Form 0920-1156 Quarterly Health Center Performance Measure Reporting To

Form Approved

OMB No.0920-1156

Exp.xx/xx/xxxx

Quarterly Health Center Performance Measure Reporting Tool

Public reporting burden of this collection of information is estimated to average 4 hours per response including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-1156).

Health Center Information

Health Center Name: _________________________ Date Completed:________________

Practice Setting Description (e.g., pediatrics, family planning): ____________________

Health Center/Practice Setting ID:____________

Reporting Period: Fiscal Year__________ (October to September)

Quarter 1 (October to December) Quarter 2 (January to March)

Quarter 3 (April to June)

Please complete the following questions for each participating practice settings within your health center. Most items request information for the past quarter that has most recently ended and for the year to date. See the appendix titled ‘Additional Guidance’ at the end of this document for more information on completing Tables 2 and 3.

Operational Changes and Project Activities

1. Please describe operational changes or other activities (e.g., training, quality improvement team meetings) undertaken as part of this project that occurred during the past quarter.

Health Care Service Use by 15 to 19 year olds

Table 1. Adolescent Clients Ages 15-19 (Unduplicated) Receiving Any Service within the Identified Practice Setting

# Female Clients Ages 15-19 (Unduplicated)		# Male Clients Ages 15-19 (Unduplicated)
Last Quarter	Fiscal Year to Date	Last Quarter	Fiscal Year to Date

Table 2. Receipt of Reproductive or Sexual Health Services by Clients, Ages 15-19 (Unduplicated) See appendix at the end of this document for additional guidance on completing this table.

	Number of Female Clients Ages 15 to 19 Years who Received the Specified Service		Number of Male Clients Ages 15 to 19 Years who Received the Specified Service
	Last Quarter	Fiscal Year to Date	Last Quarter	Fiscal Year to Date
Received any reproductive or sexual health service
Received STD screening/ counseling/treatment and/or HIV testing/counseling
Screened to determine if sexually active
Sexual health assessment conducted

Table 3. Female Clients, Ages 15-19 Years Old, (Unduplicated) Adopting or Continuing Use of Moderately or Highly Effective Contraception See appendix at the end of this document for additional guidance on completing this table.

	Number of 15-19 Year Old Clients who Adopted or Continued Use (Unduplicated)
	Last Quarter	Fiscal Year to Date
Pill, Patch, Ring, or Injectable Contraception (e.g., Depo Provera)
IUD (e.g., Mirena or ParaGard)
Contraceptive Implants (e.g., Nexplanon)

Table 3a. Past Quarter Percent Adopting or Continuing Contraception and Adopting or Continuing LARC for Female Clients, Ages 15-19 Years Old (When entering data into web interface, these rates will auto-populate based on data already entered.)

	% Adopted or Continued Contraception1	% Adopted or Continued LARC2
15-19 year old clients

Table 4. Confidence in Data Reported

After reviewing the data collected in Tables 1 through 3, please indicate your level of confidence in the accuracy of each type of data retrieved from your health center’s electronic medical record. Please reflect on the extent to which the data reflects your team’s understanding of the sexual and reproductive health services being provided in your practice setting.

	No Confidence	Low Confidence	Moderate Confidence	High Confidence
Number of clients, ages 15-19
Received any reproductive or sexual health service
Received STD screening/ counseling/treatment and/or HIV testing/counseling
Screened to determine if sexually active
Sexual health assessment conducted
Adopted or Continued Pill, Patch, Ring, or Injectable Contraception (e.g., Depo Provera)
Adopted or Continued IUD (e.g., Mirena or Paragard)
Adopted or Continued Contraceptive Implants (e.g., Nexplanon)

Appendix: Additional Guidance

Table 2 Variables

Received any reproductive or sexual health service

Include the following services:

Provision/Surveillance/Maintenance of contraceptive methods (same codes as for Table 3, see below)

STD screening/STD treatment/STD counseling/HIV testing /HIV counseling

Pregnancy Testing

Gynecological Exam/Pap Smear

HIV Counseling

Counseling on Sexual Attitude, Behavior and Orientation

STD Prevention Education/Counseling

Provided Emergency Contraception

Provided Condoms-Male and Female

Screened to determine if sexually active and sexual health assessment conducted

Accurately collecting this information will require that additional fields are added to health center partners’ EMRs. Standard, existing codes do not adequately assess for these activities. We recognize that not all health centers are able to modify their EMR. They will not be expected to report this data.

Table 3 Variables

Please de-duplicate data, so that you only report on one form of contraception per patient. If a patient is provided a service related to more than one form of contraception during a reporting period, please only consider the most recent. The one exception is that patients provided a contraceptive implant who later receive oral contraception for management of side effects associated with the implant should be counted as an implant user.

Pill, Patch, Ring, or Injectable Contraception (e.g., Depo Provera)

Number of 15-19 year old female clients who adopted or continued use of pill should be determined using codes for 1) initial prescription and 2) surveillance/prescription refill/management. Adopted or continued use of patch should be determined using codes for prescription. Adopted or continued use of ring should be determined using codes for 1) prescription and 2) surveillance/maintenance. Adopted or continued use of injectable contraception should be determined using codes for 1) initial dose and 2) surveillance/subsequent dose/management.

IUD (e.g., Mirena or ParaGard)

Number of 15-19 year old female clients who adopted or continued use of an IUD should be determined by examining codes for 1) insertion of the IUD, 2) surveillance/management of the IUD, 3) removal and reinsertion of the IUD, and 4) IUD present.

Contraceptive Implants (e.g., Nexplanon)

Number of 15-19 year old female clients who adopted or continued use of a contraceptive implant should be determined by examining codes for 1) insertion/reinsertion of the implant, 2) surveillance/management of the implant, and 3) implant present.

1 Calculated as the proportion of all unduplicated 15-19 year old female clients who adopted or continued hormonal contraception, contraceptive implants, or IUD out of all 15-19 year old female clients (use data from Table 1 for number of female clients).

2 Calculated as the proportion of all unduplicated 15-19 year old female clients who adopted or continued contraceptive implants or IUD out of all 15-19 year old female clients.

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