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 [blank for demonstration] [blank for demonstration] [blank for demonstration] Section - Cervical Cancer Screening Line Cervical Cancer Screening 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 [blank for demonstration] for demonstration] [blank for demonstration] 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 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 [blank for demonstration] [blank for demonstration] for demonstration] Section F – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Line Preventive Care and Screening: Body Mass (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 Plan Documented as Appropriate (c) 13 MEASURE: Percentage of patients 18 of age and older with (1) BMI documented and (2) follow-up plan documented if BMI is outside normal parameters [blank for demonstration] [blank for demonstration] [blank for demonstration] Section G – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Line Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Patients Aged 18 and Older (a) Number Charts Sampled or EHR (b) Number of patients Assessed for Tobacco Use and Provided Intervention if a Tobacco User (c)
Section K - Colorectal Cancer Screening Line Colorectal Cancer Screening Total Patients Aged 50 through 75 (a) Charts Sampled or EHR Total (b) Number of Patients with Appropriate Screening for Colorectal Cancer(c) 19 MEASURE: Percentage of patients 50 through 75 of age who had appropriate screening for colorectal cancer [blank for demonstration] [blank for demonstration] [blank for demonstration] Section LL - HIV Linkage to Care Line HIV Linkage to Care Total Patients First Diagnosed with HIV (a) Charts Sampled or EHR Total (b) Number of Patients Seen Within 90 Days of 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 treatment within 90 days of that first-ever diagnosis [blank for demonstration] for demonstration] [blank for demonstration] Section M – Preventive Care and Screening: Screening for Depression and Follow-Up Plan Line Preventive Care and Screening: Screening for Depression and Follow-Up Plan Patients Aged 12 and Older (a) 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 [blank for demonstration] for demonstration] 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) Charts Sampled or EHR Total (b) Number of Patients with Sealants to First Molars (c)
and Non-Clinical Support Services (c) [blank for section divide] Facility and Non-Clinical Support Services and Totals [blank for section divide] [blank for section divide] [blank for section divide] 14 Facility [blank for demonstration] [Cell not reported] [Cell not reported] 15 Non-Clinical Support Services [blank for demonstration] [Cell not reported] [Cell not reported] 16 Total Facility and Non-Clinical Support Services (Sum Lines 14 and 15) [blank for demonstration] [Cell not reported] [Cell not reported] 17 Total Accrued Costs (Sum 4 + 10 + 13 + 16) [blank for demonstration] [Cell not reported] [blank for demonstration] 18 Value of Donated Facilities, Services, and Supplies (specify: ______________) [Cell not reported] [Cell not reported] [blank for demonstration] 19 Total with Donations (Sum Lines 17 and 18) [Cell not reported] [Cell not reported] [blank for demonstration]
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 treatment (MAT), telehealth, and outreach and enrollment assistance. Respond to each question based on your health center status as of December 31. Medication-Assisted Treatment (MAT) for Opioid Use Disorder How many physicians, certified nurse practitioners and physician assistants, 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? How many patients received 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? Did your organization use telehealth in order 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.) Yes 2a1. Who did you use telehealth to communicate with? (Select all that apply) Patients at remote locations from your organization (e.g., home telehealth, satellite locations) Specialists outside your organization (e.g., specialists at referral centers) 2a2. What telehealth technologies did you use? (Select all that apply) Real-time telehealth (e.g., conference) Store-and-forward telehealth (e.g., secure email with photos or videos of patient examinations) Remote patient monitoring Mobile Health (mHealth) 2a3. What primary telehealth services were used at your organization? (Select all that apply) Primary care Oral health Behavioral health: Mental health Behavioral health: Substance use disorder Dermatology Chronic conditions Disaster management Consumer and professional health education (Please specify: ________________)