Uniform Data System Calendar Year 2014

Uniform Data System Calendar Year 2014 Bureau of Primary Health Care Agenda Brief introduction to UDS 2014 changes 2015 proposed changes Definitions used in the UDS report Step by step instructions for completing UDS tables Available assistance and strategies for successful reporting 2 1

UDS: The Who, What, When, Why, and How 3 UDS: The Who Who: 330 funded grantees under the CHC, HCH, MHC or PHPC programs Look alikes designated by BPHC BHW primary care clinics Urban Indian Health Centers (reported under separate system) Native Hawaiian Health Centers (not through EHB) Who were funded or designated prior to October 2014 4 2

UDS: The What What: Scope of Project which includes (and is limited to) the staff, services, patients, income, expenses, etc. that are spelled out in funding or designation applications Does not include sites or services which are not approved by BPHC For the period January 1, 2014 December 31, 2014 Calendar year reporting, not based on grant year or fiscal year 5 UDS: The When When: January 1, 2015: the UDS opens in your Electronic Handbook and you can begin to enter data. https://grants3.hrsa.gov/2010/webepsexternal//interface/common/accesscontrol/login.aspx by February 15, 2015: All data tables must be completed and the report must be officially submitted by CEO or their assigned delegate. March 1 March 31 (approximately): Revisions are made to correct errors or explain apparent issues. (work with reviewer.) March 31, 2015: Report must be finalized at close of business. 6 3

UDS: The Why Why: The UDS is used: To inform HHS, OMB and the Executive Branch of the accomplishments of the program To inform Congress and the legislators who are responsible for funding the program To provide information to HRSA in evaluating the operation of individual health centers and, occasionally, to alter funding levels To inform the public of the operations of federally supported health centers To provide data to scholars studying health care delivery in general and services to poor in particular 7 UDS: The How How: On line through Electronic Handbook (EHB) https://grants3.hrsa.gov/2010/webepsexternal//interface/common/accesscontrol/login.aspx By authorized staff at each health center More than one person can work on the UDS at the same time as long as they are in different tables. By the CEO or designee certifying by submission that they have reviewed and approved the data being submitted 8 4

12 Tables Provide a Detailed Picture of Your Health Center What is Reported Table(s) Patients served & their socio demographic characteristics 3A, 3B, 4, ZIP Code Types and quantities of services you provide 5, 6A Staffing mix and tenure 5, 5A The care you deliver/quality of care 6A, 6B, 7 Costs of providing services 8A Revenue sources 9D, 9E 9 Who Reports Which Tables Table 1 BPHC 330 Funded Program and BHW Primary Care Clinic: Universal Report More than 1 BPHC 330 Funded Program: Universal + Special Pop. Grant Reports Look Alike Health Center: Universal Report ZIP Codes Yes n/a Yes 3A, 3B, 4 Yes Yes Yes 5 Yes Visits & Patients, only Yes 5A Yes n/a Yes 6A Yes Yes Yes 6B Yes n/a Yes 7 Yes n/a Yes 8A Yes n/a Yes 9D Yes n/a Yes 9E Yes n/a No 330 grants 10 5

2014 Changes Table 4: Line 26: Total number of patients who live in public housing Table 6A: New Line 1 2a: Newly diagnosed with HIV Look alikes will report this table for the first time Table 6B: Tobacco use assessment and cessation intervention measures have been combined into one measure, line 14a, Tobacco Use Screening and Cessation Intervention New measure, line 20: Newly Identified HIV Cases and Follow Up New measure, line 21: Patients Screened for Depression and Follow Up Prenatal care tracking for women referred for prenatal care services 11 2014 Changes Continued Table 7: Categories of HbA1c less than 7% and 7% <8% have been combined into a single category of less than 8% Outcomes for women referred for prenatal care services at centers which do not provider prenatal care Table 9D: Look alikes will report all elements of this table 12 6

2015 Proposed Changes Table 4: New line 9a: Dually Eligible (Medicare and Medicaid)» this is a subset of line 9 (Medicare). Dually eligible patients will be reported on both line 9 and 9a. Tables 6A, 6B, and 7: Use of ICD 10 coding begins October 1, 2015» Use ICD 9 for services from January 1 through September 30» Use ICD 10 from October 1 through December 31 Table 6B: New line 22: Application of sealants to first molar teeth for children aged 6 and 9. Table 7: The detail for reporting diabetic HbA1c will be further reduced. In 2015, health centers will only report those patients with HbA1c greater than 9% or No Test During Year (Column 3f) 13 THE TABLES: Key Definitions and Step by Step Instructions 14 7

Who Counts: Patient Defined An individual who has one or more visits reported on Table 5 during the calendar year is considered a patient. Medical, dental, behavioral health, vision, other professional and selected enabling services Whenever patients are counted, it must be an unduplicated count. Each patient is counted once and only once regardless of the number or scope of visits. But they may be counted in each category of patient that they fall in E.g., could be 1 medical patient and 1 dental patient 15 ZIP CODE TABLE: Patients by ZIP Code and Insurance 16 8

Patients by ZIP Code Report all ZIP codes with 11 or more patients Combine the rest as other zip codes Patients in each ZIP code are reported by their primary medical insurance This is the third party MEDICAL insurance that would be billed first if the patient had a medical visit Must be reported for ALL patients including those patients who are not being seen for medical services There is no unknown insurance category Totals must tie to total patients on Table 3A and insured patients on Table 4 17 Patients by ZIP Code Continued Additional instructions for Special Populations Homeless: Use ZIP code of location where patient receives services if no better data exist. Agricultural: Use ZIP code of the temporary housing they occupy when patient is in the area. 18 9

TABLES 3A AND 3B: Patient Demographics 19 Table 3A: Patients by Age & Gender Report total patients by age and gender Age is calculated as of June 30 Count each patient once and only once Total on line 39 is used for unduplicated patient count totals from ZIP Code, table 3B, income of table 4, and insurance of table 4 must equal this number 20 10

Table 3B: Patients by Hispanic or Latino Ethnicity/Race/Language Use Column B if patient does not indicate Latino or Hispanic. Use Line 6 only if patient chooses two or more listed races. More than one shouldn t be a choice don t report Latino + a race as more than one race Use unreported, Line 7 if no race was specified. Total must equal Table 3A. 21 Table 3B: Patients by Language Report all patients who would best be served in a language other than English including: Bilingual persons not fluent in medical English Persons who are served by a bilingual provider Persons who receive interpretation services Persons using sign language Persons in Puerto Rico or the Pacific where a language other than English is used This is the only UDS cell that may be estimated. 22 22 11

TABLE 4: More Demographic Data 23 Table 4: Patients by Income Lines 1 6 Report income as of your most recent assessment. Income may be self reported if permitted by your policy May report using a method different than that used for your sliding discount system Income must be current (obtained within the last year) otherwise report as unknown. Total on Line 6 must equal total on table 3A. 24 12

Table 4: Patients by Medical Insurance Lines 7 12 Report principal third party insurance for medical care (even if patient is not a medical patient) Insurance is reported as of the last visit Even if insurance source did not pay for the visit Total on Line 12 must equal total on Table 3A and line 6 on Table 4 Total for each insurance type must equal totals on ZIP code table 25 Table 4: Medical Insurance Reporting Categories None/Uninsured, line 7 patients with no insurance: may include patients whose services are reimbursed through grant, contract or uncompensated care funds Medicaid, lines 8a, 8b, 8 report all Medicaid patients including those in managed care programs run by commercial insurers Medicare, line 9 report all Medicare patients including Medicare Advantage and Medi Medi patients 26 13

Table 4: Insurance Categories Continued CHIP, line 8b or 10b handled differently from state to state: If provided through Medicaid it is reported on Line 8b (CHIP Medicaid) If provided through a commercial carrier outside of Medicaid it is reported on Line 10b (Other Public CHIP) do not report as Private Other Public, lines 10a, 10b, 10 Public coverage for patients with a broad set of benefits Do not include family planning, breast and cervical programs, EPSDT, etc. Private Insurance, line 11 Commercial coverage for patients including Tricare, Trigon, Public Employees Insurance, etc. Note: Workers Comp is not medical insurance 27 Table 4: Managed Care Utilization Lines 13a, b, c Completed ONLY by health centers with capitated and/or FFS managed care (HMO) contracts. Patient is assigned to health center or their provider(s) Patient MUST go to health center for listed primary care services Do not count Primary Care Case Management patients or patients capitated for non medical service only (dental, mental health, etc.) Only report enrollment in comprehensive managed care plans A member month is 1 member enrolled for 1 month. Report the sum of the monthly enrollments for 12 months (generally from HMO reports to the health center). In some cases, members might not be patients. 28 14

Table 4: Target Populations Lines 14 26 All health centers must report total number of targeted patients (if any) on Lines 16, 23, 24, 25, and 26 even if they do not have targeted funding 330(g) MHC Grantees provide separate totals for migratory and for seasonal agricultural workers on Lines 14 and 15 others report total Line 16 330(h) HCH Grantees report patient s shelter arrangement as of first visit in 2014 (where they were housed the prior night) others report total Line 23 Patients seen at school based clinic locations are reported on Line 24 Veteran is an individual who completed service in the Uniformed Services of the US 2014 Change: Report the total number of patients who live in public housing on Line 26 29 Table 4: Agricultural Workers Defined Lines 14 16 An agricultural worker is an individual whose PRINCIPAL employment is in agriculture on a SEASONAL BASIS, who has been so employed within the last 24 months, and/or their dependents. Line 14: Migratory Workers who establish temporary home(s) for such employment. Line 15: Seasonal Workers who do not live away from home. For both categories of workers, the term agriculture means farming in all its branches as defined by the OMB developed NAICS, and includes seasonal workers included in the following codes and all sub codes within: 111, 112, 1151, and 1152. Health centers who do not have 330(g) funds report Line 16 Total only Agriculture means farming, including: Cultivation and tillage of the soil The production, cultivation, growing, and harvesting of any commodity grown on, or in the land, or as an adjunct to or part of a commodity grown on or in the land; and Any practice (including preparation and processing for market and delivery to storage or to market or to carrier for transportation to market) performed by a farmer or on a farm incident to or in conjunction with the above Fisheries 30 15

Table 4: Homeless Defined Lines 17 23 A homeless patient is any person known to be homeless at the time of any service or who was housed but eligible because of having been a homeless patient within 12 months of the service date. Health centers with no 330(h) funds report only Line 23 total Shelter arrangements (at the first visit of the year): Shelter homeless shelter Transitional So designated, participate in cost, time usually limited Street includes living outdoors, in a car, in an encampment, in makeshift housing/shelter or in other places generally not deemed fit for human occupancy Doubled up must be temporary and unstable Other SROs, motels, currently housed previously homeless Persons who spent the prior night incarcerated, in an institutional treatment, a hospital or in jail should be reported based on where they intend to spend the night after their encounter/release. If they do not know, code as street, 31 Table 4: School Based Clinics and Veterans, Lines 24 and 25 Line 24: School Based Clinics Patients who are seen at school based clinics, including any clinic so identified on Forms 5B or 5C May be sited on or next to schools May or may not accept non students Line 25: Veterans Persons who have completed service in the Uniformed Services of the United States Does not include active members of the military or Guard Does not include veterans of other nations 32 16

Table 4: New Line 26 Public Housing Patients Required of all health centers, not just 330(i) PHPC grantees. Developments (large, multi unit) created or managed for low income residents with public funds and/or support. Excludes housing supported only by Section 8 scattered site vouchers Use of patient address is acceptable to identify the population. 33 TABLES 5 AND 5A: Staffing, Tenure, and Utilization 34 17

Table 5: Staffing & Utilization Column A Staff fulltime equivalents (FTEs) reported by position Column B Clinic visits reported by provider type Column C Patients reported by service type 35 Table 5, Column A: Categories of Staff Report all staff providing in scope services Include employees, contracted staff, residents, and volunteers Do not include paid referral provider FTEs Report based on work performed, not job title A single person can be allocated across multiple categories E.g., MA works as lab tech one day a week: 80% MA, 20% lab tech Medical director s corporate time (only) can be allocated to non clinical; do not allocate administrative time of other providers Other Professional, Line 22, includes chiropractic, acupuncture, PT, OT, nutrition, podiatry, etc. Other Related, Line 29a, includes non health care program staff (e.g., WIC, childcare, housing, fitness, job training, etc.) See Appendix A in Reporting Manual for staffing categories 36 18

Calculating FTEs for Staff FTE is actual for the year, not as of last day 1.0 FTE is the equivalent of one person working full time (as defined by health center) for one year Providers: Based on employment contracts Based on hours paid including vacation, sick, continuing education, admin time etc. FTEs = Yearly paid hours divided by total hours for position: E.g., 40 hour week = 2080 yearly hours; 35 hour week = 1820 Calculate FTE for persons working part time or part year (E.g., 6 months full time = 0.50 FTE, 9 months half time = 0.375 FTE ) 37 Calculating FTEs for Hourly Work Who: Volunteers, locums, residents, on call providers, etc. who do not receive paid time off (PTO) benefits How: 1. Calculate the number of leave hours and subtract from fulltime hours for the comparable position E.g., Staff provider receives 160 hours vacation, 96 hours sick, 40 hours continuing education, 80 hours holidays, 1704 hours worked 2. Calculate number of hours person being evaluated actually works E.g., Volunteer provider worked 30 days @ 8 hours = 240 hours 3. Calculate and report FTE E.g., hours worked (240) divided by position FTE work hours (1704) =.14 FTE (240/1704 = 0.1408) 38 19

Table 5, Column B: Visit Defined A visit is: Face to face, one to one interaction between a patient and a provider Exception: Group visits and telemedicine is permitted for mental health and substance abuse visits No group health education or group medical visits. Medical, dental, vision, and some mental health staff must be licensed Other disciplines must be credentialed by the health center The service must be charted The provider must be acting independently The provider must be using professional judgment unique to their training and education 39 Visit Defined Continued Only one visit per patient per provider type per day Exception: two different providers at two different sites Only one visit per provider per patient per day regardless of the number of services provided DO COUNT paid referral visits when following current patients in a nursing home, hospital, or at home DO NOT COUNT immunization only, lab only, dental fluoride, mass screenings, health fairs, outreach or pharmacy visits Count visits provided by both paid and volunteer staff 40 20

Table 5, Column C: Patients by Service Category Defined Total number of patients of that type of service seen during the year A patient may be counted only once in each category regardless of the number of visits Patients provided with multiple types of service must be counted in each category e.g. A patient may counted as both a medical and a dental patient. 41 Table 5A: Tenure for Selected Health Center Staff Defined Reports only on providers and key management staff Starting point will be last year s work sheet Delete staff who have left and add new staff Include persons working on last day of the year and those who have the day off, but are scheduled to return Head count as of December 31 in consecutive months in current position (months will be over 12 if the person has had the position for more than one year) Do not count paid referral providers or individuals who may work many days but do not have a regular schedule Data reported: are generally available in Personnel or Human Resource (HR) employment records may be measured in a form differently than the way seniority information is stated Should be available January 1 Table can be done well in advance of the submission date 42 21

Table 5A: Tenure Report all individuals who work at the health center Full time, part time, partyear, contract, NHSC Locums, volunteers, on call, residents Report combined tenure In months (not FTE) As of last work day of year By job title Same categories / lines as T5 NOTE: It is almost impossible to have Column B = Column A and impossible for B<A or D<C. 43 Who to include in Census Include o Clinical staff: Physicians NP, PA, CNM providers Nurses Dental providers Mental Health providers Vision providers o Key non clinical staff: CEO / Executive Director CFO / Fiscal Officer CIO / IT Director CMO / Medical Director Those who worked in scope on December 31st Or who worked before then and were scheduled to return to work in the new year 44 22

Tenure for Full and Part Time Staff Column A Regular employees and persons on regular contracts who are employed at the time of the census are each counted as 1 in Column A. Regardless of when they first started working Those who are not working that day but who are scheduled to work before and after that day are counted as 1 Those with two jobs (e.g., OB/GYN + CMO) are counted as 1 in each category Those who are no longer employed on that day are not counted on this table 45 Tenure for Other Service Provider Arrangements Column C Volunteers, locums, on call providers, residents, etc. who worked before and are scheduled to work after 12/31 are each counted as 1 in Column C. Regardless of how much time they work if they are considered to be a part of the regular staff they are counted. Some examples include: Specialists who are usually present at least once each month or quarter Primary care providers present during a specific season 46 23

Tenure Months Columns B and D Months are calculated from the date the person was most recently hired into that position. Continuous months from the start date through December of the reporting year Rounded up to the closest whole number E.g., Pediatrician hired 8/1/03, promoted to CMO on 9/15/11, and serves in both roles Count 137 months as pediatrician and 40 months as CMO E.g., COO is hired 11/10/89, promoted to Deputy Director 7/12/98 and then promoted to CEO 6/22/14, retaining the obligations of the Deputy Director Count 7 months as CEO only E.g., CEO hired 5/15/11 to fill the role of CIO, CFO, and CEO Count 44 months as CEO, 44 months as CFO, 44 as CIO 47 TABLES 6A, 6B, AND 7: Diagnoses and Services Provided; Quality of Care Indicators 48 24

Clinical Profile Tables Clinical care Table 6A: Selected diagnoses and services Also completed by look alikes effective CY 2014 Also completed for each additional non CHC funding stream Table 6B: Quality of care indicators Table 7: Health outcomes and disparities EHR Capabilities and Quality Recognition Series of questions on health information technology (HIT) capabilities, including EHR interoperability, and incentives for the Meaningful Use of certified EHR technology. Includes the implementation of EHR, certification of systems, how widely adopted the system is throughout the health center and its providers, and national and/or state quality recognition (accreditation or PCMH) Not a numbered table at end of the EHB entry 49 TABLE 6A: Diagnoses and Services 50 25

Table 6A: Diagnoses and Services Lines 1 20d: Selected diagnoses Report all diagnoses, not just primary diagnosis New Line: 1 2a Newly diagnosed HIV Lines 21 34: Selected services Uses ICD 9, CPT, or ADA codes 51 Diagnoses: Column A, lines 1 20d Reports on the number of visits which reported the selected diagnosis Each row has a name (e.g. diabetes), but is defined by one or more ICD 9 codes as listed on the table and in the reporting manual Some codes are intentionally excluded, such as the code for gestational diabetes Each visit with the unique diagnosis identified is counted If patients have more than one reportable diagnoses during a visit, each is counted E.g., hypertension and diabetes and obesity 52 26

Services: Column A, lines 21 34 Reports on the number of visits which reported one or more of the selected services Each row has a name (e.g., childhood immunizations) but is defined by one or more CPT (or ICD 9) codes or in the case of dental services ADA codes Some codes are intentionally excluded, such as the codes for some surgically related procedures Each visit with the service provided is counted If patients have more than one reportable service during a visit, each is counted E.g., Pap test and contraceptive services But not multiple services in the same category at one visit E.g., an DPT and an MMR at the same visit 53 Patients by Diagnosis and Service: Column B Report the unduplicated number of patients who had a specific diagnosis or received one or more of the selected services Count a patient once and only once on each line where a visit was counted. e.g., a patient who is seen five times for hypertension will be counted as one patient in column B A patient may have a diagnosis and a service on the same day e.g., a patient seen for their diabetes and provided with a flu shot would both be counted on this table. 54 27

Table 6A: New Line 1 2a Newly Diagnosed with HIV Persons first diagnosed with HIV during the twelve months from 10/1/13 through 9/30/14 Count only individuals who had never been diagnosed in any setting prior to a visit with your provider Do not count: Persons who had been previously diagnosed but who were being seen for the first time at your health center Were diagnosed elsewhere and referred to you for treatment Had a (positive) reactive initial screening test, but not a positive supplemental test (unless you also referred them for the supplemental test and intend to provide treatment) ICD codes will not identify initial HIV diagnosis this will need to be identified from alternate EHR or other systems 55 TABLE 6B: Quality of Care Indicators 56 28

Process Measures Process measures : If patients receive timely routine and preventive care, then we can expect improved health Access to prenatal care (first prenatal visit in 1 st trimester) Childhood immunizations Cervical cancer screening Child and adolescent weight screening & counseling Adult weight screening & follow up Tobacco use assessment and cessation intervention Asthma drug therapy Cholesterol treatment (lipid therapy for coronary artery disease patients) Heart attack/stroke treatment (aspirin therapy for ischemic vascular disease patients) Colorectal cancer screening Depression screening and follow up HIV linkage to care 57 Section A, lines 1 6: Prenatal Patients by Age Changes for 2014 Report all patients, who received prenatal care and all patients who test positive for pregnancy and were referred for obstetrical care during the year, by age category. Report all women served regardless of whether they delivered, including women whose only service in 2014 was their delivery Include women who were referred for prenatal care, transferred, or were risked out Do not include patients who may have had tests, vitamins, assessments or education, but did not have their initial clinical visit with the clinic s obstetrical provider or the referral provider Do not include women who went to another provider on their own or who left without a referral 58 29

Section B, lines 7 9: Access to Prenatal Care Trimester of entry into prenatal care For all patients reported in Section A, indicate what trimester they began care and whether it was with the health center or another provider Entry into prenatal care occurs when the patient has had a visit with a physician or non physician provider at the health center or with a referral provider who initiates prenatal care with a complete physical exam (i.e., not a pregnancy test, nurse assessment, etc.) 59 Section C, line 10: Childhood Immunizations Column A: Universe All children who turned 2 years and 364 days in 2014 (born on 1/1/11 12/31/11) AND who had at least one medical visit in 2014 AND were first ever seen prior to their 3rd birthday This is the catch up schedule. Technically asks about children who were immunized before they turned 3. CDC / AAP still recommends immunization by age 2 No exclusions 60 30

Childhood Immunizations Column B: Universe or sample of 70 patients Column C: Meeting measurement standard: Number of children in Column B who, by their 3rd birthday are fully compliant for each disease listed on the next slide. A child is fully complaint if they had (1) received vaccine, or (2) shown evidence of the disease or (3) shown a contraindication for vaccine. 61 Required Vaccines Fully compliant means meeting measurement standard for each of 11 diseases normally vaccinated against with: 4 DTP/DTaP, 3 IPV, 1 MMR, 3Hib, 3 Hepatitis B, 1 VZV (Varicella), 4 Pneumococcal conjugate HepA, rotavirus and influenza were removed from reporting in 2013, but CDC / AAP still recommends these vaccines 62 31

Assessing Child Immunization Measurement Standard Notes in the medical record indicating that the patient received the immunization at delivery or in the hospital may be counted as evidence of meeting the measurement standard. A note that patient is up to date with immunizations that does not list the date of each immunization and the name of the provider does not constitute sufficient evidence of meeting the measurement standard. Good faith efforts to get a child immunized which nonetheless fail do not meet the performance measurement including: Parental failure to bring in the patient Parents who refuse for personal or religious reasons Parents who refuse because of beliefs about vaccines 63 Section D, line 11: Cervical Cancer Screening Column A: Universe All women aged 24 64 (born 1/1/50 12/31/90) AND with at least one medical visit in a health center clinic during the reporting year AND who were first seen before age 65 excluding women with hysterectomy 64 32

Cervical Cancer Screening Column B: Universe or sample of 70 patients Column C: Meeting the measurement standard: Number of patients in Column B who: received one or more Pap tests in a three year period from 2012 through 2014 or received one or more Pap tests in a five year period from 2010 through 2014 and was 30 years of age or older at the time of her last Pap test and chose to have a Pap test and an HPV test done simultaneously. 65 Assessing Cervical Cancer Measurement Standard Medical records must include a copy of the test result (your lab or another lab) or include an evidence based entry which includes the provider, test date and result, which is not based on patient self report A note that patient was referred or patient reported receiving pap test does not meet the performance standard. Good faith efforts to get the patient tested do not meet the measurement standard. Performance measurement is not met even if she: refused to have test failed to return for a scheduled test claims to have had one but cannot document it 66 33

Section E, line 12:Child & Adolescent Weight Assessment & Counseling Column A: Universe All children and adolescents From aged 3 through 17 on December 31st (born 1/1/97 12/31/11) AND with at least one medical visit in a health center clinic during the reporting year AND were first seen before age 17 excluding pregnant adolescents 67 Child and Adolescent Weight Screening Column B: Universe or sample of 70 patients Column C: Meeting the Measurement Standard: Number of patients in Column B who had their BMI percentile recorded during 2014 AND had documented counseling on nutrition (not just diet) AND had documented counseling on activity (not just exercise) 68 68 34

Assessing Child & Adolescent Weight Screening Measurement Standard Just recording that a well child visit was done does not meet the requirement All three criteria: BMI percentile, counseling on nutrition, and counseling on physical activity must be documented 69 Section F, line 13: Adult Weight Screening and Follow Up Column A: Universe All adults: aged 18 and older on December 31st (born on or before 12/31/1996) AND with at least one medical visit in a health center clinic during the reporting year AND last seen after they turned 18 Excluding pregnant women and terminally ill patients Column B: Universe or sample of 70 patients 70 35

Adult Weight Screening and Follow Up Column C: Meeting the Measurement Standard: Number of patients in Column B who had their BMI recorded at their last visit or within 6 months of that visit AND had a follow up plan documented if they were under age 65 and BMI was < 18.5 OR 25 or age 65 or older and BMI was < 23 OR 30 71 Assessing Adult Weight Measurement Standard Just recording height and weight is not adequate BMI must be visible in chart or on template Include in Column C as meeting the measurement standard, adults: with BMI in normal range with BMI outside the normal range who have documented a followup plan 72 36

Section G, line 14a:Tobacco Use Screening & Cessation Intervention: 2014 Change Column A: Universe All adults aged 18 and older on December 31 st (born on or before 12/31/1996) AND who have been seen at least twice (ever) in the practice for medical care AND with at least one medical visit in a health center clinic during the reporting year AND last seen after they turned 18 No exclusions 73 Tobacco Use Screening and Cessation Intervention Column B: Universe or sample of 70 patients Column C: Meeting the Measurement Standard: Number of patients in Column B who were queried about their tobacco use one or more times by any provider (e.g. dental, vision) during their last visit or within 24 months of their last visit AND If found to be a tobacco user: Received tobacco cessation services or Received an order for a smoking cessation medication (prescription or OTC) or Were found to be on (using) a smoking cessation agent 74 37

Assessing Tobacco Use Screening & Cessation Measurement Standard Note that universe will not be the same as adult weight universe because of the two visit criteria All adults meeting the criteria are included in the universe, not just tobacco users. Include in Column C as meeting the measurement standard, adults who were: screened and found not to be tobacco users tobacco users with intervention charted 75 Section H, line 16: Asthma Treatment Column A: Universe Patients aged 5 through 40: Initially diagnosed with persistent asthma AND born between 1/1/74 and 12/31/09 AND last seen while between ages 5 through 40 AND seen at least twice (ever) in the practice AND had at least one medical visit in a health center clinic during the reporting year excluding patients with allergic reaction to asthma medications and those diagnosed with intermittent asthma 76 38

Asthma Treatment Column B: Universe or sample of 70 patients Column C: Meeting the Measurement Standard: Patients reported in Column B who received or had a prescription for inhaled corticosteroids or received or had a prescription for an approved alternative medication or were on medication 77 Assessing Asthma Treatment Measurement Standard The diagnosis of asthma (ICD 9 493.x) is not sufficient to define the universe. Only those with persistent asthma are to be included. CPT Category II codes or EHR template choices can be used to code severity; no ICD 9 codes do so. Appendix C in the Reporting Manual describes sampling techniques that can be used to identify persistent asthmatics if no other codes are available. 78 39

Section I, line 17: Cholesterol Treatment (Lipid Therapy for CAD Patients) Column A: Universe All adults: with an active diagnosis of CAD or had a myocardial infarction (MI) or had cardiac surgery AND aged 18 and older on December 31st (born on or before 12/31/1996) AND last seen after they turned 18 AND seen at least twice (ever) for medical care AND had at least one medical visit in a health center clinic during the reporting year Excludes individuals whose last LDL lab test was <130 mg/dl or with an allergy to or a history of adverse outcomes from or intolerance to LDL lowering medications. 79 Cholesterol Treatment Column B: Universe or sample of 70 patients Column C: Meeting the Measurement Standard: Patients reported in Column B who received a prescription for, were provided with, or were taking lipid lowering medications 80 40

Section J, line 18: Heart Attack/Stroke Treatment (Aspirin Therapy for IVD Patients) Column A: Universe All adults: with an active diagnosis of IVD during 2013 or 2014 OR had been discharged after AMI or CABG or PTCA during 2013 AND aged 18 and older on December 31st (born on or before 12/31/1996) AND last seen after they turned 18 AND had at least one medical visit in a health center clinic during the reporting year No exclusions AMI: acute myocardial infarction CABG: coronary artery bypass graft PTCA: percutaneous transluminal coronary angioplasty 81 Heart Attack/Stroke Treatment Column B: Universe or sample of 70 patients Column C: Meeting the Measurement Standard: Patients reported in Column B who had documentation of aspirin or another antithrombotic medication being prescribed, dispensed, or used 82 41

Section K, line 19: Colorectal Cancer Screening Column A: Universe Patients aged 51 through 74 born between 1/1/40 and 12/31/63 AND had at least one medical visit in a health center clinic during the reporting year Excluding patients who have had colorectal cancer or colectomy 83 Colorectal Cancer Screening Column B: Universe or sample of 70 patients Column C: Meeting the Measurement Standard: Patients reported in Column B who had documentation of appropriate colorectal cancer screening: Colonoscopy conducted during reporting year or previous 9 years OR Flexible sigmoidoscopy conducted during reporting year or previous 4 years OR Fecal occult blood test (FOBT), including the fecal immunochemical (FIT) test, during the reporting year 84 42

Section L, line 20: HIV Linkage to Care: New Measure Column A: Universe All patients, regardless of age: diagnosed for the first time ever with HIV between 10/1/13 and 9/30/14 AND who had at least one medical visit during the reporting year No exclusions 85 HIV Linkage to Care Column B: Universe or sample of 70 patients Column C: Meeting the Measurement Standard: Patients reported in Column B who, within 90 days of the visit where they tested positive for HIV had: A medical visit with a health center provider who initiates treatment for HIV or A visit with a referral resource who initiates treatment for HIV 86 43

Assessing HIV Linkage to Care Measurement Standard Neither a referral nor a patient going to a referral source for the confirmatory testing meets the measurement standard. Actual treatment at the referral source must have begun. There is no code for newly diagnosed HIV patients. Health centers should develop alternative methods for tracking within the EHR or medical record. A newly diagnosed HIV patent must be confirmed by a positive supplemental, not an initial, reactive test. 87 Section M, line 21: Depression Screening and Follow up: New Measure Column A: Universe Patients age 12 or older born on or before 12/31/02 AND had at least one medical visit during the reporting year Excluding persons with active diagnosis of depression or bipolar disorder or who are currently receiving on going treatment for depression. 88 44

Depression Screening and Follow up Column B: Universe or sample of 70 patients Column C: Meeting the Measurement Standard: Patients reported in Column B who had a standardized depression screening test during the measurement year that: was negative OR was positive and who have a follow up plan documented 89 Assessing Depression Screening & Follow Up Measurement Standard All patients age 12 and older are expected to be screened for depression. Include in Column C as meeting the measurement standard, patients age 12 and older: with a negative screening result with a positive screening who have a documented follow up plan 90 45

TABLE 7: Health Outcomes and Disparities 91 Intermediate Outcome Measures Intermediate outcome measures : If this measurable intermediate outcome is improved, then later negative health outcomes will be less likely. Low birth weight Hypertensive patients with controlled blood pressure < 140/90) Diabetes patients with controlled blood sugar HbA1c <=9%) 92 46

Table 7: Disparities Format Hispanic/Latino 1a Asian 1b1 Native Hawaiian 1b2 Other Pacific Islander 1c Black/African American 1d American Indian/Alaska Native 1e White 1f More than One Race 1g Unreported/Refused to Report Race Subtotal Hispanic/Latino Non Hispanic/Latino 2a Asian 2b1 Native Hawaiian 2b2 Other Pacific Islander 2c Black/African American 2d American Indian/Alaska Native 2e White 2f More than One Race 2g Unreported/Refused to Report Race Subtotal Non Hispanic/Latino Unreported/Refused to Report Ethnicity h Unreported/Refused to Report Race and Ethnicity i Total All outcome data are reported in a matrix to show ethnicity and race. Latino patients are reported in section 1. Patients who report race but not ethnicity are assumed non Hispanic and reported in section 2. Patients who report neither race nor ethnicity are reported as Unreported in section 3. 93 Table 7: Column Format Columns 1a, 2a, and 3a: Universe requires totals of: 1a: women who delivered 2a: hypertensive patients 3a: diabetic patients Universe must be used for reporting on delivery and birth data (columns 1a 1d). Columns 2b and 3b: For diabetes and hypertension report on: The universe of patients meeting criteria (number in columns 2a and 3a) OR 70 randomly selected patients May use different method for each Random sample is across total, not 70 for each race or ethnicity 94 47

HIV Pregnancy and Deliveries by Health Center Clinicians Line 0 : Pregnant HIV patients seen in the clinic, regardless of whether or not the health center provided them with or referred them for prenatal services Line 2: Total number of deliveries performed by health center clinicians, including deliveries to non health center patients 0 HIV Positive Pregnant Women Blank 2 Deliveries Performed by Health Center s Providers Blank 95 Section A: Low Birth Weight: Change for 2014 All Health Centers must report the outcomes for all pregnant medical patients who were provided any of the following required services: no prenatal care, but were referred for prenatal care, AS WELL AS full perinatal services through delivery some or all prenatal care and then referred for delivery some prenatal care and then referred out for late prenatal care and delivery some prenatal care and then transferred because of risk status Women who decline referral are not included. Requires reporting on tracking of patients by Health Centers who never reported in the past. 96 48

Section A: Low Birth Weight Column 1a: All women who were in the health center s prenatal program OR who were referred for care who were known to have delivered during the year, even if the delivery was done by another provider Column 1a need not / will not / should not equal the sum of columns 1b + 1c + 1d except by coincidence Columns 1b 1d: Live births, by weight, born during the year to prenatal care patients and referred women, regardless of who performed the delivery. Includes multiples Prenatal Care Patients Who Delivered During the Year (1a) Live Births: <1500 grams (1b) Live Births: 1500 2499 grams (1c) Live Births: 2500 grams (1d) 97 Assessing Low Birth Weight Measurement Standard Race and Ethnicity reporting: Column 1a: Patients who delivered Indicate the race and ethnicity of the woman delivering Columns 1b, 1c, 1d: Children by birthweight Indicate the race and ethnicity of the child(ren) born Race and ethnicity of the child need not be that of the mother. Unlike other measures, here the larger the number of children born with low birth weight, the poorer the outcome. 98 49

Section B: Blood Pressure Control Column 2a: Universe Patients aged 18 to 85 diagnosed with hypertension prior to 6/30/14 AND born between 1/1/30 and 12/31/96 AND seen at least twice during the reporting year for any medical service Excluding pregnant women and patients with end stage renal disease Total Hypertensive Patients (2a) Charts Sampled or EHR Total (2b) Patients with HTN Controlled (2c) 99 Blood Pressure Control Column 2b: Universe or sample of 70 patients Column 2c: Meeting the Measurement Standard: Patients reported in Column 2b whose most recent blood pressure is less than 140/90 Total Hypertensive Patients (2a) Charts Sampled or EHR Total (2b) Patients with HTN Controlled (2c) 100 50

Assessing Blood Pressure Control Measurement Standard Patients with no documented blood pressure during the reporting year are not reported, and do not meet the measurement standard. It does not matter if hypertension was treated during the measurement year or is currently being treated. The notation of hypertension may appear during or prior to 2014. 101 Section C: Diabetes Control Column 3a: Universe Patients aged 18 to 75 diagnosed with diabetes AND were born between 1/1/40 and 12/31/96 AND were seen at least twice during the reporting year for any medical service Excluding those with only a diagnosis of gestational diabetes or steroid induced diabetes. Total Patients with Diabetes (3a) Charts Sampled or EHR Total (3b) Patients with HbA1c <8% (3d1) Patients with 8% HbA1c 9% (3e) Patients with HbA1c >9% or No Test During Year (3f) 102 51

Diabetes Control: Change for 2014 Column 3b: Universe or sample of 70 patients Columns 3d1 3f: Test Results: Patients reported in Column 3b whose last HBA1c during the reporting year is in the given range No test during the reporting year does not meet the measurement standard and is reported in Column 3f Change for 2014: Number of categories for HbA1c has been reduced. Columns 3c (<7%) and 3d (7% HbA1c <8%) have been eliminated. All patients with HbA1c < 8% will be reported in column 3d1 Performance measurement remains unchanged Total Patients with Diabetes (3a) Charts Sampled or EHR Total (3b) Patients with HbA1c <8% (3d1) Patients with 8% HbA1c 9% (3e) Patients with HbA1c >9% or No Test During Year (3f) 103 Available Webinars Introduction to UDS Clinical Measures Presented On: October 20, 2014 from 2:00 4:30 EST Objectives: Review clinical performance measures (Table 6B and 7) and discuss strategies for accurate data collection and reporting Recorded sessions are available at http://bphc.hrsa.gov/healthcenterdatastatistics/reporting/index.html UDS Sampling Methods Presented On: November 6, 2014 from 1:30 3 EST Objectives: Review purpose of random sample and correct methods for generating random sample and chart substitutions Recorded sessions are available at http://bphc.hrsa.gov/healthcenterdatastatistics/reporting/index.html 104 52

TABLES 8A, 9D, AND 9E: Financial Profile 105 Financial Profile Tables Cost of delivering services and sources and amounts of income Table 8A: Financial costs Table 9D: Income from patient services Table 9E: Other revenues 106 53

TABLE 8A: Financial Costs 107 Table 8A: Financial Costs Reports accrued costs Requires allocation of facility and non clinical services to other centers Excludes bad debt Includes depreciation Reports donated ( in kind ) costs only on line 18 after the subtotal on line 17 which is used for all cost calculations. 108 54

Table 8A and Table 5 Crosswalk FTEs Reported on Table 5, Line: Have costs reported on Table 8A, Line: 1 12: Medical providers and clinical support staff 1: Medical Staff 13 14: Lab and X Ray 2: Lab and X Ray 16 18: Dental 5: Dental 20a 20c: Mental Health 6: Mental Health 21: Substance Abuse 7: Substance Abuse 22: Other Professional (e.g., nutritionists, podiatrists, etc.) 9: Other Professional 22a 22c: Vision Services 9a: Vision 23: Pharmacy 8a: Pharmacy 24 28: Enabling (e.g., case management, outreach, eligibility, etc.) 11a 11g: Enabling 29a: Other programs/services (i.e., non health related services including WIC, job training, housing, child care, etc.) 30a 30c and 32: Non clinical Support Services and Patient Support (e.g., corporate, intake, medical records, billing, fiscal, and IT staff) 12: Other related Services 31: Facility (e.g., security, maintenance, janitorial staff, etc.) 14: Facility 15: Non clinical Support Services 109 Table 8A: Lines 1 10 Line 1: Medical care costs include: Medical staff salaries and benefits Staff dedicated to EHR and QI activities Staff on contract and contracted visits Excludes ophthalmologists and psychiatrists Line 2: All medical (not dental) lab and x ray costs including supplies, lab staff, referral labs, radiologists, etc. Line 3: All other direct medical costs including provider dues, CME, travel, supplies, depreciation, EHR system, etc. Lines 5, 6, 7, 9, & 9a: Other clinical services costs Personnel (hired or contracted) and all other direct expenses for (5) dental, (6) mental health, (7) substance abuse, 9 (other professional), and (9a) vision 110 55

Table 8A: Lines 8a and 8b Pharmacy Costs Line 8b costs of pharmaceuticals, only Line 8a all other pharmacy costs including MIS, staff, equipment, non pharmaceutical supplies, etc. If you cannot separate non drug cost from total cost report all costs on line 8b All pharmacy overhead is on Line 8a, Column B Note: Do not include donated pharmaceuticals on either line. This is shown on line 18. 111 Table 8A: Lines 11a 12 Line 11a 11g: Enabling Personnel (hired or contracted), their expenses, and all other direct enabling costs Line 12: Other program related costs Include costs associated with staff reported on Table 5 Line 29a, as well as other related direct expenses for non health care services such as: WIC Housing Corporations Job training Head Start /Early Head Start Child care Adult Day Health Care Shelters Fitness programs Include any pass through funds here 112 56

Table 8A: Lines 14 15 Non Clinical Support and Facility Line 14: Facility costs include rent or depreciation, mortgage interest payments, utilities, security, janitorial services, maintenance, etc. No CIP or FIP costs, but include appropriate depreciation Line 15: Non clinical support staff costs include corporate administration, billing and collections, medical records and intake staff, as well as all associated non clinical costs including supplies, equipment, depreciation, travel, etc. 113 Allocation of Facility Facility Allocate each building separately Captures differences in costs per building such as improvements, donated space, etc. Allocate based on proportion of square footage utilized by each cost center or based on better data, if available Include allocation to non clinical support for administration s facility costs 114 57

Allocation of Non Clinical Support Non clinical support staff and costs Allocate based on actual use Allocating billing to cost centers that bill, front desk costs to those services that use the front desk staff for check in, etc. Alternative: straight line method, using the proportion of total costs to each service category excluding all non clinical support and facility costs Can use both methods First, do specific allocations based on use Then, allocate remaining overhead based on straight line 115 TABLE 9D: Patient Related Revenue 116 58

Table 9D: Patient Related Revenue Reports on a cash basis 2014 charges and cash income for patient services are reported by payor: Medicaid, Medicare, Other Public, Private and Self Pay Look alikes now complete all parts of this table, including retros and managed care 117 Charges Full Charges Column A: Undiscounted, unadjusted charges for services based on fee schedule; charges should cover costs Include all charges (medical, dental, pharmacy, mental health, etc.). Do not include charges where no collection is attempted or expected such as charges for enabling services, donated pharmaceuticals, or free vaccines. 118 59

Collections Collections Column B: Report all payments for health services including capitation payments, payments from patients, third party insurance, FQHC reconciliations, wrap around payments, and contract payments (e.g., payments from schools, jails) received during the year. Report by payor. Do not include meaningful use payments. 119 119 Adjustments Retroactive Payments Retroactive payments, etc. Columns c1 c4: Note: c1 c4 are included in Column B, but do not equal Column B Columns (c1) and (c2): reconciliation payments for FQHC or CHIP RA settlements (c1 from current year, c2 from prior year) Column (c3): Other Retroactive Payments including risk pools, incentives, PFP, withholds and court ordered payments Column (c4): amounts which are returned to third party (report as positive number) 120 60

Adjustments Allowances Allowances Column D: Reductions in payment by a third party based on a contract Allowances do not include disallowances: non payment for services that are not covered by the third party or that are rejected by the third party deductibles or co payments that are due from the patient and not paid by a third party Reduce allowances by any amounts of subsequent FQHC payments (reconciliations in Columns c1, c2 or c3) For capitated plans, Column D = Column A Column B 121 121 Adjustments Sliding Discounts Sliding Discounts Column E: A reduction in the amount charged (paid or owed) for services rendered which: is based solely on the patient s documented income and family size at the time of service as it relates to the federal poverty level may be applied to insured patients co payments, deductibles and non covered services when the charge has been moved to self pay if consistent with how uninsured patients are treated May not be applied to past due amounts Available on Self Pay, line 13 only 122 61

Adjustments Bad Debt Bad Debt Column F: Amounts owed by patients considered to be uncollectable and formally written off during the current calendar year, regardless of when the service was provided Only self pay bad debt is reported, not third party payor bad debt Do not report as a cost on Table 8A Bad debt can never be changed to a sliding discount Available on Self Pay, line 13 only 123 Payors: Medicaid and Medicare Lines 1 3: Medicaid All routine Medicaid EPSDT under any name Medicaid part of Medi Medi or crossovers CHIP, if paid through Medicaid May also include fees for other state programs which are paid by the Medicaid intermediary Lines 4 6: Medicare All routine Medicare Medicare Advantage Medicare portion of Medi Medi or crossovers 124 62

Payors: Other Public and Private Lines 7 9: Other Public State or other public insurance programs Non Medicaid CHIP programs State based programs which cover a specific service or disease (i.e., BCCCP, Title X, Title V, TB) Does not include indigent care programs NOTE: Patients who benefit from services paid for by other public payers are not necessarily counted as other public insurance on Table 4 Lines 10 12: Private Private and commercial insurance Medi gap programs, Tricare, Workers Comp. etc. Contracts with schools, jails, head start, etc. NOTE: Patients benefiting from private contracts may not be insured in these categories on Table 4 125 Payment Types Reported Each of the four third party payor categories has three payment types: Fee for service: Payment for each charge (or global fee) on the charge slip, encounter form, or bill Managed care capitated: Payments for each month the patient is enrolled in the program. In public programs, includes reconciliations to some prospective payment system (PPS) rates Managed care fee for service: Patient is assigned to doctor or clinic, but payment is only made when a charge is reported. Reconciliation to PPS rates occur in some public programs. 126 63

Payors: Self Pay Line 13: Self Pay Charges for which patients are responsible and all associated collections, including: Full fee patients Patients receiving sliding discounts Nominal fee or zero pay patients Co payments and/or deductibles Services not covered by a patient s insurance Services which form or will form the basis for state or local safety net (uncompensated care) funds Dental patients who only have medical insurance 127 Reclassify Charges It is essential to reclassify charges which are unpaid in whole or in part, not including allowances: This includes co payments and deductibles as well as charges for non covered services which are rejected by third parties Deduct unpaid charges or portion of charge from original payor (Medicaid, Medicare, Private, or Other Public) Add to charges on line for self pay or the secondary (tertiary, etc.) payor Show collections of these amounts on the appropriate line 128 64

TABLE 9E: Other Revenues 129 Table 9E: Other Revenues Report only non patient service income Cash basis amount received/drawn down during the year Report last party to handle funds before you received them Do not include: Capital received as loan Patient related revenue, including pharmaceuticals Value of donated services, supplies, or facilities Donated community value 130 65