provide numeric data to date and a narrative explanation of progress in relation to the goal. Do not edit any information previously included in the FY 2021 forms.

If optional clinical performance measures were included in the FY 2021 limited competition application, progress toward all measures must be tracked over the course of the 3-year period of performance. Starting with the Optional Clinical Performance Measures Forms submitted with the FY 2021 limited competition application, add two new rows to provide numeric data showing progress to date and a narrative explanation of progress in relation to the goal. Do not edit any information previously included in the FY 2021 forms. If Optional Clinical Performance Measures Forms were not included in the FY 2021 limited competition application, do not include any in this submission.

OMB No.: 0915-0285. Expiration Date: 3/31/2023

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration NATIVE HAWAIIAN HEALTH CARE SYSTEM Required Clinical Performance Measures		FOR HRSA USE ONLY
		Grant Number	Application Tracking Number
1. Focus Area: Diabetes Hemoglobin A1c (HbA1c) Poor Control (> 9 percent)
Performance Measure	Percentage of patients 18–75 years of age with diabetes who had hemoglobin A1c (HbA1c) greater than 9.0 percent during the measurement period.
Target Goal Description
Numerator Description	Patients whose most recent HbA1c level performed during the measurement period was greater than 9.0 percent or patients who had no HbA1c test conducted during the measurement period.
Denominator Description	Patients 18 through 74 years of age with diabetes with a medical visit during the measurement period. Exclusions: • Patients who were in hospice care during the measurement period • Patients aged 66 or older who were living long-term in an institution for more than 90 consecutive days during the measurement period • Patients aged 66 and older with advanced illness and frailty
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
2. Focus Area: Controlling High Blood Pressure
Performance Measure	Percentage of patients 18–85 years of age who had a diagnosis of hypertension overlapping the measurement period or the year prior and whose most recent blood pressure (BP) was adequately controlled (less than 140/90 mmHg) during the measurement period.
Target Goal Description
Numerator Description	Patients whose most recent blood pressure is adequately controlled (systolic blood pressure less than 140 mmHg and diastolic blood pressure less than 90 mmHg) during the measurement period.
Denominator Description	Patients 18 through 84 years of age who had a diagnosis of essential hypertension overlapping the measurement period or the year prior to the measurement period with a medical visit during the measurement period. Exclusions: • Patients with evidence of ESRD, dialysis, or renal transplant before or during the measurement period • Patients with a diagnosis of pregnancy during the measurement period • Patients who were in hospice care during the measurement period • Patients aged 66 or older who were living long-term in an institution for more than 90 consecutive days during the measurement period • Patients aged 66 and older with advanced illness and frailty
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
3. Focus Area: Early Entry Into Prenatal Care
Performance Measure	Percentage of prenatal care patients who entered prenatal care during their first trimester.
Target Goal Description
Numerator Description	Patients who began prenatal care at the health center or with a referral provider or who began care with another prenatal provider, during their first trimester.
Denominator Description	Patients seen for prenatal care during the year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
4. 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 or four 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.
Target Goal Description
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. Exclusions: • Patients who were in hospice care during the measurement period
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
5. 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 an outpatient medical visit and who had evidence of height, weight, and body mass index (BMI) percentile documentation and who had documentation of counseling for nutrition and who had documentation of counseling for physical activity during the measurement period. Note: *Use age 16 as the final age at the start of the measurement period to include in assessment.
Target Goal Description
Numerator Description	Children and adolescents who have had: • Their height, weight, and BMI percentile recorded during the measurement period, and • Counseling for nutrition during the measurement period, and • Counseling for physical activity during the measurement period.
Denominator Description	Patients 3 through 16 years of age with at least one outpatient medical visit during the measurement period. Exclusions: • Patients who have a diagnosis of pregnancy during the measurement period • Patients who were in hospice care during the measurement period
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
6. Focus Area: Body Mass Index (BMI) Screening and Follow-Up Plan
Performance Measure	Percentage of patients aged 18 years and older with BMI documented during the most recent visit or within the previous 12 months to that visit and who had a follow-up plan documented if the most recent BMI was outside of normal parameters. Normal Parameters: Age 18 years and older with a BMI greater than or equal to 18.5 and less than 25 kg/m2.
Target Goal Description
Numerator Description	Patients with: • A documented BMI (not just height and weight) during their most recent visit in the measurement period or during the previous 12 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 Note: Include in the numerator patients within normal parameters who had their BMI documented and those with a follow-up plan if BMI is outside normal parameters.
Denominator Description	Patients 18 years of age or older on the date of their last visit with at least one medical visit during the measurement period. Exclusions: • Patients who are pregnant during the measurement period • Patients receiving palliative or hospice care during or prior to the visit Exceptions: • Patients who refuse measurement of height and/or weight • Patients with a documented medical reason • Patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration NATIVE HAWAIIAN HEALTH CARE SYSTEM Optional Clinical Performance Measures		FOR HRSA USE ONLY
		Grant Number	Application Tracking Number
1. Focus Area: Screening for Depression and Follow-up Plan
Performance Measure	Percentage of patients aged 12 years and older screened for depression on the date of the visit or 14 days prior to the visit using an age-appropriate standardized depression screening tool and, if positive, had a follow-up plan documented on the date of the visit.
Target Goal Description
Numerator Description	Patients who: • Were screened for depression on the date of the visit or up to 14 days prior to the date of the visit using an age-appropriate standardized tool and, • If screened positive for depression, had a follow-up plan documented on the date of the visit. Note: Include in the numerator patients with a negative screening and those with a positive screening who had a follow-up plan documented.
Denominator Description	Patients aged 12 years and older with at least one medical visit during the measurement period. Exclusions: • Patients with an active diagnosis for depression or a diagnosis of bipolar disorder Exceptions: • Patients: - Who refuse to participate - Who are in urgent or emergent situations where time is of the essence and to delay treatment would jeopardize the patient’s health status - Whose cognitive or functional capacity or motivation to improve may impact the accuracy of results of standardized assessment tools
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
2. Focus Area: Depression Remission At 12 Months
Performance Measure	Percentage of patients aged 12 years and older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.
Target Goal Description
Numerator Description	Patients who achieved remission at 12 months as demonstrated by a 12 month (+/- 60 days) PHQ-9 or PHQ-9M score of less than 5. Note: Patients may be screened using PHQ-9 and PHQ-9M up to 7 days prior to the office visit, including the day of the visit.
Denominator Description	Patients aged 12 years and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9 modified for teens score greater than 9 during the index event between 11/01/2019 through 10/31/2020 and had at least one medical visit during the measurement period. Exclusions: • Patients with a diagnosis of bipolar disorder, personality disorder emotionally labile, schizophrenia, psychotic disorder, or pervasive developmental disorder • Patients: - Who died - Who received hospice or palliative care services - Who were permanent nursing home residents
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
3. 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).
Target Goal Description
Numerator Description	Babies born with a birth weight below normal (under 2,500 grams).
Denominator Description	Babies born during measurement period to prenatal care patients. Exclusions: • Still-births or miscarriages
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
4. 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: • Women age 21*–64 who had cervical cytology performed within the last 3 years • Women age 30–64 who had human papillomavirus (HPV) testing performed within the last 5 years Note: *Use 23 as the initial age to include in assessment.
Target Goal Description
Numerator Description	Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria: • Cervical cytology performed during the measurement period or the 2 years prior to the measurement period for women who are at least 21 years old at the time of the test. • Cervical HPV testing performed during the measurement period or the 4 years prior to the measurement period for women who are 30 years or older at the time of the test.
Denominator Description	Women 23 through 64 years of age with a medical visit during the measurement period. Exclusions: • Women who had a hysterectomy with no residual cervix or a congenital absence of cervix • Women who were in hospice care during the measurement period
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
5. 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 12 months and who received cessation intervention, if identified as a tobacco user.
Target Goal Description
Numerator Description	Patients who were screened for tobacco use at least once within 12 months before the end of the measurement period and who received tobacco cessation intervention, if identified as a tobacco user. Note: Include patients with a negative screening and those with a positive screening who had cessation intervention if a tobacco user.
Denominator Description	Patients aged 18 years and older seen for at least two medical visits in the measurement period or at least one preventive medical visit during the measurement period. Exceptions: • Documentation of medical reason(s) for not screening for tobacco use or for not providing tobacco cessation intervention (e.g., limited life expectancy, other medical reason)
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
6. Focus Area: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Performance Measure	Percentage of the following patients at high risk of cardiovascular events aged 21 years and older who were prescribed or were on statin therapy during the measurement period: • Patients 21 years of age or older who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), or • Patients 21 years of age or older who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level greater than or equal to 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia, or • Patients 40 through 75 years of age with a diagnosis of diabetes with a fasting or direct LDL-C level of 70–189 mg/dL
Target Goal Description
Numerator Description	Patients who are actively using or who received an order (prescription) for statin therapy at any point during the measurement period.
Denominator Description	Patients 21 years of age and older who: Have an active diagnosis of ASCVD, or Ever had a fasting or direct laboratory result of LDL-C greater than or equal to 190 mg/dL, or Were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia, or Patients 40 through 75 years of age 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 calendar year or the 2 years prior; with a medical visit during the measurement period. Exclusions: • Patients who have a diagnosis of pregnancy • Patients who are breastfeeding • Patients who have a diagnosis of rhabdomyolysis Exceptions: • Patients with adverse effect, allergy, or intolerance to statin medication • Patients who are receiving palliative care • Patients with active liver disease or hepatic disease or insufficiency • Patients with end-stage renal disease (ESRD) • Patients 40 through 75 years of age with diabetes whose most recent fasting or direct LDL-C laboratory test result was less than 70 mg/dL and who are not taking statin therapy
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
7. Focus Area: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
Performance Measure	Percentage of patients aged 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), or who had a coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCIs) in the 12 months prior to the measurement period, or who had an active diagnosis of IVD during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period.
Target Goal Description
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 period or who had a diagnosis of IVD overlapping the measurement period. Exclusions: • Patients who had documentation of use of anticoagulant medications overlapping the measurement period • Patients who were in hospice care during the measurement period
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
8. Focus Area: Colorectal Cancer Screening
Performance Measure	Percentage of adults 50–75 years of age who had appropriate screening for colorectal cancer.
Target Goal Description
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)-deoxyribonucleic acid (DNA) during the measurement period or the 2 years prior to the measurement period •Flexible sigmoidoscopy during the measurement period or the 4 years prior to the measurement period •Computerized tomography (CT) colonography during the measurement period or the 4 years prior to the measurement period •Colonoscopy during the measurement period or the 9 years prior to the measurement period
Denominator Description	Patients 50 through 74 years of age with a medical visit during the measurement period. Exclusions: • Patients with a diagnosis of colorectal cancer or a history of total colectomy • Patients who were in hospice care during the measurement period • Patients aged 66 or older who were living long-term in an institution for more than 90 days during the measurement period • Patients aged 66 and older with advanced illness and frailty
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
9. Focus Area: Breast Cancer Screening
Performance Measure	Percentage of women 50*–74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period. Note: *Use 51 as the initial age to include in assessment.
Target Goal Description
Numerator Description	Women with one or more mammograms during the 27 months prior to the end of the measurement period.
Denominator Description	Women 51 through 73 years of age with a medical visit during the measurement period. Exclusions: • Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy • Patients who were in hospice care during the measurement period • Patients aged 66 or older who were living long-term in an institution for more than 90 days during the measurement period • Patients aged 66 and older with advanced illness and frailty
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
10. Focus Area: HIV Screening
Performance Measure	Percentage of patients aged 15–65 at the start of the measurement period who were between 15–65 years old when tested for HIV.
Target Goal Description
Numerator Description	Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday.
Denominator Description	Patients aged 15 through 65 years of age at the start of the measurement period and with at least one outpatient medical visit during the measurement period. Exclusions: • Patients diagnosed with HIV prior to the start of the measurement period
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
11. Focus Area: HIV Linkage to Care
Performance Measure	Percentage of patients newly diagnosed with HIV who were seen for follow-up treatment within 30 days of diagnosis.
Target Goal Description
Numerator Description	Newly diagnosed HIV patients that received treatment within 30 days of diagnosis. Include patients who were newly diagnosed by your health center providers and: • Had a medical visit with your health center provider who initiates treatment for HIV, or • Had a visit with a referral resource who initiates treatment for HIV.
Denominator Description	Patients first diagnosed with HIV by the health center between December 1 of the prior year through November 30 of the current measurement period and who had at least one medical visit during the measurement period or prior year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
12. Focus Area: Dental Sealants for Children Between 6-9 Years
Performance Measure	Percentage of children, age 6–9 years, at moderate to high risk for caries who received a sealant on a first permanent molar during the measurement period.
Target Goal Description
Numerator Description	Children who received a sealant on a permanent first molar tooth during the measurement period.
Denominator Description	Children 6 through 9 years of age with an oral assessment or comprehensive or periodic oral evaluation dental visit who are at moderate to high risk for caries in the measurement period. Exceptions: • Children for whom all first permanent molars are non-sealable (i.e., molars are either decayed, filled, currently sealed, or un-erupted/missing)
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
13. Focus Area: Prevention and Control of Otitis Media
Performance Measure	Number of patients under age 18 years with diagnosis of otitis media.
Target Goal Description
Numerator Description	Number of visits by patients under age 18 years with diagnosis of otitis media (any mention of ICD-9-CM codes 3810-3814, 382).
Denominator Description	Number of visits by patients under age 18 years who received medical care during the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
14. Focus Area: Traditional Healing
Performance Measure	Health System determines the performance measure
Target Goal Description	Health System determines the information/data provided
Numerator Description	Health System determines the information/data provided
Denominator Description	Health System determines the information/data provided
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
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:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments

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 3/31/2023. 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 hour 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].

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