NHHCIA NCC Clinical Performance Measures

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html


Clinical Performance Measures, Required and Optional Sample
You must track progress over the 3-year period of performance. Starting with the Required Clinical 
Performance Measures Progress Report submitted with the FYXX progress report, add two new rows (as 
seen in red in the table below) to provide numeric data to date and a narrative explanation of progress toward 
the goal. Do not edit any information previously included in the FYXX forms.

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, or patients for whom information on HbA1c is missing.
Denominator Description
Patients 18 through 74 years of age by the end of the measurement period with diabetes with an eligible countable 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 a nursing home any time on or before the end of the measurement period. 
    • Patients aged 66 and older with advanced illness and frailty. 
    • Patients who received palliative care for any part of the measurement period.

Baseline Data 
Baseline Year:  
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress to date
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide a narrative to explain recent data provided in the row above.
Data Source & Methodology 
Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify):   	 
Data 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 essential 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.
Excl 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 for any part of the measurement period.
    • Patients aged 66 or older who were living long-term in a nursing home any time on or before the end of the measurement period.
    • Patients aged 66–80 by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria: advanced illness with one inpatient visit or two outpatient visits, or taking dementia medications during the measurement period or the year prior.
    • Patients aged 81 or older by the end of the measurement period with an indication of frailty for any part of the measurement period.
    • Patients who received palliative care for any part of the measurement period.
Baseline Data 
Baseline Year: 
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress To Date
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide a narrative to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify):   	 
Data 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 To Date
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide a narrative to explain recent data provided in the row above.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify):   	 
Data 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: 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 
have an eligible countable visit during the measurement period.
Exclusions:
    • Children with any of the following on or before their second birthday:
        ◦ Severe combined immunodeficiency
        ◦ Immunodeficiency
        ◦ HIV
        ◦ Lymphoreticular cancer, multiple myeloma, or leukemia
        ◦ Intussusception
    • Children who were in hospice care during the measurement period
Baseline Data 
Baseline Year: 
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress To Date 
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided in the row above. 
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit  [_] Other 
(If Other, please specify):   	 
Data 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 evidence of height, weight, and body mass index (BMI) percentile 
documentation and who had documentation of (1) counseling for nutrition;
and (2) counseling for physical activity.
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 17 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 To Date
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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 during the measurement period prior to that 
visit, and who had a follow-up plan documented if 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 during the most recent visit or during the measurement period, and BMI is within normal parameters, AND

    • Patients with a documented BMI during the most recent visit or during the measurement period, and when the BMI is outside of normal parameters, a follow-up plan is documented during the most recent visit or during the measurement period.
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 for not documenting 
BMI or for not documenting a follow up plan for BMI outside the 
normal parameters.
Baseline Data 
Baseline Year:
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress Since August 1, XXXX
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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: Prevention and Control of Otitis Media 
Performance Measure 
Number of patients under age 18 years with diagnosis of otitis media who 
received medical care during the measurement year
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) during the 
measurement period.
Denominator Description 
Number of visits by patients under 18 years who received medical care 
during the measurement period.
Baseline Data 
Baseline Year: 
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress To Date
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided in the row above.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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 
 


FY26 Native Hawaiian Health Care Improvement Act (NHHCIA)
Non-Competing Continuation (NCC) Progress Report
Native Hawaiian Health Care System (NHHCS) Optional Clinical Performance Measures Sample Progress Report

If optional clinical performance measures were included in the FY24 application, you must track progress over the 3-year period of performance. Starting with the Optional Clinical Performance Measures Forms submitted with the FY25 progress report, add two new rows to provide numeric data showing progress to date and a narrative explanation of progress toward the goal since you last reported optional clinical performance measures in FY25. Do not edit any information previously included in the FY25 forms. If Optional Clinical Performance Measures Forms were not included in your FY25 progress report, do not include any in this submission.

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, a follow-up plan documented on the date of or up to two days after the date of the qualifying 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 screened negative for depression.
• 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 tool and, if screened positive for depression, a follow-up plan is documented on the date of the visit or up to two days after the date of the qualifying 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 at the beginning of the measurement period
with at least one qualifying encounter during the measurement period, as 
specified in the measure criteria.

Exclusions:
• Patients who have been diagnosed with depression or bipolar disorder at any time prior to the qualifying encounter.

Exceptions:
• Patients who refuse to participate in or complete the depression screening.
• Patients who are in urgent or emergent situations where time is of the essence and to delay treatment would jeopardize the patient’s health status.
• Patients with documentation of medical reasons for not screening the 
patient for depression (e.g., cognitive, functional, or motivational 
limitations) that may impact the accuracy of results.
Baseline Data 
Baseline Year:
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress To Date
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided in the row above. 
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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.

Denominator Description 
Patients aged 12 years and older at the start of the measurement period with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9 modified for teens (PHQ-M) score greater than 9 during the index event between 11/01/2023 through 10/31/2024 and had at least one eligible countable visit during the measurement period.
Note: Patients may be screened using PHQ-9 and PHQ-9M on the same date or up to 7 days prior to the visit (index event).
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 
Baseline Data 
Baseline Year:
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress To Date
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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, XXXX
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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 24 (as of December 31), 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 24 through 64 years of age by the end of the measurement period with an eligible countable 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
•Patients who received palliative care for any part of the measurement period
Baseline Data 
Baseline Year: 
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress To Date
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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 12 years and older who were screened for tobacco use one or more times during the measurement period and who received tobacco cessation intervention during the measurement period or in the 6 months prior to the measurement period if identified as a tobacco user.
Target Goal Description 

Numerator Description 
    • Patients who were screened for tobacco use at least once during the measurement period and NOT identified as a tobacco user, and 
    • Patients who were screened for tobacco use at least once during the measurement period and if identified as a tobacco user, received tobacco cessation intervention during the measurement period or during the 6 months prior to the measurement period.

Note: Include in the numerator patients with a negative screening and those with a positive screening who had cessation intervention if a tobacco user.
Denominator Description 
Patients aged 12 years and older at the start of the measurement period seen for at least two qualifying encounters in the measurement period or at least one preventive care qualifying encounter during the measurement period, as specified in the measure criteria
Include patients with birthdate on or before January 1, 201X.
Exclusions:
    • Patients who were in hospice care for any part of the measurement period
Baseline Data 
Baseline Year: 
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress To Date
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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 – all considered at high risk of cardiovascular events-- who were prescribed or were on statin therapy during the measurement period:
• All patients who have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD) or have ever had an ASCVD procedure, or
• Patients 20 years of age or older who have ever had a low-density lipoprotein cholesterol (LDL-C) laboratory result level greater than or equal to 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia, or
• Patients 40 through 75 years of age with a diagnosis of diabetes, or
• Patients 40 through 75 years of age with a 10-year ASCVD risk score greater than or equal to 20 percent
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 
• All patients who have an active diagnosis of ASCVD or have ever had an ASCVD procedure, or
• Patients 20 years of age and older at the start of the measurement period who:
◦ Ever had a 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 hypercholesterolemia, or
• Patients 40 through 75 years of age at the start of the measurement period with type 1 or type 2 diabetes with an eligible countable visit during the measurement period.

Include patients:
◦ of any age for the ASCVD determination.
◦ patients with birthdate on or before January 1, 200X for LDL-C or familial hypercholesterolemia determination; and 
◦ patients with birthdate on or after January 2, 19XX, and birthdate on or before January 1, 19XX for diabetes determination; and
◦ with birthdate on or after January 2, 19XX, and birthdate on or before January 1, 19XX for high 10-year ASCVD risk score.

Exclusions:
• Patients who are breastfeeding at any time during the measurement period.
• Patients who have a diagnosis of rhabdomyolysis at any time during the measurement period.
Exceptions:
• Patients with statin-associated muscle symptoms or an allergy to statin medication.
• Patients who are receiving palliative or hospice care.
• Patients with active liver disease or hepatic disease or insufficiency. 
• Patients with end-stage renal disease (ESRD).
• Patients with documentation of a medical reason for not being prescribed statin therapy.
Baseline Data 
Baseline Year: 
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress Since August 1, XXXX
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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 qualifying encounter 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, as specified in the measure criteria.

◦ Include patients with birthdate on or before January 1, 20XX 

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, XXXX
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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 45*–75 years of age who had appropriate screening for colorectal cancer.

*Use 46 on or after December 31 as the initial age to include in the assessment.
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 46 through 75 years of age by the end of the measurement period with an eligible countable visit during the measurement period.

Include patients with birthdate on or after January 1, 194X, and birthdate on or before December 31, 197X
Exclusions:
• Patients with a diagnosis of colorectal cancer or a past history of total colectomy.
• Patients who were receiving palliative or 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 by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria:
    • advanced illness with one inpatient visit or two outpatient visits during the measurement period or the year prior; or
    • taking dementia medications during the measurement period or the year prior.
Baseline Data 
Baseline Year: 
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress Since August 1, XXXX
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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 52 on or after December 31 as the initial age to include in assessment. See UDS Reporting Considerations for further details.
Target Goal Description 
 
Numerator Description 
Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of the measurement period. 
Denominator Description 
Women 52 through 74 years of age by the end of the measurement period with a qualifying encounter during the measurement period, as specified in the measure criteria. 
Denominator 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 on or before the end of the measurement period. 
• Patients who were in hospice care during the measurement period.
• Patients aged 66 or older by the end of the measurement period who were living long-term in a nursing home any time on or before the end of the measurement period.
• Patients aged 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria: advanced illness diagnosis during the measurement period or the year prior; or dementia medications during the measurement period or the year prior.
• Patients who received palliative care during the measurement period.
Baseline Data 
Baseline Year: 
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress Since August 1, XXXX
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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 eligible countable visit during the measurement period.
Include patients with birthdates on or after January 2, 19XX, and birthdate on or before January 1, 20XX.
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, XXXX
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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 eligible countable visit during the measurement period, as specified in the measure criteria.
Include patients who were diagnosed with HIV for the first time ever by the health center between December 1, 202X, and November 30, 202X, and had at least one medical visit during the measurement period. 
Baseline Data 
Baseline Year: 
Measure Type:  
Numerator:  
Denominator:  
Calculated Baseline:  
Numeric Progress Since August 1, XXXX
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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 eligible oral assessment or comprehensive or periodic oral evaluation qualifying encounter who are at moderate to high risk for caries in the measurement period, as specified in the measurement criteria. 
Exclusions:
    • Not applicable
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, XXXX
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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: 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, XXXX
Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, XXXX
Provide narrative description to explain recent data provided.
Data Source & Methodology
Data Source: [_] EHR [_] Chart Audit [_] Other 
(If Other, please specify):   	 
Data 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) are patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients and adjust fees based on income and family size. 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/202X. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1.5 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857 or [email protected].  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.