LAL ID Performance Measures Crosswalk | Bureau of Primary Health Care

Look-alike Initial Designation applicants must provide 3-year goals for the following Clinical and Financial Performance Measures. The chart below lists the focus area, performance measure description, and baseline/goal numerator and denominator for each required measure. Indicated below the focus area, most clinical measures align with Electronic clinical quality measures (eCQMs) used by the Centers for Medicare & Medicaid Services (CMS) in quality reporting programs. Refer to the UDS Manual for specific measurement details such as exclusionary criteria.

Clinical Performance Measures

Focus Area (e-CQMs reference)	Performance Measure	Numerator Description	Denominator Description
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) (CMS122v8)	Percentage of patients age 18-75 years with diabetes who had hemoglobin A1c > 9.0% during the measurement period.	Patients whose most recent HbA1c level (performed during the measurement period) is > 9.0%.	Patients age 18-75 years with diabetes with a visit during the measurement period. Exclude patients whose hospice care overlaps the measurement period; 66 and older with advanced illness and frailty, because it is unlikely that patients will benefit from the services being measured; OR who are living long term in an institution for more than 90 days during the measurement period.
Screening for Depression and Follow-up Plan (CMS2v9)	Percentage of patients age 12 years and older screened for depression on the date of the visit using an age appropriate standardized depression screening tool AND, if the screening is positive, a follow-up plan is documented on the date of the positive screening.	Patients screened for depression on the date of the medical visit or up to 14 days prior to the date of the medical visit using an age appropriate standardized screening tool AND, if positive, a follow-up plan is documented on the date of the medical visit.	All patients age 12 years and older at the beginning of the measurement period with at least one medical visit during the measurement period. Exclude patients with an active diagnosis of depression or bipolar disorder; patients who refuse to participate; patients who are in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health status; or situations where the patient's functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools.
Depression Remission At 12 Months (CMS159V8)	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.	Adolescent patients age 12 to 17 years and adult patients age 18 years and older who achieved remission at twelve months as demonstrated by a 12 month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five.	Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may be screened using PHQ-9 and PHQ-9M up to 7 days prior to the office visit (including the day of the office visit). Exclude patients who: died; received hospice or palliative care services; were permanent nursing home residents; or had a diagnosis of bipolar disorder, personality disorder, schizophrenia or psychotic disorder, or pervasive development disorder.
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (CMS155v8)	Percentage of patients age 3-17 years who had a medical visit and evidence of height, weight, and BMI percentile documentation, and who had documentation of (1) counseling for nutrition, and (2) counseling for physical activity during the measurement period.	Patients who had a height, weight, and body mass index (BMI) percentile recorded during the measurement period. Patients who had counseling for nutrition during the measurement period. Patients who had counseling for physical activity during the measurement period.	Patients age 3 - 17 years with at least one medical visit with a primary care physician or an obstetrician/gynecologist (OB/GYN) during the measurement period, excluding patients with a diagnosis of pregnancy or in hospice care during the measurement period.
Body Mass Index (BMI) Screening and Follow-up Plan (CMS69v8)	Percentage of patients age 18 years and older with a BMI documented during the most recent visit or within the previous 12 months to that visit, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the visit or during the previous 12 months of that visit. Normal Parameters: Age 18 years and older with a BMI greater than or equal to 18.5 and less than 25 kg/m2	Patients with a documented BMI during the medical visitt or during the previous twelve months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the visit or during the previous 12 months of the current visit.	All patients age 18 and older on the date of the medical visit with at least one medical visit during the measurement period, excluding patients: who are pregnant or receiving palliative care; who refuse measurement of height and/or weight or follow-up; with a documented medical reason; or patients in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.
Controlling High Blood Pressure (CMS165v8)	Percentage of patients age 18-85 years who had a diagnosis of hypertension and whose blood pressure was adequately controlled (less than 140/90 mm Hg) during the measurement period.	Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period.	Patients age 18-85 years who had a visit and a diagnosis of essential hypertension overlapping the measurement period., excluding patients with evidence of end stage renal disease (ESRD), dialysis, or renal transplant before or during the measurement period; patients who were pregnant during the measurement period; patients 66 and older who are living long term in an institution for more than 90 days during the measurement period or with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured; or patients who were in hospice care during the measurement period.
Low Birth Weight	Percentage of babies of health center prenatal care patients born whose birth weight was below normal (less than 2,500 grams).	Babies born with a birth weight under 2,500 grams.	Babies born during the measurement period to prenatal care patients, excluding stillbirths and miscarriages.
Early Entry into Prenatal Care	Percentage of prenatal care patients who entered prenatal care during their first trimester.	Women beginning prenatal care at the health center or a referral provider, or with another prenatal provider during their first trimester.	Women seen for prenatal care during the measurement period.
Childhood Immunization Status (CMS117v8)	Percentage of children 2 years of age who had four diphtheria, tetanus, and acellular pertussis (DTaP); three polio (IPV), one measles, mumps, and rubella (MMR); three H influenza type B (HiB); three Hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one Hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.	Children who have evidence showing they received recommended vaccines, had documented history of the illness, a seropositive test result, or an allergic reaction to the vaccine by their second birthday.	Children who turn 2 years old during the measurement period and who had a medical visit during the measurement period, excluding patients whose hospice care overlaps the measurement period.
Cervical Cancer Screening (CMS124v8)	Percentage of women age 21-64 years, who were screened for cervical cancer using either of the following criteria: 1) Women age 21-64 who had cervical cytology performed every three years, or 2) Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every five years.	Women with one or more screenings for cervical cancer, appropriate screenings are defined by any one of the following: 1) Cervical cytology performed during the measurement period, or the two years prior to the measurement period, for women who are at least 21 years old at the time of the test, or 2) Cervical cytology/human papillomavirus (HPV) co-testing performed during the measurement period, or the four years prior to the measurement period, for women who are at least 30 years old at the time of the test.	Women age 23-64 years with a medical visit during the measurement period, excluding women who had a hysterectomy with no residual cervix or a congenital absence of cervix, or patients whose hospice care overlaps the measurement period.
Tobacco Use: Screening and Cessation Intervention (CMS138v8)	Percentage of patients age 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation intervention, if defined as a tobacco user.	Patients who were screened for tobacco use at least once within 24 months before the end of the measurement period AND who received tobacco cessation intervention, if identified as a tobacco user.	Patients age 18 years and older seen for at least two medical visits, or at least one preventive medical visit, during the measurement period OR who were screened for tobacco use and identified as a tobacco user, excluding documentation of medical reason(s) for not screening for tobacco use OR for not providing tobacco cessation intervention for patients identified as tobacco users.
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (CMS347v3)	Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: Adults age >= 21 years who were previously diagnosed with, or currently have, an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR Adults age >= 21 years who have ever had a fasting, or direct low-density lipoprotein cholesterol (LDL-C) level, >= 190 mg/dL or were previously diagnosed with, or currently have an active diagnosis of familial or pure hypercholesterolemia; OR Adults age 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL.	Patients who are actively using or who receive an order (prescription) for statin therapy at any point during the measurement period.	All patients who meet one or more of the following criteria (considered at “high risk” for cardiovascular events, under ACC/AHA guidelines): Patients age >= 21 years at the beginning of the measurement period with clinical ASCVD diagnosis. Patients age >= 21 years at the beginning of the measurement period who have ever had a fasting, or direct laboratory result of LDL-C, >=190 mg/dL or were previously diagnosed with, or currently have, an active diagnosis of familial or pure hypercholesterolemia. Patients age 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with an LDL-C result of 70-189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period. Except Patients who are pregnant, breastfeeding, have a diagnosis of rhabdomyolysis, adverse effect, allergy, or intolerance to statin medication; have active liver disease of hepatic disease or insufficiency, have end stage renal disease, with diabetes who have the most recent fasting or direct LDL-C laboratory test result < 70 mg/dL and are not taking statin therapy, or receiving palliative or hospice care.
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet	Percentage of patients age 18 years and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and had documentation of use of aspirin or another antiplatelet during the measurement period.	Patients who had an active medication of aspirin or another antiplatelet during the measurement period.	Patients age 18 years and older with a medical visit during the measurement period who had an AMI, CABG, or PCI during the 12 months prior to the measurement year or who had a diagnosis of IVD overlapping the measurement period, excluding patients who had documentation of use of anticoagulant medications overlapping the measurement period, and patients who were in hospice care during the measurement period.
Colorectal Cancer Screening (CMS130v8)	Percentage of patients age 50-75 years who had appropriate screening for colorectal cancer.	Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria: Fecal occult blood test (FOBT) during the measurement period; Fecal immunochemical test (FIT)-DNA during the measurement period or the two years prior to the measurement period; Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period; CT colonography during the measurement period or the four years prior to the measurement period; or Colonoscopy during the measurement period or the nine years prior to the measurement period.	Patients age 50-75 years with a medical visit during the measurement period, excluding patients with a diagnosis or past history of total colectomy or colorectal cancer, or patients whose hospice care overlaps the measurement period.
Breast Cancer Screening (CMS125V8)	Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.	Women with one or more mammograms during the 27 months prior to the end of the measurement period.	Women age 51-74 years with a medical visit during the measurement period. Exclude women who had a bilateral mastectomy or who have a history of a bilateral mastectomy, or for whom there is evidence of a right and a left unilateral mastectomy.
HIV Screening (CMS349V2)	Percentage of patients age 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV.	Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday.	Patients age 15 to 65 years at the start of the measurement period AND who had at least one medical visit during the measurement period. Exclude patients diagnosed with HIV prior to the start of the measurement period.
HIV Linkage To Care	Percentage of patients newly diagnosed with HIV who were seen for follow-up treatment within 30 days of diagnosis.	Newly diagnosed HIV patients that received treatment within 30 days of diagnosis, including patients who were newly diagnosed by health center providers, and: Had a medical visit with a health center provider who initiates treatment for HIV, or Had a visit with a referral resource who initiates treatment for HIV.	Patients first diagnosed with HIV by the health center between December 1 of the prior year through November 30 of the current measurement year, and who had at least one medical visit during the measurement period or prior year.
Dental Sealants for Children between 6 -9 Years	Percentage of children, age 6- 9 years at moderate to high risk for caries who received a sealant on a permanent first molar during the measurement period.	Children who received a sealant on a permanent first molar tooth during the measurement period.	Children age 6-9 years who had an oral assessment, or comprehensive or periodic oral evaluation dental visit, and are at moderate to high risk for caries, excluding children for whom all first permanent molars are non-sealable.

Date Last Reviewed:

December 2021