Quality of Care

Performance measures used by the Health Center Program place emphasis on quality of care and health outcomes, and demonstrate the value of care delivered by health centers. These measures align with those of national standard setting organizations, and are commonly used by Medicare, Medicaid, and health insurance/managed care organizations to assess quality performance.

HRSA selected these measures to provide a balanced and comprehensive representation of health center services, clinically prevalent conditions among underserved communities, and the population across life cycles. The majority of health centers with extensive experience working to improve the quality of perinatal, chronic, and preventative care services will be familiar with these measures.

HRSA-funded health centers are evaluated on a set of performance measures emphasizing health outcomes and the value of care delivered. In addition to Quality of Care, additional performance measure categories in Health Outcomes and Disparities and Financial Viability/Costs

Percentage of prenatal care patients who entered treatment during their first trimester

Numerator: Women entering prenatal care at the health center or with the referred provider during their first trimester

Denominator: Women seen for prenatal care during the measurement period

Percentage of children 2 years of age who had 4 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); 4 pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday

Numerator: Children who have evidence showing they received recommended vaccines, had documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine by their second birthday

Denominator: Children who turn 2 years of age during the measurement period and who have a visit during the measurement period

CMS Reference: CMS117

Percentage of women 21-64 years of age, who received one or more Pap tests to screen for cervical cancer

Numerator: Women with one or more Pap tests during the measurement period or the two years prior to the measurement period

Denominator: Women 23-64 years of age with a visit during the measurement period

CMS Reference: CMS124

Percentage of patients 3-17 years of age who had evidence of Body Mass Index (BMI) percentile documentation and who had documentation of counseling for nutrition and who had documentation of counseling for physical activity during the measurement year

Numerator: Number of patients in the denominator who had their BMI percentile documented during the measurement year and who had documentation of counseling for nutrition and who had documentation of counseling for physical activity during the measurement year

Denominator: Patients 3 through 17 years of age with at least one medical visit during the measurement period

CMS Reference: CMS155

Percentage of patients age 18 years and older with a BMI documented during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. Normal parameters: Age 18-64 years BMI =>18.5 and <25 kg/m², and Age 65 years and older BMI =>23 and <30 kg/m²

Numerator: Patients with a documented BMI (not just height and weight) during their most recent visit or during the previous six months of the most recent visit, and when the BMI is outside of normal parameters, a follow-up plan is documented during the visit or during the previous six months of the current visit

Denominator: All patients 18 years of age or older who had at least one medical visit during the measurement period

CMS Reference: CMS69

Percentage of patients 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user

Numerator: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Denominator: All patients age 18 years and older seen for at least two visits or at least one preventive visit during the measurement period

CMS Reference: CMS138

Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period

Numerator: Patients who were dispensed at least one prescription for a preferred therapy during the measurement period

Denominator: Patients 5-64 years of age with persistent asthma and a visit during the measurement period

CMS Reference: CMS126

Percentage of patients aged 18 years and older with a diagnosis of Coronary Artery Disease (CAD) who were prescribed a lipid-lowering therapy

Numerator: Number of patients who received a prescription for, were provided, or were taking lipid lowering medications

Denominator: Number of patients who were seen during the measurement year after their 18th birthday, who had at least one medical visit during the measurement year, at least two medical visits ever, and who had an active diagnosis of coronary artery disease (CAD) including any diagnosis for myocardial infarction (MI) or who had had cardiac surgery in the past

Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of IVD during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period

Numerator: Patients who have documentation of use of aspirin or another antithrombotic during the measurement period

Denominator: Patients 18 years of age and older with a visit during the measurement period, and an active diagnosis of IVD or who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period

CMS Reference: CMS164

Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer

Numerator: Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria: fecal occult blood test (FOBT) during the measurement period; flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period; or colonoscopy during the measurement period or the nine years prior to the measurement period

Denominator: Patients 50-75 years of age with a visit during the measurement period

CMS Reference: CMS130

Percentage of patients age 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

Numerator: Patients screened for clinical depression on the date of the encounter using an age appropriate standardized tool AND if positive, a follow-up plan is documented on the date of the positive screen

Denominator: All patients age 12 years and older before the beginning of the measurement period with at least one eligible encounter during the measurement period

CMS Reference: CMS2

Percentage of newly diagnosed HIV patients who had a medical visit for HIV care within 90 days of first-ever HIV diagnosis

Numerator: Patients who had a medical visit for HIV care within 90 days of first-ever HIV diagnosis

Denominator: Patients first diagnosed with HIV by the health center between October 1 of the prior year through September 30 of the current measurement year

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

Numerator: Patients who received a sealant on a permanent first molar tooth in the measurement year

Denominator: Dental patients age 6-9 who had an oral assessment or comprehensive or periodic oral evaluation visit during the measurement period and documented as having moderate to high risk for caries

CMS Reference: CMS277



Related

Health centers annually report their performance in the Uniform Data System (UDS).

View Health Center Program Grantee Data at the national, state, and individual health center level.

View Health Center Program Look-Alike Data at the national and individual health center level.

Uniform Data System (UDS) Resources offer help with submission and reporting, types of data, and reporting requirements.

Uniform Data System (UDS) Program Assistance Letters provide the proposed and approved reporting changes.