Form 1 Outreach Final PIMS Measures

OMB Number: 0906-0009
Expiration date: 05/31/2018
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 0906-0009. Public reporting burden for this collection of
information is estimated to average 150 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 14N39, Rockville, Maryland, 20857.

Rural Health Care Services Outreach (Outreach) Grant Program

SECTION I: ACCESS TO CARE (applicable to all Outreach grantees)
Table Instructions: This table collects information about an aggregate count of the number of
people served through the program and the types of services that were provided during this budget
period. Please report responses using a numeric figure. If the total number is zero (0), please put
zero in the appropriate section. Do not leave any sections blank. There should not be an N/A (not
applicable) response since all measures are applicable to all grantees.
Please refer to these detailed definitions and guidelines in providing your answers to the following
measures:
Number of counties served in project and number of people in target population should be
consistent with the figures your program reported in your grant application. The number of counties
served should reflect your project’s service area.
Direct Services are defined as a documented interaction between a patient/client and a clinical or
non-clinical health professional that has been funded with ORHP grant dollars. Examples of direct
services include (but are not limited to) patient visits, counseling, and education.
For the purposes of this data collection activity, indirect services will be limited to:
1) billboards,
2) flyers,
3) health fairs,
4) mailings/newsletters, and
5) other mass media (radio, television, newspaper and social media)*
*For radio, television and newspaper please report estimated total circulation. For social media,
please report the reach (number of followers).
Baseline
1 Number of counties served in project
2 Number of people in the target population
(This is the number of people in your target
population, but not the number of people who
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OMB Number: 0906-0009
Expiration date: 05/31/2018
actually received your direct services)
3 Number of unique individuals who received
direct services during this budget period
Please report the number of unique (i.e.
unduplicated count) patients/clients that received
direct services from your organization
4 Number of individuals who received indirect
services during this budget period
Please report the total estimated number of
individuals your organization reaches through the
following indirect services: billboards, flyers,
health fairs, mailings/newsletters, and other mass
media (including social media). NOTE: You can
add together estimated totals across the various
indirect services you have completed. These
estimates may be obtained from vendors, health
fair organizers, etc. and added together to generate
an estimated total number of persons reached.
5 Type of new and/or expanded services provided
through this grant funding during this budget
period
Please check the box(es) that applies to your
program.
Cardiovascular disease prevention
Cardiovascular disease treatment and management
Case management
Dental/oral health education
Dental/oral health treatment
Diabetes prevention
Diabetes treatment and management
Emergency medical services
Health education
Maternal and child health
Mental/behavioral health treatment and/or
education
Nutrition
Obesity prevention
Obesity treatment and management
All other chronic disease prevention
All other chronic disease treatment and
management
All other health promotion/disease prevention
Primary care
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OMB Number: 0906-0009
Expiration date: 05/31/2018
Substance abuse treatment and/or education
Telehealth/telemedicine
Transportation
Workforce recruitment and/or retention
All other new and/or expanded services
Specify:

SECTION II: POPULATION DEMOGRAPHICS (applicable to all Outreach grantees)
Table Instructions: This table collects information about an aggregate count of the people served
by race, ethnicity, age and insurance status. The total for each of the following questions should
equal the total of the number of unique individuals who received only direct services reported in the
previous section. Please do not leave any sections blank. There should not be a N/A (not applicable)
response since the measures are applicable to all grantees. If the number for a particular category is
zero (0), please put zero in the appropriate section (e.g., if the total number that is Hispanic or
Latino is zero (0), enter zero in that section).
Number of people served through program by ethnicity (Hispanic or Latino/Not Hispanic or Latino)
is defined as:
 Hispanic or Latino origin includes Mexican, Mexican American, Chicano, Puerto Rican,
Cuban and other Hispanic, Latino or Spanish origin (i.e., Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, etc.)
Baseline

End of Budget
Period

Equal to the total
of the number of
unique individuals
who received
direct services

Equal to the total
of the number of
unique individuals
who received
direct services

6 Number of people served by ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown

Total (automatically calculated)
7 Number of people served by race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
More than one race
Unknown
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OMB Number: 0906-0009
Expiration date: 05/31/2018

Total (automatically calculated)
8 Number of people served, by age group:
Children (0-12)
Adolescents (13-17)
Adults (18-64)
Elderly (65 and over)
Unknown

Total (automatically calculated)
9 Number of people by insurance status:
Uninsured/self-pay
Dual Eligible (covered by both Medicaid and
Medicare)
Medicaid/CHIP only
Medicare only
Other third party
Unknown

Total (automatically calculated)

Equal to the total
of the number of
unique individuals
who received
direct services

Equal to the total
of the number of
unique individuals
who received
direct services

Equal to the total
of the number of
unique individuals
who received
direct services

Equal to the total
of the number of
unique individuals
who received
direct services

Equal to the total
of the number of
unique individuals
who received
direct services

Equal to the total
of the number of
unique individuals
who received
direct services

SECTION III: STAFFING (applicable to all Outreach grantees)
Table Instructions: This table collects information about an aggregate number of clinical and nonclinical positions funded by this grant during this budget period. If you are not sure who is funded
by this grant, please refer to the staffing plan and budget narrative that was submitted with your
grant application. Please report a numeric figure. There should not be a N/A (not applicable)
response since all measures are applicable to all grantees.
Please report each staff person who is funded by this program only once. If a staff person’s time is
split between clinical and non-clinical activities, please include that staff person within the category
that reflects the majority of their time.

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OMB Number: 0906-0009
Expiration date: 05/31/2018
Clinical staff includes, but is not limited to, physician (general or specialty), physician assistant,
nurse, nurse practitioner, dentist, dental hygienist, psychiatrist, social worker, pharmacist,
technician (medical, pharmacy, laboratory, etc.), therapist (behavioral, physical, occupational,
speech, etc.), health educator, community health worker, promotora, case manager,
interpreter/translator. Clinical staff are individuals that directly interact with patients/clinics.
Non-clinical staff includes management (CEO, CFO, CIO, etc.), support staff, fiscal and billing
staff, information technology (IT). Non-clinical staff are individuals that do not directly interact
with patients/clients.

10

Number of positions funded by grant dollars during
this budget period

End of Budget Period
Full-Time
Part-Time
(1.0 FTE)
(less than 1.0
FTE)

Total number of new clinical staff
Total number of new non-clinical staff

SECTION IV: CONSORTIUM/NETWORK (applicable to all Outreach grantees)
Table Instructions: This table collects information about an aggregate count of the types and
number of consortium/network members. Consortium/network members are defined as members
who have signed a Memorandum of Understanding or Memorandum of Agreement for this grant
project. There should not be a N/A (not applicable) response since the measures are applicable to all
grantees.
Please report information about collaboration among the consortium/network members. Refer to the
activities listed in the project workplan for this budget period.
11

Identify the types and number of organizations in the consortium/network for your
project:

Non-Profit
Organization

Type of Member Organizations in
the Consortium/Network
Area Health Education Center
Behavioral/Mental Health Organization
Community College
Community Health Center
Critical Access Hospital
Faith-based organization
Free Clinic
Health Department
Hospice
Hospital
Migrant Health Center
Private Practice
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End of Budget Period
Number

OMB Number: 0906-0009
Expiration date: 05/31/2018
Rural Health Clinic
School District
Social Services Organization
University
Other – Specify type
TOTAL for non-profit organization
For-Profit
Organization

Critical Access Hospital
Hospice
Hospital
Private Practice
Rural Health Clinic
Other – Specify Type
TOTAL for-profit organization

12

13

14

(Automatically
calculated by system)

Total number of NEW member organizations that joined
the consortium/network and signed the MOU/A during this
budget period.
How many activities from the project workplan were
initiated by at least two consortium/network members
during this budget period?

(Automatically
calculated by system)
Number

How many activities from the project workplan were
completed by at least two consortium/network members
during this budget period?

Number

Number

SECTION V: SUSTAINABILITY (applicable to all Outreach grantees)
Table Instructions: This table collects information/data about the grant’s programmatic
sustainability. There should not be a N/A (not applicable) response since the measures are
applicable to all grantees.
In Year 3 of grant funding, grantees will need to report on the additional measures:
• Question #20 - The ratio impact for Economic Impact vs. HRSA Program Funding using
HRSA’s Economic Impact Analysis Tool (http://www.raconline.org/econtool/)
 Question #21 - If your current consortium/network will sustain after the grant project period
is over
• Question #22 - If any of the activities will sustain after the grant project period is over
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Period
15

Annual program award
Please report the annual program award based on box 12a of your
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Dollar amount

OMB Number: 0906-0009
Expiration date: 05/31/2018
Notice of Award (NOA).
16

17
18

19

20

21
22

Annual program revenue
Please report the amount of annual program revenue made through the
services offered through the program. Program revenue is defined as
payments received for the services provided by the program that the
grant supports. These services should be the same services outlined in
your grant application work plan. Please do not include donations. If
the total amount of annual revenue made is zero (0), please put zero in
the appropriate section.
Additional funding already secured to assist in sustaining the
project
Sources of Sustainability
Select the type(s) of sources of funding for sustainability. Please check
all that apply.
Program revenue
In-kind Contributions (In-Kind contributions are defined as donations
of anything other than money, including goods or services/time.)
Membership fees/dues
Fundraising/ Monetary donations
Contractual Services
Other grants
Fees charged to individuals for services
Reimbursement from third-party payers (e.g. private insurance,
Medicare, Medicaid)
Product sales
Government (non-grant)
Other – specify type
None
Which of the following activities have you engaged in to enhance your
sustained impact? Check all that apply.
Local, State and Federal Policy changes
Media Campaigns
Community Engagement Activities
Other – Specify activity
What is your ratio for Economic Impact vs. HRSA Program
Funding?
Use the HRSA’s Economic Impact Analysis Tool
(http://www.raconline.org/econtool/) to identify your ratio.
Will the consortium/network sustain?
Will any of the program’s activities be sustained after the project
period?
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Dollar amount

Dollar amount

Selection list

Ratio

OMB Number: 0906-0009
Expiration date: 05/31/2018

SECTION VI: PROJECT SPECIFIC DOMAINS
HOME HEALTH (only applicable to projects that had home health activities that were funded by
this grant)
Table Instructions: If your grant supported any home health activities that were implemented
during this budget year, please discuss how you were able to measure “activities of daily living”.
The term "activities of daily living," or ADLs, refers to common, everyday tasks (ex: eating,
bathing, dressing, toileting, and transferring, performance) of which is required for personal selfcare and independent living. If your grant did support home health activities, but you do not know
the information, then select/enter DK (do not know). If your grant did not support any home health
activities, then select/enter N/A (not applicable).
23
24

What tool did you use to measure “Activities of Daily
Living”?
What was the average score/result based on the tool
that was used?

Text
Number

CARE COORDINATION (only applicable to projects that had care coordination activities
funded by this grant)
Table Instructions: If your grant supported any care coordination activities, select the
mechanisms/activities that were implemented during this budget year. Care coordination is defined
as care that is coordinated across all elements of the broader healthcare system. If your grant did
support care coordination activities, but you do not know the information, then select/enter DK (do
not know). If your grant did not support any care coordination activities, then select/enter N/A (not
applicable).

Baseline
25

Which of the following care
coordination mechanisms/activities
have you implemented during this
budget year? Select all that apply.
Facilitate transitions across settings
Linkage to community resources
Patient support and engagement
Case management
Create care plans
Medication management
Other – specify
Not applicable
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Year

OMB Number: 0906-0009
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INTEGRATION OF CARE (only applicable to projects that had integration of care activities
funded by this grant)
Table Instructions: If your grant supported any integration of care activities, select the activities
that were implemented during this budget year. Integration of care is defined as systematic
coordination of general/primary care and other types of care (ex: behavioral health, substance
abuse, mental health, oral health). If your grant did support integration of care activities, but you do
not know the information, then select/enter DK (do not know). If your grant did not support any
integration of care activities, then select/enter N/A (not applicable).
26

Which of the following care
integration activities have you
implemented during this budget
period? Select all that apply
Care team expertise – develop a
unified care plan that builds a team—
with necessary members and
functions—to care for a given patient
Clinical workflow – clinical protocols
and workflows are clearly documented
for integration of care
Patient identification – establish
systematic methods to identify
individuals for integrated care
Clinical outcomes – monitor patient’s
clinical outcomes to assess impact of
integration of care
Other – specify
Not applicable

Baseline

End of Budget
Period

WORKFORCE/ RECRUITMENT & RETENTION (only applicable to projects that focused on
student/resident workforce recruitment and retention)
Table Instructions: This table collects information/data about student/resident workforce
recruitment and/or retention activities during this budget period. Please refer to the detailed
definitions and guidelines to provide responses for the following measures. Please report a numeric
figure; if the total number is zero, please put zero (0) in the appropriate section. Do not leave any
sections blank. If your grant did support workforce recruitment and/or retention activities, but you
do not know the information, then select/enter DK (do not know). If your grant did not support any
student/resident workforce recruitment and/or retention activities, then select/enter N/A (not
applicable).
For the purposes of this data collection, “trainees” are persons who are working towards a
professional degree.
Trainees (students and residents) are considered “New” if:
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1. They have never engaged in a training/rotation within a rural community as a part of their
certificate/degree/residency program and/or
2. They do not self-identify as “having lived”/ “living”/ “claiming residence” within a rural
area.
Trainees (students and residents) are considered “Existing” if:
1. They have had prior exposure to rural areas by either engaging in a training/rotation within
a rural area as a part of their certificate/degree/residency program prior to the respective
budget year and/or
2. They self-identify as “having lived”/ “living”/ “claiming residence” within a rural area.
Please report the number of trainees by type that complete the trainings/rotations; this figure should
not exceed the total number of all trainees recruited by type. Please also report the number of
trainees by type that plan to practice in a rural area after completing their trainings/rotations. Of
those trainees that completed their trainings/rotations, please specify the number that returned to
formally practice in rural areas; for this measure, please report a numeric figure or indicate DK for
“do not know”. For example, if zero (0) students completed their trainings/rotations and returned to
formally practice in a rural area, please put zero (0) in the appropriate section. Do not leave any
sections blank.
STUDENTS
27

Number of New Trainees
Recruited to Work on the
Program:
Number of New
Number of Existing
TOTAL (Number
(automatically calculated
by the system)
Of the total number
recruited, how many
completed the
training/rotation
Of the total number that
complete the
training/rotation, how many
plan to practice in a rural
area
Percentage trained that plan
to practice in a rural area
(automatically calculated by
the system)
Of the total number that
complete the
training/rotation, how many

Baseline

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End of
Budget
Year

RESIDENTS
Baseline

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returned to formally practice
in rural areas
Percentage trained that return
to formally practice in rural
areas (automatically
calculated by the system)
28

Trainee Primary Care Focus Area(s):
Medical
Mental/Behavioral Health
Oral Health

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Number

OMB Number: 0906-0009
Expiration date: 05/31/2018
29

Trainee Discipline Type(s):
Note that psychiatrists are either allopathic (MD) or
osteopathic (DO) physicians. Also, please specify the types of
non-physician practitioners, nurses, and allied health
professionals as appropriate. For example, physician assistants,
nurse practitioners, certified nurse mid-wives, and certified
registered nurse anesthesiologists are considered non-physician
practitioners. Allied health professionals include dental
hygienists, diagnostic medical sonographers, dietitians, medical
technologists, occupational therapists, physical therapists,
pharmacists, radiographers, respiratory therapists, community
health workers, and speech language pathologists. If the
targeted trainee does not fall under the listed categories, please
refer to the detailed definition for Allied Health Professionals
and specify the discipline(s) in the Allied Health Professionals
category.
Please check all that apply.
Allied Health Professional – Please specify type(s)
Dentist
Non-physician practitioners – Please specify type(s)
Nurse – Please specify type(s)
Physician (DO)
Physician (MD)
Baseline

30

31

Number of New Trainings/Rotations provided:
Please report the number of trainings/rotations provided
during the respective budget period. Please report a
numeric figure. If the total number of trainings/rotations is
zero (0), please put zero in the appropriate section. Do not
leave any sections blank.
Number of Training Site(s) by Type:
Please report the number of training sites by type where
the trainings/rotations were conducted. Please report a
numeric figure. If the total number of training sites is zero
(0), please put zero in the appropriate section. Do not
leave any sections blank.
Critical Access Hospital
Other Rural Hospital
Clinic
Rural Health Clinic
Community Health Center
Federally Qualified Health Center (FQHC)
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Number

End of
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Period

OMB Number: 0906-0009
Expiration date: 05/31/2018
Health Department
Indian Health Service (IHS) or Tribal Health Sites
Migrant Health Center (MHC)
Other Community Based Site – Please specify type(s)
COMMUNITY HEALTH PREVENTION, EDUCATION, AND PROMOTION (only
applicable to projects that had community health prevention, education, and promotion activities
funded by this grant)
Table Instructions: This table collects information/ data about the types of preventative services
that were funded with this grant and the outputs for the respective preventative services. Preventive
services consist of screening tests, counseling, immunizations or medications used to prevent
disease, detect health problems early, or provide people with the information they need to make
good decisions about their health. While preventive services are traditionally delivered in clinical
settings, some can be delivered within communities, work sites, schools, residential treatment
centers, or homes. If your grant did support community health prevention, education and promotion
activities, but you do not know the information, then select/enter DK (do not know). If your grant
did not support any community health prevention, education and/or promotion activities, then
select/enter N/A (not applicable).
Baseline
32

33
34

35

36

Total number of health
screenings held in clinical
and non-clinical settings
Total number of health
screening participants
Of the total number of
health screening
participants, how many
were referred to a health
care provider?
Total number of health
education/counseling
activities (these are
activities aimed at
improving knowledge,
attitudes, self-efficacy
and individual capacity
to change) held
Total number of
participants who
participated in health
education/counseling
activities
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End of Budget
Period

OMB Number: 0906-0009
Expiration date: 05/31/2018
MENTAL/BEHAVIORAL HEALTH (only applicable to projects that had mental/behavioral
health activities funded by this grant)
Table Instructions: This table collects information about an aggregate number of people receiving
mental and/or behavioral health services among the unique individuals who received direct services.
This number should not exceed the number of unique individuals receiving direct services. If you
provided direct mental/behavioral health care, please answer clinical measure #3 (if applicable).
This clinical measure is found under the “Clinical Measures” section. If your grant did support
mental/behavioral health activities, but you do not know the information, then select/enter DK (do
not know). If your grant did not support any mental/behavioral health activities, then select/enter
N/A (not applicable).
Baseline
37

Number of people receiving mental and/or
behavioral health services (among the unique
individuals receiving direct services).

38

Is your project working on integrating
primary care and mental/behavioral health
services? (y/n)

Should not
exceed the # of
unique
individuals
receiving direct
services

End of Budget
Period
Should not
exceed the # of
unique
individuals
receiving direct
services

DENTAL/ORAL HEALTH (only applicable to projects that had oral health activities funded by
this grant)
Table Instructions: Use this table to report the aggregate number(s) of persons receiving
dental/oral health services among those unique individuals (e.g., an unduplicated count of persons)
who received direct services. Aggregate number(s) should not exceed the number of unique
individuals who received direct services. If you provided direct patient dental/oral health care,
please answer clinical measure #2 (if applicable). This clinical measure is found under the “Clinical
Measures” section. If your grant did support dental/oral health activities, but you do not know the
information, then select/enter DK (do not know). If your grant did not support any dental/oral
activities, then select/enter N/A (not applicable).
Baseline
39

Number of people receiving dental / oral
health services (among the unique individuals
receiving direct services).

40

Is your project working on integrating
primary care and dental/oral health services?
Page 14 of 19

Should not
exceed the # of
unique
individuals
receiving direct
services

End of Budget
Period
Should not
exceed the # of
unique
individuals
receiving direct
services

OMB Number: 0906-0009
Expiration date: 05/31/2018

41

(y/n)
Type(s) and quantity of dental/oral health services provided.
Please report the number of persons who received specific dental/oral health services
during this budget period. Report a numeric figure or indicate N/A for “not applicable” if
your grant program did not fund this particular service.
Baseline
End of Budget
Period
Screenings / Exams
Sealants
Varnish
Oral Prophylaxis
Restorative
Extractions
Health education
Other (please specify):

CLINICAL MEASURES (only applicable to projects in which direct outpatient care was
provided under this grant)
Table Instructions: This table collects information about measures for the clinical outcomes of
certain direct outpatient care services provided to the unique individuals who received direct
services funded by this grant during this budget period. The denominator for all measures should be
based only on the population of unique persons (i.e., an unduplicated count of persons) who
received direct services through this grant during this budget period.
If your grant did support direct outpatient care services, but you do not know the information for
that particular clinical measure, then select/enter DK (do not know). If your grant did not support
direct outpatient care services related to that particular clinical measure, then select/enter N/A (not
applicable).
////////////////////
Measure 1 – Hospitalization for Ambulatory Care Sensitive Condition – Diabetes Short Term
Complications: The rate of admissions for a principal diagnosis of diabetes with short-term
complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 population, ages 18 years and
older.
Measure 2 – Tooth loss: Percentage of adults with permanent tooth loss due to dental caries or
periodontal disease.
Measure 3 - Screening for clinical depression: Percentage of patients aged 12 years and older
screened for clinical depression using an age appropriate standardized tool AND a documented
follow-up plan.

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Measure 4 - Controlling high blood pressure: Percentage of adult patients, 18-85 years of age, who
had a diagnosis of hypertension whose blood pressure was adequately controlled during the budget
period.
Measure 5 – Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%): Percent
of adult patients, 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c less
than 8.0%.
Measure 6 - Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg): The
percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent blood
pressure (BP) reading is <140/90 mm Hg during the budget period.
Measure 7 - Comprehensive Diabetes Care: LDL-C Control <100 mg/dL: Percent of adult
patients, 18- 75 years of age with diabetes (type 1 or type 2) who had LDL-C less than 100 mg/dL.
Measure 8 - Weight Assessment and Counseling for Nutrition and Physical Activity for
Children/Adolescents: Percentage of patients 3-17 years of age who had an outpatient visit with a
primary care physician (PCP) or an OB/GYN and who had evidence of the following during the
budget period:
- Body mass index (BMI) percentile documentation
- Counseling for nutrition
- Counseling for physical activity
Measure 9 - Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up:
Percentage of patients aged 18 years and older with a documented BMI 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
encounter.
Clinical Measures

Numerator (Number)

Denominator
(Number)

1

Hospitalization for Ambulatory
Care Sensitive Condition –
Diabetes Short Term
Complications: The rate of
admissions for a principal
diagnosis of diabetes with
short-term complications
(ketoacidosis, hyperosmolarity,
or coma) per 100,000
population, ages 18 years and
older.

Discharges for patients
18 years and older, with a
principal ICD-9-CM
diagnosis code for
diabetes short term
complications
(ketoacidosis,
hyperosmolarity, or
coma)

Among the unique
individuals who
received the Outreach
grant funded direct
services, the number of
people ages 18 years
and older in the target
service area

2

Tooth loss
Percentage of adults with

Number of persons aged
45 to 64 years with a

Among the unique
individuals who

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Percent/Rate
(Automatically
calculated by
system)

OMB Number: 0906-0009
Expiration date: 05/31/2018

3

4

permanent tooth loss due to
dental caries or periodontal
disease

clinical confirmation of
less than 28 natural teeth
present (tooth loss due to
caries or periodontal
disease) exclusive of
third molars.

Screening for clinical
depression: Percentage of
patients aged 12 years and older
screened for clinical depression
using an age appropriate
standardized tool AND followup plan documented.
Controlling High Blood
Pressure: Percentage of adult
patients, 18-85 years of age,
who had a diagnosis of
hypertension and whose blood
pressure was adequately
controlled during the
measurement year

Patients screened for
clinical depression using
an age appropriate
standardized tool AND
follow-up plan is
documented

5

Comprehensive Diabetes Care:
Hemoglobin A1c (HbA1c)
Control (<8.0%): Percent of
adult patients, 18-75 years of
age with diabetes (type 1 or
type 2) who had hemoglobin
A1c less than 8.0%

6

Comprehensive Diabetes Care:
Blood Pressure Control
(<140/90 mm Hg): The
percentage of patients 18-75
years of age with diabetes (type

The number of patients in
the denominator whose
most recent BP is
adequately controlled
during the budget period.
For a patient’s BP to be
controlled, both the
systolic and diastolic BP
must be <140/90
(adequate control). To
determine if a patient’s
BP is adequately
controlled, the
representative BP must
be identified.
Patients whose HbA1c
level is <8.0% during the
budget period.

Patients whose most
recent BP reading is
<140/90 mm Hg during
the budget period.
Page 17 of 19

received the Outreach
grant funded direct
services, the number of
persons aged 45 to 64
years with valid codes
for 28 permanent teeth,
exclusive of third
molars
Among the unique
individuals who
received the Outreach
grant funded direct
services, all patients
aged 12 years and older
Among the unique
individuals who
received the Outreach
grant funded direct
services, patients 18-85
years of age by the end
of the budget period
who had at least one
outpatient encounter
with a diagnosis of
hypertension (HTN)
during the first six
months of the budget
period.
Among the unique
individuals who
received the Outreach
grant funded direct
services, patients 18-75
years of age by the end
of the budget period
who had a diagnosis of
diabetes (type 1 or type
2) during the budget
period or the year prior
to the budget period.
Among the unique
individuals who
received the Outreach
grant funded direct
services, patients 18-75

OMB Number: 0906-0009
Expiration date: 05/31/2018
1 and type 2) whose most recent
blood pressure (BP) reading is
<140/90 mm Hg during the
budget period.

7

Comprehensive Diabetes Care:
LDL-C Control <100 mg/dL:
Percent of adult patients, 18-75
years of age with diabetes (type
1 or type 2) who had LDL-C
less than 100 mg/dL

Patients whose most
recent LDL-C test is
<100 mg/dL during the
budget period.

8

Weight Assessment and
Counseling for Nutrition and
Physical Activity for
Children/Adolescents:
Percentage of patients 3-17
years of age who had an
outpatient visit with a primary
care physician (PCP) or an
OB/GYN and who had
evidence of the following
during the budget period:
- Body mass index (BMI)
percentile documentation
- Counseling for nutrition
- Counseling for physical
activity
Preventive Care and Screening:
Body Mass Index (BMI)
Screening and Follow-Up:
Percentage of patients aged 18
years and older with a
documented BMI 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

Body mass index (BMI)
percentile
documentation,
counseling for nutrition
and counseling for
physical activity during
the budget period.

9

Patients with a
documented BMI during
the encounter or during
the previous six months,
AND when the BMI is
outside of normal
parameters, follow-up is
documented during the
encounter or during the
previous six months of
the encounter with the
BMI outside of normal
Page 18 of 19

years of age by the end
of the budget period
who had a diagnosis of
diabetes (type 1 or type
2) during the budget
period or the year prior
to the budget period.
Among the unique
individuals who
received the Outreach
grant funded direct
services, patients 18-75
years of age by the end
of the budget period
who had a diagnosis of
diabetes (type 1 or type
2) during the budget
period or the year prior
to the budget period
Among the unique
individuals who
received the Outreach
grant funded direct
services, patients 3-17
years of age with at
least one outpatient
visit with a primary
care physician (PCP) or
OB-GYN.

Among the unique
individuals who
received the Outreach
grant funded direct
services, all patients
aged 18 years and older

OMB Number: 0906-0009
Expiration date: 05/31/2018
previous six months of the
encounter.

parameters

Page 19 of 19