Form 2 Grant Report - 2020 UDS Tables Redline

OMB No. 0915-0193

Expires: XX/XX/20XX

Table: Patients by ZIP Code

Reporting Period: January 1, 2019, through December 31, 2019

ZIP Code (a)	None/ Uninsured (b)	Medicaid/ CHIP/Other Public (c)	Medicare (d)	Private (e)	Total Patients (f)
[Blank for demonstration]
[Blank for demonstration]
Other ZIP Codes
Unknown Residence
Total

Note: This is a representation of the form. The actual online input process looks significantly different and the printed output from the EHBs may be modified.

Table 3A: Patients by Age and by Sex Assigned at Birth

Reporting Period: January 1, 2019, through December 31, 2019

Line	Age Groups	Male Patients (a)	Female Patients (b)
1	Under age 1
2	Age 1
3	Age 2
4	Age 3
5	Age 4
6	Age 5
7	Age 6
8	Age 7
9	Age 8
10	Age 9
11	Age 10
12	Age 11
13	Age 12
14	Age 13
15	Age 14
16	Age 15
17	Age 16
18	Age 17
19	Age 18
20	Age 19
21	Age 20
22	Age 21
23	Age 22
24	Age 23
25	Age 24
26	Ages 25–29
27	Ages 30–34
28	Ages 35–39
29	Ages 40–44
30	Ages 45–49
31	Ages 50–54
32	Ages 55–59
33	Ages 60–64
34	Ages 65–69
35	Ages 70–74
36	Ages 75–79
37	Ages 80–84
38	Age 85 and over
39	Total Patients (Sum of Lines 1-38)

Table 3B: Demographic Characteristics

Reporting Period: January 1, 2019, through December 31, 2019

Patients by Race and Hispanic or Latino Ethnicity

Line	Patients by Race	Hispanic/ Latino (a)	Non- Hispanic/ Latino (b)	Unreported/Refused to Report Ethnicity (c)	Total (d) (Sum Columns a+b+c)
1	Asian
2a	Native Hawaiian
2b	Other Pacific Islander
2	Total Native Hawaiian/Other Pacific Islander (Sum Lines 2a + 2b)
3	Black/African American
4	American Indian/Alaska Native
5	White
6	More than one race
7	Unreported/Refused to report race
8	Total Patients (Sum of Lines 1 + 2 + 3 to 7)

Line	Patients Best Served in a Language Other than English	Number (a)
12	Patients Best Served in a Language Other than English

Line	Patients by Sexual Orientation	Number (a)		Line	Patients by Gender Identity	Number (a)
13	Lesbian or Gay			20	Male
14	Straight (not lesbian or gay)			21	Female
15	Bisexual			22	Transgender Male/Female-to- Male
16	Something else			23	Transgender Female/Male-to- Female
17	Don’t know			24	Other
18	Chose not to disclose			25	Chose not to disclose
19	Total Patients (Sum of Lines 13 to 18)			26	Total Patients (Sum of Lines 20 to 25)

Table 4: Selected Patient Characteristics

Reporting Period: January 1, 2019, through December 31, 2019

Line	Income as Percent of Poverty Guideline	Number of Patients (a)
1	100% and below
2	101–150%
3	151–200%
4	Over 200%
5	Unknown
6	TOTAL (Sum of Lines 1–5)

Line	Principal Third-Party Medical Insurance	0-17 years old (a)	18 and older (b)
7	None/Uninsured
8a	Medicaid (Title XIX)
8b	CHIP Medicaid
8	Total Medicaid (Line 8a + 8b)
9a	Dually Eligible (Medicare and Medicaid)
9	Medicare (Inclusive of dually eligible and other Title XVIII beneficiaries)
10a	Other Public Insurance (Non-CHIP) (specify)
10b	Other Public Insurance CHIP
10	Total Public Insurance (Line 10a + 10b)
11	Private Insurance
12	TOTAL (Sum of Lines 7 + 8 + 9 +10 +11)

Line	Managed Care Utilization	Medicaid (a)	Medicare (b)	Other Public Including Non- Medicaid CHIP (c)	Private (d)	TOTAL (e)
13a	Capitated Member Months
13b	Fee-for-service Member Months
13c	Total Member Months (Sum of Lines 13a + 13b)

Table 4: Selected Patient Characteristics (continued)

Reporting Period: January 1, 2019, through December 31, 2019

Line	Special Populations	Number of Patients (a)
14	Migratory (330g awardees only)
15	Seasonal (330g awardees only)
16	Total Agricultural Workers or Dependents (All health centers report this line)
17	Homeless Shelter (330h awardees only)
18	Transitional (330h awardees only)
19	Doubling Up (330h awardees only)
20	Street (330h awardees only)
21a	Permanent Supportive Housing (330h awardees only)
21	Other (330h awardees only)
22	Unknown (330h awardees only)
23	Total Homeless (All health centers report this line)
24	Total School-Based Health Center Patients (All health centers report this line)
25	Total Veterans (All health centers report this line)
26	Total Patients Served at a Health Center Located In or Immediately Accessible to a Public Housing Site (All health centers report this line)

Table 5: Staffing and Utilization

Reporting Period: January 1, 2019, through December 31, 2019

Line	Personnel by Major Service Category	FTEs (a)	Clinic Visits (b)	Virtual Visits (b2)	Patients (c)
1	Family Physicians
2	General Practitioners
3	Internists
4	Obstetrician/Gynecologists
5	Pediatricians
7	Other Specialty Physicians
8	Total Physicians (Lines 1–7)
9a	Nurse Practitioners
9b	Physician Assistants
10	Certified Nurse Midwives
10a	Total NPs, PAs, and CNMs (Lines 9a–10)
11	Nurses
12	Other Medical Personnel
13	Laboratory Personnel
14	X-ray Personnel
15	Total Medical (Lines 8 + 10a through 14)
16	Dentists
17	Dental Hygienists
17a	Dental Therapists
18	Other Dental Personnel
19	Total Dental Services (Lines 16–18)
20a	Psychiatrists
20a1	Licensed Clinical Psychologists
20a2	Licensed Clinical Social Workers
20b	Other Licensed Mental Health Providers
20c	Other Mental Health Staff
20	Total Mental Health (Lines 20a–c)
21	Substance Use Disorder Services
22	Other Professional Services (specify )

Table 5: Staffing and Utilization (continued)

Reporting Period: January 1, 2019, through December 31, 2019

Line	Personnel by Major Service Category	FTEs (a)	Clinic Visits (b)	Virtual Visits (b2)	Patients (c)
22a	Ophthalmologists
22b	Optometrists
22c	Other Vision Care Staff
22d	Total Vision Services (Lines 22a–c)
23	Pharmacy Personnel
24	Case Managers
25	Patient/Community Education Specialists
26	Outreach Workers
27	Transportation Staff
27a	Eligibility Assistance Workers
27b	Interpretation Staff
27c	Community Health Workers
28	Other Enabling Services (specify )
29	Total Enabling Services (Lines 24–28)
29a	Other Programs/Services (specify )
29b	Quality Improvement Staff
30a	Management and Support Staff
30b	Fiscal and Billing Staff
30c	IT Staff
31	Facility Staff
32	Patient Support Staff
33	Total Facility and Non-Clinical Support Staff (Lines 30a–32)
34	Grand Total (Lines 15+19+20+21+22+22d+23+29+29a+29b+33)

Table 5: Selected Service Detail Addendum

Reporting Period: January 1, 2019, through December 31, 2019

Line	Personnel by Major Service Category: Mental Health Service Detail	Personnel (a1)	Clinic Visits (b)	Virtual Visits (b2)	Patients (c)
20a01	Physicians (other than Psychiatrists)
20a02	Nurse Practitioners
20a03	Physician Assistants
20a04	Certified Nurse Midwives
Line	Personnel by Major Service Category: Substance Use Disorder Detail	Personnel (a1)	Clinic Visits (b)	Virtual Visits (b2)	Patients (c)
21a	Physicians (other than Psychiatrists)
21b	Nurse Practitioners (Medical)
21c	Physician Assistants
21d	Certified Nurse Midwives
21e	Psychiatrists
21f	Licensed Clinical Psychologists
21g	Licensed Clinical Social Workers
21h	Other Licensed Mental Health Providers

Table 6A: Selected Diagnoses and Services Rendered

Reporting Period: January 1, 2019, through December 31, 2019

Line	Diagnostic Category	Applicable ICD-10-CM Code	Number of Visits by Diagnosis Regardless of Primacy (a)	Number of Patients with Diagnosis (b)
Selected Infectious and Parasitic Diseases
1-2	Symptomatic/Asymptomatic human immunodeficiency virus (HIV)	B20, B97.35, O98.7-, Z21
2a	Pre-Exposure Prophylaxis (PrEP) Prescription	Through possible exposure risk at encounters: Z20.2, Z11.4, Z11.3, Z20.6, Z72.5, Z72.51, Z72.52, Z72.53, Z11.59, Z20.5, Z71.7, F19.20, Z70.1, Z20.82, Z77.21, Z77.9, W46, W46.0, W46.1 Through possible counseling during initiation or continuation: (CPT codes) 99201-99205, 99211-99215, 99401-99404, 99411, 99412 Through possible lab codes during initiation or surveillance: (CPT codes) 86689, 86701-86703, 87534-87539, 87389-87391, G0432, G0433, G0435 Z01.812, Z51.81, Z79.899, Z86.59, Z87.898, F11.20, F11.21, F11.10, F11.90 Through codes associated with possible PrEP prescribing: Z79.899 and (RXNorm codes) Truvada 495430, Descovy 1747692, TDF 322248, FTC 276237, TAF 1721604
3	Tuberculosis	A15- through A19-, O98.0-
4	Sexually transmitted infections	A50- through A64- (exclude A63.0)
4a	Hepatitis B	B16.0 through B16.2, B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, O98.4-
4b	Hepatitis C	B17.10, B17.11, B18.2, B19.20, B19.21
Selected Diseases of the Respiratory System
5	Asthma	J45-
6	Chronic lower respiratory diseases	J40- through J44-, J47-
Selected Other Medical Conditions
7	Abnormal breast findings,	C50.01-, C50.11-, C50.21-,
	female	C50.31-, C50.41-, C50.51-,
		C50.61-, C50.81-, C50.91-,
		C79.81, D05-, D48.6-, D49.3, N60-
		, N63-, R92-
8	Abnormal cervical findings	C53-, C79.82, D06-, R87.61-, R87.629, R87.810, R87.820

Table 6A: Selected Diagnoses

Selected Diseases of the Respiratory System

Selected Other Medical

Line	Diagnostic Category	Applicable ICD-10-CM Code	Number of Visits by Diagnosis Regardless of Primacy (a)	Number of Patients with Diagnosis (b)
9	Diabetes mellitus	E08- through E13-, O24- (exclude O24.41-)
10	Heart disease (selected)	I01-, I02- (exclude I02.9), I20- through I25-, I27-, I28-, I30- through I52-
11	Hypertension	I10- through I16-, O10-, O11-
12	Contact dermatitis and other eczema	L23- through L25-, L30- (exclude L30.1, L30.3, L30.4, L30.5), L58-
13	Dehydration	E86-
14	Exposure to heat or cold	T33-, T34-, T67-, T68-, T69-, W92-, W93-
14a	Overweight and obesity	E66-, Z68- (exclude Z68.1, Z68.20 through Z68.24, Z68.51, Z68.52)
Selected Childhood Conditions (limited to ages 0 through 17)
15	Otitis media and Eustachian tube disorders	H65- through H69-
16	Selected perinatal/neonatal medical conditions	A33-, P19-, P22- through P29- (exclude P29.3), P35- through P96- (exclude P54-, P91.6-, P92-, P96.81), R78.81, R78.89
17	Lack of expected normal physiological development (such as delayed milestone, failure to gain weight, failure to thrive); nutritional deficiencies in children only. Does not include sexual or mental development.	E40- through E46-, E50- through E63-, P92-, R62- (exclude R62.7), R63.3
Selected Mental Health Conditions and Substance Use Disorders
18	Alcohol-related disorders	F10-, G62.1, O99.31-
19	Other substance-related disorders (excluding tobacco use disorders)	F11- through F19- (exclude F17-), G62.0, O99.32-
19a	Tobacco use disorder	F17-, O99.33-
20a	Depression and other mood disorders	F30- through F39-
20b	Anxiety disorders, including post-traumatic stress disorder (PTSD)	F06.4, F40- through F42-, F43.0, F43.1-, F93.0
20c	Attention deficit and disruptive behavior disorders	F90- through F91-

Selected Childhood Conditions

Selected Mental Health and Substance Abuse Conditions

Line	Diagnostic Category	Applicable ICD-10-CM Code	Number of Visits by Diagnosis Regardless of Primacy (a)	Number of Patients with Diagnosis (b)
20d	Other mental disorders, excluding drug or alcohol dependence	F01- through F09- (exclude F06.4), F20- through F29-, F43- through F48- (exclude F43.0- and F43.1-), F50- through F99- (exclude F55-, F84.2, F90-, F91-, F93.0, F98-), O99.34-, R45.1, R45.2, R45.5, R45.6, R45.7, R45.81, R45.82, R48.0
20e	Human Trafficking	T74.5- through T74.6-, T76.5- through T76.6-, Z04.8-, Z62.813, Z91.42
20f	Intimate Partner Violence	T74.11, T74.21, T74.31, Z69.11, Y07.0

Line	Service Category	Applicable ICD-10-CM Code or CPT-4/II Code		Number of Visits (a)	Number of Patients (b)
Selected Diagnostic Tests/ Screening/Preventive Services
21	HIV test	CPT-4: 86689, 86701 through 86703, 87389 through 87391, 87534 through 87539, 87806
21a	Hepatitis B test	CPT-4: 86704 through 86707, 87340, 87341, 87350
21b	Hepatitis C test	CPT-4: 86803, 86804, 87520 through 87522
22	Mammogram	CPT-4: 77065, 77066, 77067	OR
		ICD-10: Z12.31
23	Pap test	CPT-4: 88141 through 88153, 88155, 88164 through 88167, 88174, 88175 OR ICD-10: Z01.41-, Z01.42, Z12.4 (exclude Z01.411 and Z01.419)
24	Selected immunizations: hepatitis A; haemophilus influenzae B (HiB); pneumococcal, diphtheria, tetanus, pertussis (DTaP) (DTP) (DT); mumps, measles, rubella (MMR); poliovirus; varicella; hepatitis B	CPT-4: 90632, 90633, 90634, 90636, 90643, 90644, 90645, 90646, 90647, 90648, 90669, 90670, 90696, 90697, 90698, 90700, 90701, 90702, 90703, 90704, 90705, 90706, 90707, 90708, 90710, 90712, 90713, 90714, 90715, 90716, 90718, 90720, 90721, 90723, 90730, 90731, 90732, 90740, 90743, 90744, 90745, 90746, 90747, 90748
24a	Seasonal flu vaccine	CPT-4: 90630, 90653 through 90657, 90658, 90661, 90662, 90672, 90673, 90674, 90682, 90685 through 90689, 90749, 90756
25	Contraceptive management	ICD-10: Z30-
26	Health supervision of infant or child (ages 0 through 11)	CPT-4: 99381 through 99383, 99391 through 99393 ICD-10: Z00.1-
26a	Childhood lead test screening (9 to 72 months)	ICD-10: Z13.88 CPT-4: 83655
26b	Screening, Brief Intervention, and Referral to Treatment (SBIRT)	CPT-4: 99408, 99409 HCPCS: G0396, G0397, G0443, H0050
26c	Smoke and tobacco use cessation counseling	CPT-4: 99406, 99407 OR HCPCS: S9075 OR CPT-II: 4000F, 4001F, 4004F
26d	Comprehensive and intermediate eye exams	CPT-4: 92002, 92004, 92012, 92014

Table 6A: Selected Services Rendered

Selected Diagnostic

Line	Service Category	Applicable ADA Code	Number of Visits (a)	Number of Patients (b)
Selected Dental Services
27	Emergency services	ADA: D0140, D9110
28	Oral exams	ADA: D0120, DO145, D0150, D0160, D0170, D0171, D0180
29	Prophylaxis–adult or child	ADA: D1110, D1120
30	Sealants	ADA: D1351
31	Fluoride treatment–adult or child	ADA: D1206, D1208 CPT-4: 99188
32	Restorative services	ADA: D21xx through D29xx
33	Oral surgery (extractions and other surgical procedures)	ADA: D7xxx
34	Rehabilitative services (Endo, Perio, Prostho, Ortho)	ADA: D3xxx, D4xxx, D5xxx, D6xxx, D8xxx

Sources of Codes:

• ICD-10-CM (2019)–National Center for Health Statistics (NCHS)

• CPT (2019)–American Medical Association (AMA)

• Code on Dental Procedures and Nomenclature CDT Code (2019)–Dental Procedure Codes. American Dental Association (ADA)

Note: “X” in a code denotes any number including the absence of a number in that place. Dashes (–) in a code indicate that additional characters are required. ICD-10-CM codes all have at least four digits. These codes are not intended to reflect if a code is billable or not. Instead, they are used to point out that other codes in the series are to be considered.

Table 6B: Quality of Care Measures

Reporting Period: January 1, 2019, through December 31, 2019

0

Prenatal Care Provided by Referral Only (Check if Yes)

Section A – Age Categories for Prenatal Care Patients: Demographic Characteristics of Prenatal Care Patients

Line	Age	Number of Patients (a)
1	Less than 15 years
2	Ages 15-19
3	Ages 20-24
4	Ages 25-44
5	Ages 45 and over
6	Total Patients (Sum of Lines 1-5)

Line	Early Entry into Prenatal Care	Women Having First Visit with Health Center (a)	Women Having First Visit with Another Provider (b)
7	First Trimester
8	Second Trimester
9	Third Trimester

Line	Childhood Immunization Status	Total Patients with 2nd Birthday (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Immunized (c)
10	MEASURE: Percentage of children 2 years of age who received age appropriate vaccines by their 2nd birthday

Line	Cervical Cancer Screening	Total Female Patients Aged 23 through 64 (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Tested (c)
11	MEASURE: Percentage of women 23- 64 years of age who were screened for cervical cancer
Line	Breast Cancer Screening	Total Female Patients Aged 50 through 74 (a)	Number Charts Sampled or EHR total (b)	Number of Patients with Mammogram (c)
11a	MEASURE: Percentage of women 50- 74 years of age who had a mammogram to screen for breast cancer

Section E - Weight Assessment and Counseling for Nutrition and Physical Activity of Children and Adolescents

Line	Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents	Total Patients Aged 3 through 17 (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with Counseling and BMI Documented (c)
12	MEASURE: Percentage of patients 3– 17 years of age with a BMI percentile and counseling on nutrition and physical activity documented

Section F – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Line	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Total Patients Aged 18 and Older (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with BMI Charted and Follow-Up Plan Documented as Appropriate (c)
13	MEASURE: Percentage of patients 18 years of age and older with (1) BMI documented and (2) follow-up plan documented if BMI is outside normal parameters

Section G – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Line	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Total Patients Aged 18 and Older (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Assessed for Tobacco Use and Provided Intervention if a Tobacco User (c)
14a	MEASURE: Percentage of patients aged 18 years of age and older who (1) were screened for tobacco use one or more times within 24 months, and (2) if identified to be a tobacco user received cessation counseling intervention

Section H – Use of Appropriate Medications for Asthma

Line	Use of Appropriate Medications for Asthma	Total Patients Aged 5 through 64 with Persistent Asthma (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with Acceptable Plan (c)
16	MEASURE: Percentage of patients 5 through 64 years of age identified as having persistent asthma and were appropriately ordered medication

Section I - Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Line	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Total Patients Aged 21 and Older at High Risk of Cardiovascular Events (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Prescribed or On Statin Therapy (c)
17a	MEASURE: Percentage of patients 21 years of age and older at high risk of cardiovascular events who were prescribed or were on statin therapy

Line	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet	Total Patients Aged 18 and Older with IVD Diagnosis or AMI, CABG, or PCI Procedure (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with Documentation of Aspirin or Other Antiplatelet Therapy (c)
18	MEASURE: Percentage of patients 18 years of age and older with a diagnosis of IVD or AMI, CABG, or PCI procedure with aspirin or another antiplatelet

Line	Colorectal Cancer Screening	Total Patients Aged 50 through 75 (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with Appropriate Screening for Colorectal Cancer(c)
19	MEASURE: Percentage of patients 50 through 75 years of age who had appropriate screening for colorectal cancer

Section L - HIV MeasuresLinkage to Care

Line	HIV Linkage to Care	Total Patients First Diagnosed with HIV (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Seen Within 30 Days of First Diagnosis of HIV (c)
20	MEASURE: Percentage of patients whose first ever HIV diagnosis was made by health center staff between October 1 of the prior year and September 30 of the measurement year and who were seen for follow-up treatment within 30 days of that first- ever diagnosis
Line	HIV Screening	Total Patients Aged 15 through 65 (a)	Charts Sampled or EHR Total (b)	Number of Patients Tested for HIV (c)
20a	MEASURE: Percentage of patients 15-65 years of age who have been tested for HIV within that age range

Section M – Preventive Care and Screening: Screening for Depression and Follow-Up PlanDepression Measures

Line	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Total Patients Aged 12 and Older (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Screened for Depression and Follow-Up Plan Documented as Appropriate (c)
21	MEASURE: Percentage of patients 12 years of age and older who were (1) screened for depression with a standardized tool and, if screening was positive, (2) had a follow-up plan documented
Line	Depression Remission at 12 Months	Total Patients Aged 18 and Older with Major Depression or Dysthymia (a)	Charts Sampled or EHR Total (b)	Number of Patients who Reached Remission (c)
21a	MEASURE: Percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event	[blank for]	[blank for demonstration]	[blank for demonstration]

Section N – Dental Sealants for Children between 6–9 Years

Line	Dental Sealants for Children between 6–9 Years	Total Patients Aged 6 through 9 at Moderate to High Risk for Caries (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with Sealants to First Molars (c)
22	MEASURE: Percentage of children 6 through 9 years of age at moderate to high risk of caries who received a sealant on a first permanent molar

Table 7: Health Outcomes and Disparities

Reporting Period: January 1, 2019, through December 31, 2019

Line	Race and Ethnicity	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)
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 Race & Ethnicity
h	Unreported/Refused to Report Race and Ethnicity
i	Total

Section A: Deliveries and Birth Weight

Line	Description	Patients (a)
0	HIV-Positive Pregnant Women
2	Deliveries Performed by Health Center’s Providers

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Line	Race and Ethnicity	Total Patients 18 through 85 Years of Age with Hypertension (2a)	Number Charts Sampled or EHR Total (2b)	Patients with Hypertension Controlled (2c)
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 Race and Ethnicity
h	Unreported/Refused to Report Race and Ethnicity
i	Total

Section B: Controlling High Blood Pressure

subtotal

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subtotal

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Line	Race and Ethnicity	Total Patients 18 through 75 Years of Age with Diabetes (3a)	Number Charts Sampled or EHR Total (3b)	Patients with HbA1c >9% or No Test During Year (3f)
	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	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	Subtotal Non- Hispanic/Latino
	Unreported/Refused to Report Race and Ethnicity
h	Unreported/Refused to Report Race and Ethnicity
i	Total

Section C: Diabetes: Hemoglobin A1c Poor Control

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Table 8A: Financial Costs

Reporting Period: January 1, 2019, through December 31, 2019

Line	Cost Center	Accrued Cost (a)	Allocation of Facility and Non- Clinical Support Services (b)	Total Cost After Allocation of Facility and Non- Clinical Support Services (c)
Financial Costs of Medical Care
1	Medical Staff
2	Lab and X-ray
3	Medical/Other Direct
4	Total Medical Care Services (Sum of Lines 1 through 3)
	Financial Costs of Other Clinical Services
5	Dental
6	Mental Health
7	Substance Use Disorder
8a	Pharmacy not including pharmaceuticals
8b	Pharmaceuticals
9	Other Professional (Specify: )
9a	Vision
10	Total Other Clinical Services (Sum of Lines 5 through 9a)
Financial Costs of Enabling and Other Services
11a	Case Management
11b	Transportation
11c	Outreach
11d	Patient and Community Education
11e	Eligibility Assistance
11f	Interpretation Services
11g	Other Enabling Services (Specify: )
11h	Community Health Workers
11	Total Enabling Services Cost (Sum of Lines 11a through 11h)
12	Other Related Services (Specify: )
12a	Quality Improvement
13	Total Enabling and Other Services (Sum of Lines 11, 12, and 12a)

[section divide]

[blank for section divide]

Line	Cost Center	Accrued Cost (a)	Allocation of Facility and Non- Clinical Support Services (b)	Total Cost After Allocation of Facility and Non- Clinical Support Services (c)
Facility and Non-Clinical Support Services and Totals
14	Facility
15	Non-Clinical Support Services
16	Total Facility and Non-Clinical Support Services (Sum of Lines 14 and 15)
17	Total Accrued Costs (Sum of Lines 4 + 10 + 13 + 16)
18	Value of Donated Facilities, Services, and Supplies (specify: )
19	Total with Donations (Sum of Lines 17 and 18)

Table 9D: Patient Related Revenue

Reporting Period: January 1, 2019, through December 31, 2019

Line	Payer Category	Full Charges This Period (a)	Amount Collected This Period (b)	Retroactive S	tlements, Receip	s, and Paybacks	c)	Allowances (d)	Sliding Fee Discounts (e)	Bad Debt Write Off (f)
				Collection of Reconciliation/ Wrap-Around Current Year (c1)	Collection of Reconciliation/ Wrap-Around Previous Years (c2)	Collection of Other Payments: P4P, Risk Pools, etc. (c3)	Penalty/ Payback (c4)
1	Medicaid Non-Managed Care
2a	Medicaid Managed Care (capitated)
2b	Medicaid Managed Care (fee- for-service)
3	Total Medicaid (Sum of Lines 1 + 2a + 2b)
4	Medicare Non-Managed Care
5a	Medicare Managed Care (capitated)
5b	Medicare Managed Care (fee- for-service)
6	Total Medicare (Sum of Lines 4 + 5a + 5b)
7	Other Public, including Non- Medicaid CHIP, Non-Managed Care
8a	Other Public, including Non- Medicaid CHIP, Managed Care (capitated)
8b	Other Public, including Non- Medicaid CHIP, Managed Care (fee-for-service)
9	Total Other Public (Sum of Lines 7 + 8a + 8b)
10	Private Non-Managed Care

Line	Payer Category	Full Charges This Period (a)	Amount Collected This Period (b)	Retroactive S	tlements, Receip	s, and Paybacks	c)	Allowances (d)	Sliding Fee Discounts (e)	Bad Debt Write Off (f)
				Collection of Reconciliation/ Wrap-Around Current Year (c1)	Collection of Reconciliation/ Wrap-Around Previous Years (c2)	Collection of Other Payments: P4P, Risk Pools, etc. (c3)	Penalty/ Payback (c4)
11a	Private Managed Care (capitated)
11b	Private Managed Care (fee-for- service)
12	Total Private (Sum of Lines 10 + 11a + 11b)
13	Self-pay
14	TOTAL (Sum of Lines 3 + 6 + 9 + 12 + 13)

Table 9E: Other Revenues

Reporting Period: January 1, 2019, through December 31, 2019

Line	Source	Amount (a)
	BPHC Grants (Enter Amount Drawn Down – Consistent with PMS 272)
1a	Migrant Health Center
1b	Community Health Center
1c	Health Care for the Homeless
1e	Public Housing Primary Care
1g	Total Health Center (Sum Lines 1a through 1e)
1k	Capital Development Grants, including School-Based Health Center Capital Grants
1	Total BPHC Grants (Sum of Lines 1g + 1k)
	Other Federal Grants
2	Ryan White Part C HIV Early Intervention
3	Other Federal Grants (specify: )
3a	Medicare and Medicaid EHR Incentive Payments for Eligible Providers
5	Total Other Federal Grants (Sum of Lines 2–3a)
	Non-Federal Grants or Contracts
6	State Government Grants and Contracts (specify: )
6a	State/Local Indigent Care Programs (specify: )
7	Local Government Grants and Contracts (specify: )
8	Foundation/Private Grants and Contracts (specify: )
9	Total Non-Federal Grants and Contracts (Sum of Lines 6 + 6A + 7 + 8)
10	Other Revenue (non-patient related revenue not reported elsewhere) (specify: )
11	Total Revenue (Sum of Lines 1 + 5 + 9 + 10)

Appendix D: Health Center Health Information Technology (HIT) Capabilities

Instructions

The HIT Capabilities Form includes a series of questions on HIT capabilities, including EHR interoperability and eligibility for Meaningful Use. The HIT Form must be completed and submitted as part of the UDS submission. The form includes questions about the health center’s implementation of an EHR, certification of systems, and how widely adopted the system is throughout the health center and its providers.

Questions

The following questions appear in the EHBs. Complete them before you file the UDS Report. Instructions for the HIT questions are on-screen in EHBs as you complete the form. Respond to each question based on your health center status as of December 31.

1. Does your center currently have an Electronic Health Record (EHR) system installed and in use?

   1. Yes, installed at all sites and used by all providers

   2. Yes, but only installed at some sites or used by some providers

   3. No

If the health center installed it, indicate if it was in use by December 31, by:

1. Installed at all sites and used by all providers: For the purposes of this response, “providers” mean all medical providers, including physicians, nurse practitioners, physician assistants, and certified nurse midwives. Although some or all of the dental, mental health, or other providers may also be using the system, as may medical support staff, this is not required to choose response a. For the purposes of this response, “all sites” means all permanent sites where medical providers serve health center medical patients and does not include administrative-only locations, hospitals or nursing homes, mobile vans, or sites used on a seasonal or temporary basis. You may check this option even if a few, newly hired, untrained employees are the only ones not using the system.

2. Installed at some sites or used by some providers: Select option b if one or more permanent sites did not have the EHR installed, or in use (even if this is planned), or if one or more medical providers (as defined above) do not yet use the system. When determining if all providers have access to the system, the health center should also consider part-time and locum providers who serve clinic patients. Do not select this option if the only medical providers who did not have access were those who were newly hired and still being trained on the system.

3. Select “no” if no EHR was in use on December 31 even if you had the system installed and training had started.

This question seeks to determine whether the health center installed an EHR by December 31 and, if so, which product is in use, how broad is access to the system, and what features are available and in use. Do not include PMS or other billing systems even though they can often produce much of the UDS data. If the health center purchased an EHR, but has not yet placed it into use, answer “no.”

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If a system is in use (i.e., if a or b has been selected above), indicate it has been certified by the Office of the National Coordinator - Authorized Testing and Certification Bodies.

1a. Is your system certified by the Office of the National Coordinator for Health IT (ONC) Health IT Certification Program?

1. Yes

2. No

Health centers are to indicate in the blanks the vendor, product name, version number, and ONC-certified health IT product list number. (More information is available at https://chpl.healthit.gov/#/search). If you have more than one EHR (if, for example, you acquired another practice with its own EHR), report the EHR that will be the successor system.

1a1. Vendor

1a2. Product Name 1a3. Version Number

1a4. ONC-certified Health IT Product List Number

1b. Did you switch to your current EHR from a previous system this year?

1. Yes

2. No

If “yes, but only at some sites or for some providers” is selected above, a box expands for health centers to identify how many sites have the EHR in use and how many (medical) providers are using it. Please enter the number of sites (as defined above) where the EHR is in use and the number of providers who use the system (at any site). Include part-time and locum medical providers who serve clinic patients. Count a provider who has separate login identities at more than one site as just one provider.

1c. Do you use more than one EHR or data system across your organization?

If yes, what is the reason?

1. Second EHR/data system is used during transition to primary EHR

2. Second EHR/data system is specific to one service type (e.g. dental, behavioral health)

3. Second EHR/data system is used at specific sites with no plan to transition

4. Other (please specify)

How many sites have the EHR system in use?

1d. Is your EHR up to date with the latest software and system patches?How many providers use the EHR system?

1e. When do you plan? to install the EHR system?

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With reference to your EHR, BPHC would like to know if your system has each of the specified capabilities that relate to the CMS Meaningful Use criteria for EHRs and if you are using them (more information on Meaningful Use). For each capability, indicate:

a. Yes if your system has this capability and it is being used by your center; b. No if your system does not have the capability or it is not being used; or

3. Not sure if you do not know if the capability is built in and/or do not know if your center is using it.

Select “a” (has the capability and it is being used) if the software can perform the function and some or all of your medical providers are using it. It is not necessary for all providers to be using a specific capability in order to select “a.”

Select “b” or “c” if the capability is not present in the software, if the capability is present but still unused, or if it is not currently in use by any medical providers at your center. Select “b” or “c” only if none of the providers use the function.

2. Does your center send prescriptions to the pharmacy electronically? (Do not include faxing.) a. Yes

2. No

3. Not sure

3. Does your center use computerized, clinical decision support, such as alerts for drug allergies, checks for drug-drug interactions, reminders for preventive screening tests, or other similar functions?

   1. Yes b. No

c. Not sure

4. Which ith which of the following key providers/health care settings does your center electronically exchange clinical information with? (Select all that apply)

   1. Hospitals/Emergency rooms

   2. Specialty clinicians

   3. Other primary care providers d. Labs or imaging

c.e. Health information exchange (HIE)

d.f. None of the above

e.g.Other (please describe )

5. Does your center engage patients through health IT in any of the following ways? (Select all that apply)

   1. Patient portals

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2. Kiosks

3. Secure messaging

4. Other (please describe )

5. No, we do not engage patients using HIT

1. Question removed.

2. How do you collect data for UDS clinical reporting (Tables 6B and 7)?

   1. We use the EHR to extract automated reports

   2. We use the EHR but only to access individual patient charts

   3. We use the EHR in combination with another data analytic system

   4. We do not use the EHR

3. Question removed.

4. Question removed.

5. How does your health center utilize HIT and EHR data beyond direct patient care? (Select all that apply)

   1. Quality improvement

   2. Population health management

   3. Program evaluation

   4. Research

   5. Other (please describe )

   6. We do not utilize HIT or EHR data beyond direct patient care

6. Does your health center collect data on individual patients’ social risk factors, outside of the data reportable in the UDS?

   1. Yes

   2. No, but we are in planning stages to collect this information

   3. No, we are not planning to collect this information

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12. Which standardized assessment(s) to collect information on the social determinants of health or social risk factors, if any, do you use? (Select all that apply)

    1. Accountable Health Communities Screening Tools

    2. Upstream Risks Screening Tool and Guide

    3. iHELP

    4. Recommend Social and Behavioral Domains for EHRs

    5. Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

    6. Well Child Care, Evaluation, Community Resources, Advocacy Referral, Education (WE CARE)

    7. WellRx

g.h.Health Leads Screening Toolkit

h.i. Other (please describe )

j. We do not use a standardized screener

12a. Please provide the total number of patients that screened positive for the following:

1. Food insecurity

2. Housing insecurity

3. Financial strain

4. Lack of transportation/access to public transportation

12b. If you do not use a standardized assessment to collect this information, please comment why (Select all that apply)

1. Have not considered/unfamiliar with assessments

2. Lack of funding for addressing these unmet social needs of patients c. Lack of training for staff to discuss these issues with patients

d. Inability to include in patient intake and clinical workflow e. Not needed

f. Other (Please specify: )

13. Does your center integrate a statewide Prescription Drug Monitoring Program (PDMP) database into the health information systems such as Health Information Exchanges,

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electronic health record (EHR) systems, and/or pharmacy dispensing software (PDS) to streamline provider access to controlled substance prescriptions?

1. Yes b. No

c. Not sure

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Appendix E: Other Data Elements Instructions

Health centers are becoming increasingly diverse

and comprehensive in the care and services provided. These questions capture the changing landscape of healthcare centers to include expanded services and delivery systems.

Questions

Report on these data elements as part of your UDS submission. Topics include medication- assisted treatment (MAT), telehealth, and outreach and enrollment assistance. Respond to each question based on your health center status as of December 31.

1. Medication-Assisted Treatment (MAT) for Opioid Use Disorder

   1. How many physicians, certified nurse practitioners, and physician assistants,¹

on-site or with whom the health center has contracts, have obtained a Drug Addiction Treatment Act of 2000 (DATA) waiver to treat opioid use disorder with medications specifically approved by the U.S. Food and Drug Administration (FDA) for that indication?

2. How many patients received medication- assisted treatment for opioid use disorder from a physician, certified nurse practitioner, or physician assistant, with a DATA waiver working on behalf of the health center?

¹ With the enactment of the Comprehensive Addiction and Recovery Act of 2016, Public Law 114-198, opioid treatment prescribing privileges have

2. Did your organization use telemedicine to provide remote clinical care services?

(The term “telehealth” includes “telemedicine” services but encompasses a broader scope of remote healthcare services. Telemedicine is specific to remote clinical services whereas telehealth may include remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services.)

1. Yes

2a1. Who did you use telemedicine to communicate with? (Select all that apply)

1. Patients at remote locations from your organization (e.g., home telehealth, satellite locations)

2. Specialists outside your organization (e.g., specialists at referral centers)

2a2. What telehealth technologies did you use? (Select all that apply)

1. Real-time telehealth (e.g., live videoconferencing)

2. Store-and-forward telehealth (e.g., secure email with photos or videos of patient examinations)

3. Remote patient monitoring

4. Mobile Health (mHealth)

been extended beyond physicians to include certain qualifying nurse practitioners (NPs) and physician assistants (PAs).

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2a3. What primary telemedicine services were used at your organization? (Select all that apply)

1. Primary care

2. Oral health

3. Behavioral health: Mental health

4. Behavioral health: Substance use disorder

5. Dermatology

6. Chronic conditions

7. Disaster management

8. Consumer health education

9. Provider-to-provider consultation

10. Radiology

11. Nutrition and dietary counseling

12. Other (Please specify:

)

2. No. If you did not have telemedicine services, please comment why (Select all that apply).

   1. Have not considered/unfamiliar with telehealth service options

   2. Policy barriers (Select all that apply) i.Lack of or limited reimbursement ii.Credentialing, licensing, or

privileging iii.Privacy and security

iv.Other (Please specify:

)

3. Inadequate broadband/ telecommunication service (Select all that apply)

   1. Cost of service ii.Lack of infrastructure iii.Other (Please specify:

)

4. Lack of funding for telehealth equipment

5. Lack of training for telehealth services

6. Not needed

7. Other (Please specify:

)

3. Provide the number of all assists provided during the past year by all trained assisters (e.g., certified application counselor or equivalent) working on behalf of the health center (employees, contractors, or volunteers), regardless of the funding source that is supporting the assisters’ activities. Outreach and enrollment assists are defined as customizable education sessions about affordable health insurance coverage options (one-on-one or small group) and any other assistance provided by a health center assister to facilitate enrollment.

Enter number of assists

Note: Assists do not count as visits on the UDS tables.

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Appendix F: Workforce Instructions

It is important to understand the current state of health center workforce training and different

staffing models to better support recruitment and retention of health center professionals. This section includes a series of questions on health center workforce.

Questions

Report on these data elements as part of your UDS submission. Topics include health professional education/training and satisfaction surveys. Respond to each question based on your health center status as of December 31.

1. Does your health center provide health professional education/training? Health professional education/training does not include continuing education units.

   1. Yes

   2. No

1a. If yes, which category best describes your health center’s role in the health professional education/training process?

1. Sponsor²

2. Training site partner³

3. Other (please describe )

2. Please indicate the range of health professional education/training offered at your health center and how many individuals you have trained in each category within the last year.

	a. Pre-Graduate/Certificate	b. Post-Graduate Training
Medical	[blank]	[blank]
1. Physicians	[blank for demonstration]	[blank for demonstration]
a. Family Physicians	[blank for demonstration]	[blank for demonstration]
b. General Practitioners	[blank for demonstration]	[blank for demonstration]
c. Internists	[blank for demonstration]	[blank for demonstration]
d. Obstetrician/Gynecologists	[blank for demonstration]	[blank for demonstration]
e. Pediatricians	[blank for demonstration]	[blank for demonstration]
f. Other Specialty Physicians	[blank for demonstration]	[blank for demonstration]
2. Nurse Practitioners	[blank for demonstration]	[blank for demonstration]
3. Physician Assistants	[blank for demonstration]	[blank for demonstration]
4. Certified Nurse Midwives	[blank for demonstration]	[blank for demonstration]
5. Registered Nurses	[blank for demonstration]	[blank for demonstration]
6. Licensed Practical Nurses/ Vocational Nurses	[blank for demonstration]	[blank for demonstration]
7. Medical Assistants	[blank for demonstration]	[blank for demonstration]
Dental	[blank]	[blank]

2. A sponsor hosts a comprehensive health profession education and/or training program, the implementation of which may require partnerships with other entities that deliver focused, time-limited education and/or training (e.g., a teaching health center with a family medicine residency program).

3. A training site partner delivers focused, time-limited education and/or training to learners in support of a comprehensive curriculum hosted by another health profession education provider (e.g., month-long primary care dentistry experience for dental students).

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	a. Pre-Graduate/Certificate	b. Post-Graduate Training
8. Dentists	[blank for demonstration]	[blank for demonstration]
9. Dental Hygienists	[blank for demonstration]	[blank for demonstration]
10. Dental Therapists	[blank for demonstration]	[blank for demonstration]
Mental Health and Substance Use Disorder	[blank]	[blank]
11. Psychiatrists	[blank for demonstration]	[blank for demonstration]
12. Clinical Psychologists	[blank for demonstration]	[blank for demonstration]
13. Clinical Social Workers	[blank for demonstration]	[blank for demonstration]
14. Professional Counselors	[blank for demonstration]	[blank for demonstration]
15. Marriage and Family Therapists	[blank for demonstration]	[blank for demonstration]
16. Psychiatric Nurse Specialists	[blank for demonstration]	[blank for demonstration]
17. Mental Health Nurse Practitioners	[blank for demonstration]	[blank for demonstration]
18. Mental Health Physician Assistants	[blank for demonstration]	[blank for demonstration]
19. Substance Use Disorder Personnel	[blank for demonstration]	[blank for demonstration]
Vision	[blank]	[blank]
20. Ophthalmologists	[blank for demonstration]	[blank for demonstration]
21. Optometrists	[blank for demonstration]	[blank for demonstration]
Other Professionals	[blank]	[blank]
22. Chiropractors	[blank for demonstration]	[blank for demonstration]
23. Dieticians/Nutritionists	[blank for demonstration]	[blank for demonstration]
24. Pharmacists	[blank for demonstration]	[blank for demonstration]
25. Other (please specify )	[blank for demonstration]	[blank for demonstration]

3. Provide the number of health center staff serving as preceptors at your health center

4. Provide the number of health center staff (non-preceptors) supporting health center training programs

5. How often does your health center implement satisfaction surveys for providers?

   1. Monthly

   2. Quarterly

   3. Annually

   4. We do not currently conduct provider satisfaction surveys

   5. Other (please describe )

6. How often does your health center implement satisfaction surveys for general staff?

   1. Monthly

   2. Quarterly

   3. Annually

   4. We do not currently conduct staff satisfaction surveys

   5. Other (please describe )

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 0915-0193. Public reporting burden for this collection of information is estimated to average xx 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 14N136B, Rockville, Maryland, 20857.

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