SAC FY 2015 Clinical Performance Measures Form Field Guide

OMB No.: 0915-0285 Expiration Date: 09/30/2016

FOR HRSA USE ONLY Grant Number Application Tracking Number Clinical Performance Measures Form Field Guide

Project Period Date Focus Area: Diabetes Performance Measure: Percentage diabetic patients whose HbA1c levels are less than less than 8 percent, less than or equal to 9 percent, or greater than 9 percent. Is this Performance Measure Applicable to your Yes Organization? Target Goal Description All applicants must complete this field Numerator Description Number of adult patients age 18 to 75 years with a diagnosis of Type 1 or Type 2 diabetes whose most recent HbA1c level during the measurement year is <8%, <=9%, or >9%, among those patients in the denominator. Denominator Description Number of adult patients age 18 to 75 years as of December 31 of the measurement year with a diagnosis of Type 1 or Type 2 diabetes, who have had a visit at least twice during the reporting year and do not meet any of the exclusion criteria. Baseline Data Baseline Year: Projected Data All applicants must Measure Type: (by End of Project complete this field Numerator: Period) Denominator:

Current Grantees: These fields will be prepopulated and locked from last UDS report

Other Applicants: Complete these fields based on current data Progress Field Current grantees applying to continue serving their current service area must use this field to provide progress updates since the last application (BPR, SAC, or NAP that initiated the current budget period). N/A for new applicants and current grantees applying to serve an additional service area. Data Source & Methodology Data Source: [_] EHR [_] Chart Audit [_] Other (If Other, please specify) : ______All applicants must select one of the options above

Data Source and Methodology Description: All applicants must complete this field Key Factor and Major Planned Action #1 Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable All applicants must select one of the options above (must select at least one contributing and one restricting factor)

Key Factor Description: All applicants must complete this field

Major Planned Action Description: All applicants must complete this field Key Factor and Major Planned Action #2 Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable

All applicants must select one of the options above (must select at least one contributing and one restricting factor)

Key Factor Description: All applicants must complete this field

Major Planned Action Description: All applicants must complete this field Key Factor and Major Planned Action #3 Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:

Optional Key Factor Comments Optional field – Current Grantees can use this field to provide baseline data updates, if applicable, and other comments as desired