Form 17 Clinical Performance Measures (track changes)

OMB No.: 0915-0285     Expiration Date: 10/31/2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

CLINICAL PERFORMANCE MEASURES

FOR HRSA USE ONLY

Grant Number

Application Tracking Number

Project Period Date

Focus Area: Diabetes: Hemoglobin A1c Poor Control

Performance Measure: Percentage diabetic of patients 18-75 years of age with diabetes who had hemoglobin A1c greater than 9.0% during the measurement periodwhose HbA1c levels are less than 7 percent, less than 8 percent, less than or equal to 9 percent, or greater than 9 percent.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Patients whose most recent HbA1c level (performed during the measurement period) is greater than 9.0%.Number of adult patients age 18 to 75 years with a diagnosis of Type 1 or Type 2 diabetes whose most recent HbA1c level during the measurement year is <7%, <8%, <=9%, or >9%, among those patients in the denominator.
Denominator Description	Patients 18-75 years of age with diabetes with a visit during the measurement period.Number of adult patients age 18 to 75 years as of December 31 of the measurement year with a diagnosis of Type 1 or Type 2 diabetes, who have had a visit at least twice during the reporting year and do not meet any of the exclusion criteria.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Data Goal (by End of Project Periodby December 31, 2018)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Hypertension: Controlling High Blood PressureCardiovascular Disease

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 periodadult patients with diagnosed hypertension whose most recent blood pressure was less than 140/90.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
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 period18 to 85 years of age with a diagnosis of hypertension with most recent systolic blood pressure measurement < 140 mm Hg and diastolic blood pressure < 90 mm Hg.
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, excluding patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement periodAll patients 18 to 85 years of age as of December 31 of the measurement year with a diagnosis of hypertension and have been seen at least twice during the reporting year, and have a diagnosis of hypertension before June 30 of the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Cervical Cancer Screening

Performance Measure: Percentage of women 21-64 years of age who received one or more Pap tests to screen for cervical cancer.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Women with one or more Pap tests during the measurement period or the two years prior to the measurement periodNumber of female patients 24–64 years of age receiving one or more Pap tests during the measurement year or during the two years prior to the measurement year, among those women included in the denominator.
Denominator Description	Women 23-64 years of age with a visit during the measurement period, excluding women who had a hysterectomy with no residual cervixNumber of female patients 24-64 years of age as of December 31 of the measurement year who were seen for a medical visit at least once during the measurement year and were first seen by the grantee before their 65th birthday.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Access to Prenatal HealthCare

Performance Measure: Percentage of prenatal care patients who entered treatment during their pregnant women beginning prenatal care in first trimester.
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Women entering prenatal care at the health center or with the referred provider during their first trimesterAll female patients who received perinatal care during the program year (regardless of when they began care) who initiated care in the first trimester either at the grantee’s service delivery location or with another provider.
Denominator Description	Women seen for prenatal care during the yearNumber of female patients who received prenatal care during the program year (regardless of when they began care), either at the grantee’s service delivery location or with another provider. Initiation of care means the first visit with a clinical provider (MD, NP, CNM) where the initial physical exam was done and does not include a visit at which pregnancy was diagnosed or one where initial tests were done or vitamins were prescribed.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Low Birth WeightPerinatal Health

Performance Measure: Percentage of patients born to health center patients whose birth weight was below normal (less than 2,500 grams).births less than 2,500 grams to health center patients.
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Children born with a birth weight of under 2,500 gramsWomen whose child weighed less than 2,500 grams during the measurement year, regardless of who did the delivery, among those women included in the denominator.
Denominator Description	Live births during the measurement year for women who received prenatal care from the health center or by a referral providerTotal births for all women who were seen for prenatal care during the measurement year regardless of who did the delivery.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Childhood Immunization StatusHealth

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 birthdaywith 2nd birthday during the measurement year with appropriate immunizations.
Is this Performance Measure Applicable to your Organization?	Yes
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 birthdayNumber of children who received all of the following: 4 DTP/DTaP, 3 IPV, 1 MMR, 2 Hib*, 3 HepB, 1VZV (Varicella), 4 Pneumococcal conjugate, 2 HepA, 2 or 3 RV, and 2 influenza vaccines prior to or on their 2nd birthday whose second birthday occurred during the measurement year, among those children included in the denominator. *Note: While 2 Hib shots are required, HRSA recommends that 3 Hib shots be given per the CDC recommendation.
Denominator Description	Children who turn 2 years of age during the measurement period and who have a visit during the measurement periodNumber of children with at least one medical visit during the reporting period, who had their second birthday during the reporting period, who did not have a contraindication for a specific vaccine. This includes only children who were seen for the first time in the clinic prior to their second birthday, regardless of whether or not they came to the clinic for vaccinations or well child care.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Behavioral Health

Performance Measure:
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Performance Measure Categories	[_] Mental Health [_] Substance Abuse Conditions [_] Other If ‘Other’, please specify: ___________
Target Goal Description
Numerator Description
Denominator Description
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Oral HealthDental Sealants

Performance Measure: Percentage of children, age 6 through 9 years, at moderate to high risk for caries who received a sealant on a permanent first molar during the measurement period.
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Performance Measure Categories	[_] Emergency Services [_] Oral Exams [_] Restorative Services [_] Oral Surgery [_] Rehabilitative Services [_] Prophylaxis - Adult or Child [_] Sealants [_] Fluoride Treatment - Adult or Child [_] Other If ‘Other’, please specify: ___________
Target Goal Description
Numerator Description	Patients who received a sealant on a permanent first molar tooth in the measurement year.
Denominator Description	Dental patients aged 6- 9 who had an oral assessment or comprehensive or periodic oral evaluation visit during the measurement year and documented as having moderate to high risk for caries, excepting children for whom all first permanent molars are non-sealable.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Weight Assessment and Counseling for Children and Adolescents

Performance Measure: Percentage of patients aged 3 -17 years of age who had evidence of BMI percentile documentation and who had documentation of counseling for nutrition and who had documentation ofage 2 to 17 years who had a visit during the current year and who had Body Mass Index (BMI) Percentile documentation, counseling for nutrition, and counseling for physical activity during the measurement year.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Number of patients in the denominator who had their BMI percentile (not just BMI or height and weight) documented during the measurement year and who had documentation of counseling for nutrition and who had documentation of counseling for physical activity during the measurement yearchild and adolescent patients age 3 to 17 years who had Body Mass Index (BMI) Percentile documentation, counseling for nutrition, and counseling for physical activity during the measurement year, among those patients included in the denominator.
Denominator Description	Number of patients who were 3 years of age through adolescents who were aged 17 at some point during the measurement year, who had at least one medical visit during the reporting year, and were seen by the health center for the first time prior to their 18th birthdaychild and adolescent patients age 3 to 17 years as of December 31 of the measurement year, who have been seen in the clinic at least once during the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Adult Weight Screening and Follow-Up

Performance Measure: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounterage 18 years or older who had their Body Mass Index (BMI) calculated at the last visit or within the last six months and, if they were overweight or underweight, had a follow-up plan documented.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Number of patients in the denominator who had their BMI (not just height and weight) documented during their most recent visit or within 6 months of the most recent visit and if the most recent BMI is outside of normal parameters, a follow-up plan is documentedadult patients age 18 years or older who had their Body Mass Index (BMI) calculated at the last visit or within the last six months and, if they were overweight or underweight, had a follow-up plan documented among those patients included in the denominator.
Denominator Description	Number of adult patients who were 18 years of age or older during the measurement year, who had at least one medical visit during the reporting age 18 years or older as of December 31 of the measurement year, who have been seen in the clinic at least once during the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Tobacco Use Screening and Cessation InterventionAssessment and Counseling (Tobacco Use Assessment)

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 counseling intervention if identified as a tobacco userage 18 years and older who were queried about tobacco use one or more times within 24 months.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco userNumber of patients age 18 years and older who were queried about tobacco use one or more times during their most recent visit or within 24 months of their most recent visit, among those patients included in the denominator.
Denominator Description	All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period, excluding patients whose medical record reflects documentation of medical reason(s) for not screening for tobacco useNumber of patients age 18 years and older who had at least one medical visit during the measurement year and have been seen for at least two office visits ever.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Tobacco Use Assessment and Counseling (Tobacco Cessation Counseling)

Performance Measure: Percentage of patients age 18 years and older who are users of tobacco and who received (charted) advice to quit smoking or tobacco use.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Number of patients age 18 years and older who are users of tobacco and who received (charted) advice to quit smoking or tobacco use during their most recent visit or within 24 months of their most recent visit, among those patients included in the denominator.
Denominator Description	Number of patients age 18 years and older seen identified as users of tobacco during their most recent visit or within 24 months of their most recent visit and who had at least one medical visit during the current year and have been seen for at least two visits ever.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Asthma : Use of Appropriate Medications– Pharmacological Therapy

Performance Measure: Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement periodage 5 to 40 years with a diagnosis of persistent asthma (either mild, moderate, or severe) who were prescribed either the preferred long term control medication or an acceptable alternative pharmacological therapy during the current year.
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Patients who were dispensed at least one prescription for a preferred therapy during the measurement periodNumber of patients age 5 to 40 years included in the denominator with a diagnosis of persistent asthma (either mild, moderate, or severe) who were prescribed either the preferred long term control medication (inhaled corticosteroid) or an acceptable alternative pharmacological therapy (leukotriene modifiers, cromolyn sodium, nedocromil sodium, or sustained released methylxanthines) during the current year.
Denominator Description	Patients 5-64 years of age with persistent asthma and a visit during the measurement period, excluding patients with emphysema, COPD, cystic fibrosis, or acute respiratory failure during or prior to the measurement periodNumber of patients age 5 to 40 years with a diagnosis of persistent asthma (either mild, moderate, or severe) and who had at least one medical visit during the current year and have been seen for at least two visits ever.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Coronary Artery Disease (CAD): Lipid Therapy

Performance Measure: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) who were prescribed a lipid-lowering therapyCAD prescribed a lipid lowering therapy (based on current ACC/AHA guidelines) during the measurement year.
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Number of patients who received a prescription for or were provided or were taking lipid lowering medicationsage 18 years and older with a diagnosis of CAD prescribed a lipid lowering therapy (based on current ACC/AHA guidelines) during the measurement year, among those patients included in the denominator.
Denominator Description	Number of patients who were seen during the measurement year after their 18th birthday, who had at least one medical visit during the measurement year, at least two medical visits ever, and who had an active diagnosis of coronary artery disease (CAD) including any diagnosis for myocardial infarction (MI) or who had had cardiac surgery in the past, excluding patients whose last LDL lab test during the measurement year was less than 130 mg/dL, individuals with an allergy to or a history of adverse outcomes from or intolerance to LDL lowering medicationsage 18 years and older as of December 31 of the measurement year with a diagnosis of CAD who have been seen in the clinic at least once during the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Ischemic Vascular Disease (IVD): Use of Aspirin or Another AntithromboticTherapy

Performance Measure: Percentage of patients 18 years of age and older who were discharged alive for 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 who had documentation of use of aspirin or another antithrombotic during the measurement periodage 18 years and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA), or who had a diagnosis of Ischemic Vascular Disease (IVD), and who had documentation of use of aspirin or another antithrombotic during the measurement year.
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Patients who have documentation of use of aspirin or another antithrombotic during the measurement periodNumber of patients age 18 years and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA), or who had a diagnosis of Ischemic Vascular Disease (IVD), and who had documentation of use of aspirin or another antithrombotic during the measurement year, among those patients included in the denominator.
Denominator Description	Patients 18 years of age and older with a visit during the measurement period, and an active diagnosis of ischemic vascular disease (IVD) or who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement periodNumber of patients age 18 years and older as of December 31 of the measurement year who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA), or who had a diagnosis of Ischemic Vascular Disease (IVD), who have been seen in the clinic at least once during the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Colorectal Cancer Screening

Performance Measure: Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.age 50 to 75 years who had appropriate screening for colorectal cancer (includes colonoscopy <= 10 years, flexible sigmoidoscopy <= 5 years, or annual fecal occult blood test).
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
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; flexible sigmoidoscopy 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 periodNumber of patients age 50 to 75 years who had appropriate screening for colorectal cancer (includes colonoscopy <= 10 years, flexible sigmoidoscopy <= 5 years, or annual fecal occult blood test), among those patients included in the denominator.
Denominator Description	Patients 50-75 years of age with a visit during the measurement period, excluding patients with a diagnosis or past history of total colectomy or colorectal cancerNumber of patients age 50 to 75 years as of December 31 of the measurement year, who have been seen in the clinic at least once during the measurement year.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: HIV Linkage to CareOther

Performance Measure: Percentage of newly diagnosed HIV patients who had a medical visit for HIV care within 90 days of first-ever HIV diagnosis.
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Performance Measure Categories (Applicable for Oral/Behavioral Focus Areas only)	[_] Mental Health [_] Substance Abuse Conditions [_] Emergency Services [_] Oral Exams [_] Restorative Services [_] Oral Surgery [_] Rehabilitative Services [_] Prophylaxis - Adult or Child [_] Sealants [_] Fluoride Treatment - Adult or Child [_] Other If ‘Other’, please specify: ___________
Target Goal Description
Numerator Description	Patients who had a medical visit for HIV care within 90 days of first-ever HIV diagnosis.
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.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)Data (by End of Project Period)
Progress Field
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 [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Depression Screening and Follow-Up

Performance Measure: Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.
Target Goal Description
Numerator Description	Patients screened for clinical depression on the date of the encounter using an age appropriate standardized tool AND if positive, a follow-up plan is documented on the date of the positive screen.
Denominator Description	All patients aged 12 years and older before the beginning of the measurement period with at least one eligible encounter during the measurement period, excluding patients with an active diagnosis for depression or a diagnosis of bipolar disorder, or patient refuses to participate, or medical reason(s), such as patient is 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.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:	Projected Goal (by December 31, 2018)
Progress Field
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: 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 project is 0915-0285. Public reporting burden for this collection of information is estimated to average 3.5 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N0-393, Rockville, Maryland, 20857.