Exhibit 13-6

CLINICAL OUTCOME MEASURES

The Clinical Outcome Measures initiative began as a Bureau of Primary Health Care (BPHC), Department of Health and Human Services' demonstration project to strengthen quality assurance programs and enhance the provision of primary care services at community health centers throughout the nation. Lifecycle-specific clinical outcome measures provide a tool for documenting the impact of community health center care on the health status of patients served. This data informs and ultimately strengthens the quality of health services provided by community health centers.

The Connecticut Primary Care Association, Inc. (CPCA) and its Clinical Issues Committee (CIC) first worked with the clinical indicators in 1990 when BPHC released the Clinical Measures Workbook for review and comment. In 1992, the CPCA was one of five primary care associations nationally to be selected to participate in a pilot project to apply and implement these clinical measures. Among the strengths presented by CPCA's pilot project proposal was the early and active participation by all Connecticut community health centers in review of these measures. Provider participation has continued and grown, led by the CIC. The CIC worked as a group to review and examine clinical measures, define minimal review criteria within each lifecycle and facilitate review of medical records for each lifecycle. In addition, an indicator for domestic violence was added to the clinical measures data collection instruments as a part of the CPCA's Community Health Center Domestic Violence Initiative funded by the University of Connecticut's Domestic Violence Training Project through a grant from the Commonwealth Fund, Commission on Women's Health.

This Clinical Outcome Measures Instruction Manual is a result of efforts undertaken by the Connecticut Primary Care Association, Inc. under the leadership and guidance of its Clinical Issues Committee. This Manual was developed to facilitate Connecticut community health center's efforts to audit medical records for clinical measures. Guidelines presented herein provide recommendations and tools for application by community health center staff for ongoing chart reviews in a manner that will yield uniform lifecycle-specific clinical indicator data.

Community health center (CHC) clinical outcome measures data for each lifecycle is reported annually to the CPCA, blinded, and then forwarded to the Regional Office. Data gathered from audits provides insight into service delivery for specific clinical indicators within each lifecycle. The clinical outcome measures audit methodology presented in this Manual is designed to be integrated within community health centers' comprehensive Quality Assurance/Improvement Plans. By incorporating the clinical measures in a process that includes assessment, modification, review and feedback, this project works to support community health centers' efforts to deliver quality, comprehensive health care services to patients in need.

Connecticut Primary Care Association, Inc. Clinical Outcome Measures Instruction Manual, Fourth Edition, August, 2000.

CLINICAL OUTCOME MEASURES

Instruction Manual
TABLE OF CONTENTS

PART A
	Preparing for a Clinical Outcome Measures Audit	1
	1. Medical Records	1
	2. Audit Forms	1
	3. Clinical Protocols	2
PART B
	Instructions for Auditing Medical Records for Clinical Outcome Measures	3
	1. Gather Medical Record Sample	3
	2. Ensure Medical Records Meet Eligibility Criteria	4
	3. Gather Audit Form	5
	4. Review the Medical Record/Enter Findings on Audit Form	5
PART C
	Performance Standards and Recording Results	7
	Perinatal Lifecycle	7
	Alternate - Perinatal Lifecycle	10
	Pediatric Lifecycle	13
	Two Year Olds	13
	Six Year Olds	15
	Adolescent Lifecycle	17
	Adult Lifecycle	20
	Adult Males	20
	Adult Females 20 - 39 Years of Age	23
	Adult Females 40 - 64 Years of Age	26
	Geriatric Lifecycle	29
PART D
	Summarizing and Reporting Audit Results	32
	Summarizing Audit Results	32
	Perinatal Lifecycle	33
	Alternate - Perinatal Lifecycle	33
	Pediatric: Two-Year Olds	34
	Pediatric: Six-Year Olds	34
	Adolescent	35
	Adult Lifecycle: Males	35
	Adult Females: 20 - 39 Years of Age	36
	Adult Females: 40 - 64 Years of Age	36
	Geriatric	37
	Projecting One and Three Year Performance Goals	37
	Documenting Clinical Outcome Measures Implementation Experience	38
	Updating Institutional Clinical Health Plans	40
PART E
	Pediatric Immunization Schedule	41
PART F
	Audit and Summary Forms	43
	Audit Forms	43
	Perinatal Lifecycle	43
	Alternate - Perinatal Lifecycle	44
	Pediatric: Two-Year Olds	45
	Pediatric: Six-Year Olds	46
	Adolescent	47
	Adult Lifecycle: Males	48
	Adult Females: 20 - 39 Years of Age	49
	Adult Females: 40 - 64 Years of Age	50
	Geriatric	51
	Summary Forms	52
	Perinatal Lifecycle	52
	Alternate - Perinatal Lifecycle	53
	Pediatric: Two-Year Olds	54
	Pediatric: Six-Year Olds	55
	Adolescent	56
	Adult Lifecycle: Males	57
	Adult Females: 20 - 39 Years of Age	58
	Adult Females: 40 - 64 Years of Age	59
	Geriatric	60

PART A

Preparing for a Clinical Outcome Measures Audit

In order to conduct a clinical outcome measures audit, several items are required: medical records, audit forms, and clinical protocols. Medical records provide the data, audit forms document performance of clinical indicators and protocols provide the standards by which to judge clinical performance. Understanding the content and meaning of each of these three components will facilitate audit efforts and ultimately strengthen health service delivery.

Items required to conduct an audit:

1. Medical Records
   The medical record, or chart, contains the clinical measures data an auditor will review. The auditor will review each chart for the completeness of a common core of data. The core data, which will be referred to as clinical measure indicators, represents a minimum standard of clinical care to be reviewed within eight target populations. In reviewing the medical records, an auditor should be able to locate desired clinical information as easily as possible. CHC staff can employ such techniques as grouping clinical indicators in a prominent location such as a flowsheet, or utilizing checklists, stamps, or stickers. These methods serve to not only remind clinicians to perform clinical indicators but to document their interventions. The chart should be designed so that neither clinical staff nor auditors have to read every progress note in order to gather information with respect to the clinical measures.
2. Audit Forms
   Clinical outcome measures audit forms provide a uniform template to document health center performance of clinical indicators. The audit forms for each lifecycle are divided into several common sections (further defined on pages 5 and 6): chart #, comments, clinical indicators (grouped by common assessment areas), performance status, and management plan status. Each audit form provides space for recording clinical measures performance for up to ten (10) charts. Blank copies are located in Part F.
   Clinical measures audit forms are divided into several common sections:

   1. chart #
   2. comments
   3. clinical indicators (grouped by common assessment areas)
   4. performance status
   5. management plan status

   Using the Adolescent Lifecycle as an example, the audit tool is divided into five main columns: chart #, comments, domestic violence, substance abuse and family planning (Part C; Adolescent Lifecycle). Domestic violence, substance abuse and family planning measures each contain unique clinical indicators that together comprise the Adolescent Lifecycle Behavioral Risk Assessment. For each clinical indicator listed under Domestic Violence, Substance Abuse Assessment and Family Planning, there is a column to document if the indicator was performed. If appropriate, there is also a column to indicate if a Management Plan was completed. This format is similar across the other seven target populations. The eight target populations are grouped into the following five lifecycles: Perinatal, Pediatric, Adolescent, Adult and Geriatric.

   In an effort to reduce writing and simplify entries to the audit form, a one-letter code is used to signify a concept (i.e. "N" means that there is no documentation that the clinical indicator was performed and is therefore interpreted as not performed). A legend is located at the bottom of each Audit Form defining the single letter codes.

   LEGEND

   P = Performance of Clinical Measure	MP = Management Plan
   Y = Yes	C = Present and complete
   N = Absent from documentation; not done	A = Absent; present and incomplete
   R = Refused	O = Not applicable
   X = Allergies or contraindications
   O = Not applicable
   L = Referral

3. Clinical Protocols
   Clinical protocols provide the standards by which clinicians and auditors determine performance of clinical measures. The Connecticut Primary Care Association, Inc.'s Clinical Issues Committee, utilizing the Bureau of Primary Health Care, United States Public Health Service (USPHS) guidelines, reached consensus on the minimum standards for performance of each clinical indicator (Part C). In performing an audit, these are the standards against which performance is judged. While the CPCA utilizes the term "protocols" throughout this Manual to refer to clinical measure standards, we recognize that the clinical measures do not represent complete guidance or standards for comprehensive primary care delivery but rather a minimal set of clinical indicators. Community health centers may choose to set additional or more stringent standards as to what constitutes performance for any clinical measure.

PART B

Instructions for Auditing Medical Records for Clinical Outcome Measures

1. Gather Medical Record Sample (required number of charts)
   Within each lifecycle, a sample of medical records will be obtained from the total pool of eligible patients seen at your community health center. This subset of medical records is called the sample. Samples should include only those records that meet each lifecycle's eligibility criteria. The five lifecycles include Perinatal, Pediatric, Adolescent, Adult and Geriatric. At a minimum, each lifecycle must be audited annually, although sites may choose to audit more frequently. Connecticut community health center lifecycle-specific audit due dates can be found on page thirty-two (32) of this Manual.
   anticipate needing to gather two to three times the number of desired charts for each lifecycle in order to identify the required number of eligible records.

   The Perinatal lifecycle requires the review of a minimum of twenty-five (25) charts and Pediatric, Adolescent and Geriatric lifecycles each require the review of a minimum of fifty (50) charts of patients meeting the eligibility criteria. The Adult lifecycles requires a minimum of seventy-five (75) charts. Thus, a minimum of 250 charts should be reviewed annually for performance of clinical measures. Charts should be selected at random from the total population of patients within each lifecycle. A list of medical records audited should be retained for at least two years after the audit; community health centers should make every effort to not audit the same charts within this two-year period.

   Method for gathering required sample:

   • For each lifecycle, generate a list of all patients seen at your center within the last two years (centers without computerized medical records can use the billing system if computerized). If you cannot generate lists specific to the last two years, generate a list of all patients ever seen; you can discard those who are not eligible later. From the list you produce, select every fifth, tenth or other __th chart until the required number of charts have been pulled (remember you may need to gather two to three times the number of desired charts for each lifecycle in order to identify the required number of eligible records).
   Minimum number of required chart reviews, by lifecycle:
   Perinatal 25 charts
   Pediatric 50 charts (25 two years olds; 25 six year olds)
   Adolescent 50 charts
   Adult 75 charts (25 males 20 - 64 years of age; 25 females 20 - 39 years of age; and 25 females 40 - 64 years of age)
   Geriatric 50 charts

2. Ensure Medical Records Meet Eligibility Criteria

   A chart is eligible for auditing if it meets the required number of visits, age parameters and timeframe. After obtaining your sample of medical records, skim each chart for eligibility (ie. for the Pediatric Lifecycle, check that the patient is within the appropriate age parameters and has had three or more visits to the clinic over a period of three or more months with the last visit within two years). For all the lifecycles, visits to the CHC for mental health, social services or specialty services only, WIC, dental care or other visits where a primary care provider is not seen are not counted toward the required minimum of three visits.

   Before beginning to audit any lifecycle, it is suggested that you indicate in the space provided in the bottom right corner of the Audit Form, the birthdates a patient needs to fall between in order to be ageeligible.

   Eligibility criteria for review of medical records, by lifecycle, are as follows:

   Prenatal:	25 charts of women who attended the CHC for prenatal care 3 times within the last 6 months. Only charts of women who have already delivered should be audited.
   Alternate	25 charts of women with 3 visits to the CHC over a period of 3 or more months with the last visit within the past two years and who have a positive pregnancy test and are referred out for prenatal services.
   Pediatric:	25 charts of children two years of age; and 25 charts of children six years of age with >3 visits to the CHC over a period of 3 or more months with the last visit within the past two years.
   Adolescent:	50 charts of males or females 12 - 19 years of age with 3 visits to the CHC over a period of 3 or more months with the last visit within the past two years.
   Adult:	25 charts of adult males 20 - 64 years of age; and 25 charts of women 20 - 39 years of age; and 25 charts of women 40 - 64 years of age with 3 visits to the CHC over a period of 3 or more months with the last visit within the past two years.
   Geriatric:	50 charts of males or females >65 years of age with 3 visits to the CHC over a period of 3 or more months with the last visit within the past two years.

3. Gather Audit Form

   Gather the audit form that corresponds to the lifecycle (or in the case of the Pediatric or Adult Lifecycle, the specific target population) you plan to audit (Part F). The audit form provides columns to enter data for each medical record: chart #, comments, performance status (for each clinical measure) and management plan status (for most clinical measures; not all indicators require documentation of a management plan). Each audit form provides space for recording clinical measures performance for up to 10 charts.

   Components of the Audit Form:
   Chart # (to document the medical record number for each chart reviewed)
   Comments (to enter information that may be useful at a later date, ie. gender, date of birth)
   Performance of Clinical Measure (P) (to document performance of each clinical measure)
   Management Plan (MP) (to document whether a management plan was completed or indicated as not necessary)

4. Review the Medical Record/Enter Findings on Audit Form

   Medical Record #
   If the medical record meets the minimum eligibility criteria, enter the medical record number in the "Chart #" column on the Audit Form.

   Comments
   Enter any information that may prove useful at a later date in the "Comments" column of the Audit Form. Useful data includes patient's gender and date of birth. You may choose to enter other pertinent information that is revealed during your chart review.

   Performance
   Review chart to determine whether a clinical measure was performed. Performance of a clinical measure refers to whether it was addressed by a primary care provider (i.e. documented as assessed, discussed or reviewed). If a patient is referred to another provider for performance of a clinical measure, this is entered as a referral or "L." Patients referred to another provider for services require documentation as to whether services were provided and/or follow-up necessary.

   Indicate in the "P" or Performance column whether a measure was performed. Each clinical measure performed must indicate one of the following in the "P" or Performance column:

   "Y"	Clinical measure performed.
   "N"	Clinical measure not performed or not documented.
   "R"	Clinical measure attempted but refused by patient.
   "X"	Clinical measure not performed due to allergies or contraindications.
   "O"	Clinical measure not applicable (i.e. last menstrual period measure for male).
   "L"	Patient referred to another provider for performance of clinical measure.

   Important: all clinical measure indicators within a column need to be addressed in order to score a "Y" or yes for performance of that clinical measure. Using the Perinatal Lifecycle as an example, all clinical indicators in the column entitled "Pre-existing problems noted" must be assessed or referred for assessment for a "Y" to be entered in the box documenting performance of this clinical measure. Therefore, failure to inquire into one or more clinical indicators in any column results in a "N" or no for performance of the entire measure.

   Management Plan
   If the medical record documents any conditions requiring clinical follow-up, a management plan or plan for corrective/preventive action is required. Clinical outcome measure definitions and conditions under which a management plan is required are outlined in this manual (Part C).

   Indicate in the "MP" or Management Plan column whether a plan was documented. Each clinical measure performed or referred for management ("Y" or "L") must indicate one of the following in the "MP" or Management Plan column:

   "C"	Management Plan documented and completed.
   "A"	Management Plan absent; Management Plan necessary but not documented or documented inadequately.
   "O"	Management Plan is not necessary or not applicable.

   Important: if a clinical measure was not performed (ie. "N" entered in the Performance box), enter a dashed line (---) in the Management Plan column to signify that the question is not relevant; DO NOT ENTER a "O" (not applicable; not necessary) as this refers only to patients for whom the clinical measure is not applicable or who had performance of a clinical measure and do not require a Management Plan.

   Continue reviewing medical records until the target number of charts have been reviewed!!!

PART C

Performance Standards and Recording Results

Audit results for patient charts within the Perinatal Lifecycle are recorded on the Perinatal Audit Form (Part F). Each Audit Form provides space to record the performance results of clinical measures for up to ten (10) patients. Each horizontal line of the Audit Form records the performance of all clinical measures for one patient. Below are guidelines to facilitate determinations with respect to performance of Perinatal Lifecycle clinical measures.

Domestic Violence:
Documentation is required that the patient was questioned about domestic violence at least once during the prenatal period or at each visit if there are signs of physical injury. Record in the performance column whether a domestic violence assessment was performed (Y), not documented as performed (N), refused (R), etc. during the prenatal period. Any identified risks require documentation of a management plan.

Trimester of Enrollment into Prenatal Care:
Documentation is required on the trimester a woman first enrolled into prenatal care. Enter a "Y" in the appropriate column for the trimester the woman enrolled into prenatal care. First trimester enrollment is defined as receiving prenatal care by 13 weeks gestation; second trimester enrollment includes women who first seek prenatal care between 13 and 27 weeks; third trimester enrollment indicates women who first seek prenatal care at 27 weeks gestation.

Medical Risk Assessment:
Medical risk assessment requires documentation of a review by a clinician for pre-existing problems and current health and social factors. An assessment of pre-existing problems is required at least once during the prenatal period. An assessment for pre-existing problems must address all of the following: age, number of previous deliveries, weight, date(s) of previous pregnancy(s), assessment of pre-existing medical conditions, assessment for prior obstetrical complications, review of significant diseases and genitourinary anomalies/surgery, assessment for parental genetic abnormalities, varicella (chickenpox) immunity, determination of Rh factor and serum antibody test for rubella (german measles). All clinical indicators must be assessed, an attempt at assessment made (but patient refused), or referred for assessment, in order to score a "Y" for this measure. Any identified problem requires a management plan consistent with CHC protocols.

Assessment of current problems is also required at each visit. An assessment of current medical problems must address all of the following: date of access to care, number of developing fetuses, weight gain during pregnancy, assessment for significant infections, evaluations for diabetes, assessment for bleeding, review of previous placental problems, assessment for nausea and vomiting, assessment of amniotic fluid levels, monitoring of hemoglobin and hematocrit, monitoring of Rh factor, blood pressure measured at each visit, fetal developmental assessments, cervical assessments, and review for previous history of spontaneous premature rupture of membranes. All clinical indicators must be assessed, an attempt at assessment made (but patient refused), or referred for assessment, in order to score a "Y" for this measure. Any identified problems require a management plan consistent with CHC protocols.

Behavioral/Environmental Risk Assessment:
An assessment for behavioral/environmental risk is required at least once during the prenatal period. Record in the performance column whether a behavioral/environmental risk assessment was performed (Y), not documented as performed (N), refused (R), etc. A behavioral/ environmental risk assessment requires at least one review by a clinician or other appropriate staff of all the following: educational level, economic resources, marital status, eating habits, smoking, history, alcohol use, substance use, exposure to toxic substances (ie. pesticides), exposure to occupational hazards, TB exposure/disease status, HIV exposure/disease status, and parenting/family planning skills. Any identified risks require documentation of a management plan.

Post-Partum Follow-up:
Record whether a post-partum visit was performed. Compliance with the post-partum visit is documentation of a visit within 8 weeks of delivery that addresses all of the following: medical status, social issues and parenting skills. CHCs may choose to note in the "Comments" column the number of women who had a post-partum visit scheduled but who did not attend.

Clinical Measure Indicators	Documentation Required	Management Plan Required If:
DOMESTIC VIOLENCE
Domestic violence assessment	Patient questioned about domestic violence at least once within the last two years or at each visit if there are signs of physical injury	Patient reports she is a victim of, or at risk of, domestic violence; any sign of physical injury
PRE-EXISTING MEDICAL RISKS
Age, parity, low weight for height, pregnancy within the last six months, pre-existing medical conditions, poor obstetrical history, significant diseases, genitourinary anomalies/surgery, history of parental genetic abnormalities, varicella, Rh antigen, lack of rubella immunity	Age, number of previous deliveries, weight, date(s) of previous pregnancy(s), assessment of pre-existing medical conditions, assessment for prior obstetrical complications, review of significant diseases and genitourinary anomalies/surgery, assessment for parental genetic abnormalities, varicella immunity, determination of Rh factor and serum antibody test for rubella	<15 years, >35 years, 7 deliveries, > 20% below ideal body weight, pregnancy within the last six months, any significant history that indicates medical risk (i.e. diabetes, HTN), documentation of prior obstetrical complications (i.e. previous low birthweight or multiple spontaneous abortions), any significant diseases (i.e. HIV, syphilis), genitourinary anomalies/surgery, parental genetic abnormalities, lack of varicella immunity, patient Rh negative, abnormal serum antibody test
CURRENT MEDICAL PROBLEMS
Late access to care, multiple gestation, poor weight gain, significant infections, gestational diabetes, first or second trimester bleeding, placental problems, hyperemesis, oligo/polyhydraminos, anemia, isoimmunization, hyper/hypotension, fetal anomalies, incompetent cervix, spontaneous premature membrane rupture	Date of access to care, number of developing fetuses, weight gain during pregnancy, assessment for significant infections, evaluation for diabetes, assessment for bleeding, review of previous placental problems, assessment for nausea and vomiting, assessment of amniotic fluid levels, monitoring hemoglobin and hematocrit, monitor Rh factor, blood pressure monitored at each visit, fetal development assessments, cervical assessments, assess for previous history of spontaneous rupture of membranes	First prenatal care visit in third trimester ( 27 weeks gestation), multiple gestation, less than 20 pounds weight gain during pregnancy, significant infections (i.e. rubella, HIV, cytomegalovirus) that pose a medical risk, onset of diabetes during pregnancy, evidence of first or second trimester bleeding, excessive nausea or vomiting during pregnancy, amniotic fluid levels below/above normal, hematocrit <36%, hemoglobin <12 g/dl, Rh agglutins in an Rh negative mother, hypotension (diastolic <60 or systolic <90), hypertension (diastolic >90 or systolic >140), abnormal fetal development, incompetent cervix, previous premature membrane rupture
BEHAVIORAL/ENVIRONMENTAL RISK ASSESSMENT
Low educational level, low socioeconomic level (SES), unmarried, poor nutritional/oral status, smoking, alcohol, other substance abuse, toxic exposure, occupational hazards, TB, HIV, parenting/family planning skills	Educational level, economic resources, marital status, age, eating habits, smoking history, alcohol use, substance use, exposure to occupational hazards, TB exposure/disease status, HIV exposure/disease status, exposure to domestic violence, parenting/family planning skills	<8th grade education, women receiving public assistance and in need, unmarried women, inadequate intake or other nutritional/oral complications, smoking, alcohol use, any other substance use, toxic substance exposure, occupational hazards, TB exposure/disease, HIV exposure/disease, absence of parenting/family planning skills
POST-PARTUM FOLLOW-UP
Post-partum visit	A visit within 8 weeks of delivery that addresses medical, social and parenting issues	Abnormal findings on post-partum visit, missed visit

Performance Standards and Recording Results

Audit results for patient charts within the Alternate - Perinatal Lifecycle are recorded on the Alternate - Perinatal Audit Form (Part F). Each Audit Form provides space to record the performance results of clinical measures for up to ten (10) patients. Each horizontal line of the Audit Form records the performance of all clinical measures for one patient. Below are guidelines to facilitate determinations with respect to performance of Alternate - Perinatal Lifecycle clinical measures.

Domestic Violence:
Documentation is required that the patient was questioned about domestic violence at least once following a positive pregnancy test and prior to referral to a prenatal provider or at each visit if there are signs of physical injury. Record in the performance column whether a domestic violence assessment was performed (Y), not documented as performed (N), refused (R), etc. within the period prior to referral. Any identified risks require documentation of a management plan.

Trimester Referred to Prenatal Care:
Documentation is required on the trimester when a woman is referred to prenatal care services outside the community health center. Enter a "Y" in the appropriate column for the trimester the woman was referred to outside prenatal care. First trimester referral is defined as referral to prenatal care by 13 weeks gestation; second trimester referral includes women referred to prenatal care between 13 and 27 weeks; third trimester referral indicates women first referred to prenatal care at 27 weeks gestation.

Medical Risk Assessment:
Medical risk assessment requires documentation of a review by a community health center clinician for a minimum set of pre-existing medical risks prior to referral for care outside the center. An assessment for pre-existing problems must address all of the following: date of last menstrual period, age, number of previous deliveries, preexisting medical conditions, and review for significant diseases. All clinical indicators must be assessed or an attempt at assessment made (but patient refused) in order to score a "Y" for this measure. Any identified problems require a management plan consistent with CHC protocols.

Assessment of current problems is also required following a positive pregnancy test and prior to referral to an outside provider for prenatal services. An assessment of current medical problems must include blood pressure and weight measurements. Both clinical indicators must be assessed or an attempt at assessment made (but patient refused) in order to score a "Y" for this measure. Any identified problems require a management plan consistent with CHC protocols.

Behavioral/Environmental Risk Assessment:
An assessment for behavioral/environmental risks by the community health center is required at least once between the time of a positive pregnancy test and referral to an outside provider. Record in the performance column whether a behavioral/environmental risk assessment was performed (Y), not documented as performed (N), refused (R), etc. A behavioral/ environmental risk assessment requires at least one review by a clinician or other appropriate staff of all the following: educational level, economic resources, marital status, pregnancy during adolescence, eating habits, smoking, history, alcohol use, other substance use, and parenting/family planning skills. Any identified risks require documentation of a management plan.

Referral Information documented:
Record whether information on a woman's referral to a provider outside of the community health center for prenatal services is documented. Referral information must include, at a minimum, the date when the woman was referred, the name and address of the provider to whom patient was referred and confirmation that referral was successful (ie. patient was seen by the provider to whom referred).

Clinical Measure Indicators	Documentation Required	Management Plan Required If:
DOMESTIC VIOLENCE
Domestic violence assessment	Patient questioned about domestic violence at least once within the last two years or at each visit if there are signs of physical injury	Patient reports she is a victim of, or at risk of, domestic violence; any sign of physical injury
PRE-EXISTING MEDICAL RISKS
Date of last menstrual period, age, parity, preexisting medical conditions, significant diseases	Date of last menstrual period, age, number of previous deliveries, assessments for preexisting medical conditions, review for significant diseases	<15 years, >35 years, 7 deliveries, pregnancy within the last six months, any significant history that indicates medical risk (ie diabetes, HTN), any significant diseases (ie HIV, syphilis)
CURRENT MEDICAL PROBLEMS
Blood pressure, weight	Blood pressure monitored at each visit after a positive pregnancy test, weight measured at each visit after a positive pregnancy test	Hypotension (diastolic <60 or systolic <90), hypertension (diastolic >90 or systolic >140), >20% below ideal body weight
BEHAVIORAL/ENVIRONMENTAL RISK ASSESSMENT
Low educational level, low socioeconomic level (SES), unmarried, adolescent, poor nutritional/oral status, smoking, alcohol, other substance abuse, parenting/family planning skills	Educational level, economic resources, marital status, age, eating habits, smoking history, alcohol use, substance use, parenting/family planning skills	<8th grade education, women receiving public assistance and in need, unmarried women, teens (12-19 years of age), inadequate intake or other nutritional/oral complications, smoking, alcohol use, any other substance use, absence of parenting/family planning skills
REFERRAL INFORMATION
Referral information	Name of provider to whom woman was referred for prenatal care and date of referral	No referral provider identified

Performance Standards and Recording Results

Audit results for patient charts within the Pediatric Lifecycle are recorded on either the Pediatric Audit Form: Two Year Olds or Pediatric Audit Form: Six Year Olds (Part F). Each Audit Form provides space to record the performance results of clinical measures for up to ten (10) patients. Each horizontal line of the Audit Form records the performance of all clinical measures for one patient. Below are guidelines to facilitate determinations with respect to performance of Pediatric Lifecycle clinical measures.

Domestic Violence:
Documentation is required that the patient or patient's parent/guardian was questioned for domestic violence at least once within the last two years or at each visit if there are signs of physical injury. Any identified risks require documentation of a management plan.

Immunizations
In the date of comments column, enter the month and year of child's birth. In the immunization column, indicate whether the child received 4DTaP, 3IPV/OPV, 3HIB (refer to the catch-up schedule on the immunization schedule in Part E if the first HIB was administered after 12 months), 1MMR and 3HepB by the age of 24 months of age. Use the immunization schedule that was appropriate for the time at which the immunizations were due, if different from the current schedule. Although management plans are not required, standard clinical practice would suggest that preventative/corrective action be taken if clinical indicator is not performed.

Growth and Development:
Record whether each of the six indicators of this measure: monitoring of growth and development, nutritional assessment, anemia status, lead screening, gross and fine motor development, and language skills assessment were performed. Documentation of height, weight and head circumference must occur at the majority of visits (>50%) for children < l year of age and at least annually thereafter. At least one nutrition screening should be performed by the age of two. Children with identified nutritional deficiencies require a nutrition referral. Anemia screenings are required at least once for children < 1 year of age. Children with identified abnormalities should have a management plan consistent with CHC protocols. A blood test for lead exposure should be performed at least once by 18 months of age. Blood lead levels 10 μg/dL require confirmation testing and appropriate referrals. Gross and fine motor skills and language development assessments (developmental milestones) should be documented at the majority of visits (>50%) through the first year of life and annually thereafter. Children with identified abnormalities should have a management plan consistent with CHC protocols.

Oral Health:
Review each chart for documentation of an oral cavity examination and discussion of good oral health practices on an annual basis. Children with identified oral disease require a management plan that includes a referral to dental clinical personnel. In addition, a discussion regarding baby bottle tooth decay should have occurred within the past two years (some sites may record this data in the dental section of the chart). Children who are reported to go to bed with a bottle, or have sweeteners added to their bottle, require a management plan consistent with CHC protocols.

Immunization standards are based upon the American Academy of Family Practice (AAFP) and the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP)

Clinical Measure Indicators	Documentation Required	Management Plan Required If:
DOMESTIC VIOLENCE
Domestic violence assessment	Infant or infant's parent/guardian questioned about domestic violence at least once within the last two years or at each visit if there are signs of physical injury	Infant or infant's parent/guardian reports infant is a victim, or at risk of, domestic violence; any sign of physical injury
IMMUNIZATIONS1
Up to date by 24 months of age	4DTaP, 3IPV/OPV, 3HIB*, 1MMR and 3HepB	n/a2
GROWTH AND DEVELOPMENT
Growth chart update	Height and weight at the majority (>50%) of visits until two years of age	n/a2
Nutritional assessment	Assessment of nutritional intake and discussion of proper nutrition at least once by age two	Nutritional deficiencies; plan to include referral to nutritionist
Anemia screening	Hemoglobin and hematocrit measured at least once for children <1 year of age	Hemoglobin and hematocrit levels below normal
Lead screening	Blood test for lead exposure performed at least one (1) time by age 18 months	Blood lead levels 10 μg/dL require intervention to include counseling, education, confirmation testing and appropriate referrals
Motor skills	Assessment of gross and fine motor skills at a majority (>50%) of visits until two years of age	Delays in gross and fine motor skills
Language skills	Assessment of language development at a majority (>50%) of visits until two years of age	Delays in language development
ORAL HEALTH
Oral health screening	Oral cavity examination and discussion of good oral health practices on annual basis	Oral disease; plan to include referral to dental clinical personnel
Baby bottle tooth decay (BBTD)	Discussion regarding baby bottle tooth decay	Baby sleeping with bottle; baby receiving excess sugar in bottle

* If first HIB was administered after 12 months, only 2 necessary. If first HIB was administered after 15 months, only 1 necessary.

¹ Immunizations are considered on time if delivered within one month from the schedule indicated in parentheses next to the immunization.

Domestic Violence:
Documentation is required that the patient or parent/guardian was questioned about domestic violence at least once within the last two years or at each visit if there are signs of physical injury. Record in the performance column whether a domestic violence assessment was performed. Any identified risks require documentation of a management plan.

Immunizations
In the box under each vaccine, indicate if the vaccine was administered (Y), not documented as given (N), refused (R), etc. A child is considered to be immunized if, after four years of age, there is documentation of DPT and OPV vaccination, including month and year immunized. CHCs can choose to be more comprehensive in their audit and review for the completeness of other required documentation including informed consent, manufacturing lot#, and name/address/title of person administering vaccine. In the "TB Screen" column, document whether a TB screening was performed at least once during the child's first five years of life. Management plans are not required documentation for immunizations.

Growth and Development:
Record whether each of the five indicators of this measure: monitoring of growth and development, nutritional assessment, anemia status, lead screening and gross and fine motor development, were performed. Documentation of height and weight must occur at least annually. At least one nutrition screening should be performed between the ages of two and six. Children with identified nutritional deficiencies require a nutrition referral. An anemia screening is required at least once between one and five years of age. Children with identified abnormalities should have a management plan consistent with CHC protocols. A blood test for lead exposure should be performed at least two times between the ages of two and six. Blood lead levels 10 μg/dL require confirmation testing and appropriate referrals. Gross and fine motor skills and language development assessments (developmental milestones) should be documented annually. Children with identified abnormalities should have a management plan consistent with CHC protocols.

Oral Health:
Review each chart for documentation of an oral cavity examination and discussion of good oral health practices on an annual basis. In addition, all children, regardless of place of residence (ie. live in a city where water is fluoridated), require an assessment of fluoridation sources. Record in the appropriate column of the Audit Form whether this indicator was ever performed. Children who are reported to have no fluoridation source require a management plan consistent with CHC protocols.

Clinical Measure Indicators	Documentation Required	Management Plan Required If:
DOMESTIC VIOLENCE
Domestic violence assessment	Patient or parent/guardian questioned about domestic violence at least once within the last two years or at each visit if there are signs of physical injury	Patient or parent/guardian reports s/he is a victim, or at risk of, domestic violence; any sign of physical injury preventive/corrective action be taken if clinical indicator not performed.
IMMUNIZATIONS2
4-6 Years	DPT#5 (4-6 years) OPV#4 (4-6 years)	n/a1
TB Screen	One screening by 5 years of age	n/a1
GROWTH AND DEVELOPMENT
Growth chart update	height and weight	n/a1
Nutritional assessment	Assessment of nutritional intake and discussion of proper nutrition at least once by age two	Nutritional deficiencies; plan to include referral to nutritionist
Anemia screening	Hemoglobin and hematocrit measured at least once between one and five years of age	Hemoglobin and hematocrit levels below normal
Lead screening	Blood test for lead exposure performed at least two times between the ages of two and six	Blood lead levels 10 μg/dL require intervention to include counseling, education, confirmation testing and appropriate referrals
Motor skills	Assessment of language development and gross and fine motor skills at a majority (>50%) of visits within the last two years	Delays in gross and fine motor skills
Language skills	Assessment of language development at a majority (>50%) of visits within the last two years	Delays in language development
ORAL HEALTH
Oral health screening	Oral cavity examination and discussion of good oral health practices on annual basis	Oral disease; plan to include referral to dental clinical personnel
Fluoridation	Inquiry about fluoridated water or other sources of fluoride regardless of child's place of residence	Absence of fluoride source

¹ Although clinical outcome measures do not require a management plan, standard clinical practice would suggest that preventive/corrective action be taken if clinical indicator not performed.

² Immunizations considered on time if delivered within one month from the schedule indicated in parentheses next to the immunization.

Performance Standards and Recording Results

Audit results for patient charts within the Adolescent Lifecycle are recorded on the Adolescent Audit Form (Part F). Each Audit Form provides space to record the performance results of clinical measures for up to ten (10) patients. Each horizontal line of the Audit Form records the performance of all clinical measures for one patient. Below are guidelines to facilitate determinations with respect to performance of Adolescent Lifecycle clinical measures.

Domestic Violence:
Documentation is required that the patient was questioned about domestic violence at least once within the last two years or at each visit if there are signs of physical injury. Record in the performance column whether a domestic violence assessment was performed (Y), not documented as performed (N), refused (R), etc. within the last two years. Any identified risks require documentation of a management plan.

Behavioral Risk Assessment: Substance Abuse
For each chart, document if both substance abuse assessments (current use and history) were ever performed (Y), not documented as performed (N), refused (R), etc. Assessment of current substance use must occur at each physical exam and/or 50% of other visits. A substance abuse history must include documentation of at least one review by a clinician or other appropriate staff of an adolescent's history of alcohol, tobacco, marijuana or other drugs and/or exposure to family, friends or sexual partner(s) who are known or suspected drug users within the past two years. Any identified risk should have a management plan consistent with CHC protocols. Ideally, prevention focused management plans are documented for adolescents with no identified risks.

Behavioral Risk Assessment: Family Planning
Enter in the appropriate box whether an adolescent has had each of the family planning indicators performed. Performance of the sexual history clinical measure requires inquiry at each physical exam and/or 50% of other visits by a clinician or other appropriate staff, as to whether an adolescent is currently, or has been, sexually active. Adolescents reporting sexual activity require a management plan that includes their choice of a family planning method at each visit. Charts of sexually active adolescents must also include documentation that the use, efficacy and side effects of the selected method were addressed at each visit as well as discussions regarding possible alternatives.

If an adolescent reports no sexual activity, it is not necessary to document performance of the three indicators which follow: method selected, discussion of use, and discussion of alternatives; enter dashes [---] in these three columns. CHCs may choose to include prevention focused indicators for adolescents not yet sexually active as part of their performance criteria.

Record whether each patient received counseling on the prevention of sexually transmitted/ infectious diseases; all adolescents should receive counseling on HIV/STD prevention and the availability of further counseling and testing services at each pap smear or physical exam and/or 50% of other visits within the last two years. Document whether each female had the date of her last menstrual period assessed at each visit.

Report the number of adolescents with a planned follow-up visit. All adolescents are required to have a return visit planned after each visit.

Clinical Measure Indicators	Documentation Required	Management Plan Required If:
DOMESTIC VIOLENCE
Domestic violence assessment	Patient questioned about domestic violence at least once within the last two years or at each visit if there are signs of physical injury	Patient reports s/he is a victim of, or at risk of, domestic violence; any sign of physical injury
SUBSTANCE ABUSE ASSESSMENT
Current use assessment	Current alcohol, tobacco, marijuana or other substance use discussed at every physical exam and/or 50% of other visits.	Any substance abuse
History and exposure risk	Substance abuse history of self, sexual partner(s) and family taken once in last two years	Any substance abuse history
FAMILY PLANNING
Sexual history	Discussion of current and/or past sexual activity at every physical exam and/or 50% of other visits	n/a1
Method selected2	Family planning method documented	n/a1
Discussion of use, efficacy2	For family planning method selected, use, efficacy and side effects discussed at each physical exam and/or 50% of visits	n/a1
Alternatives2	Alternatives to selected family planning method discussed at each physical exam and/or 50% of visits	n/a1
HIV/STD prevention	HIV/STD prevention, counseling and testing discussed at annual pap smear (females only), physical exam and/ or 50% of visits	n/a1
Last menstrual period	Last menstrual period documented	n/a1
Return visit	Documentation of a planned return visit	n/a1

¹ Although clinical outcome measures do not require a management plan, standard clinical practice would suggest that preventive/corrective action be taken if clinical indicator not performed.

² Only relevant if patient reports current or past sexual activity.

Performance Standards and Recording Results

Audit results for patient charts within the Adult Lifecycle are recorded on the appropriate forms: Adult Males, Adult Females 20 - 39 years of age or Adult Females 40 - 64 years of age (Part F). Each Audit Form provides space to record the performance results of clinical measures for up to ten (10) patients. Each horizontal line of the Audit Form records the performance of all clinical measures for one patient. Below are guidelines to facilitate determinations with respect to performance of Adult Lifecycle clinical measures

Cardiovascular Risk Assessment:
For each chart, document in the appropriate column whether each clinical indicator for cardiovascular risk assessment was performed (Y), not documented as performed (N), refused (R), etc. Performance of cardiovascular risk assessment includes documentation of the following at a majority (greater than 50%) of patient visits within the last two years: smoking, blood pressure, activity level, weight and dietary fat. Any person who currently smokes, regardless of the amount of cigarettes smoked per day or the number of years smoking, requires a management plan. Hypertension is defined as blood pressure readings of >140/90 mm Hg on two or more occasions or treatment for hypertension. Individuals with diastolic blood pressures exceeding this reading on two occasions and not already receiving medication for control of hypertension require a management plan. Ideally, individuals with elevated diastolic and/or systolic blood pressures, but who do not meet the definition of hypertension, will receive preventive management plans. Inactivity is defined as less than 20 minutes of sustained, purposeful exercise three times per week. Management plans are required for inactive patients. Excessive weight is defined by provider assessment and documentation in the medical record. Excess dietary fat is measured in two ways: (1) dietary history - with >30% of calories reported from fat and >10% from saturated fat (as per USPHS clinical outcome measures guidance) and (2) cholesterol levels (as per CPCA/CIC recommendation). Documenting the use of cholesterol testing in addition to dietary histories is expected to result in a more accurate representation of clinician practices with respect to screening for excess dietary fat. Reports of saturated fat intakes >10% or cholesterol levels >200 mg/dl require management plans. Document the number of patients who have been screened for diabetes; tests are to be performed once every three years on all patients over 40 with risk factors of obesity or family history of diabetes. Abnormal results include two random glucose readings >200 or two blood sugar levels >126. Any abnormal results require a management plan.

Colon Cancer Screening:
Document the number of patients over that age of 50 who have had fecal occult blood testing performed; fecal occult blood tests are to be performed annually on all patients aged 50 and over. Any abnormal results require a management plan that includes follow-up within six weeks.

If a fecal occult blood test was not performed or refused, no answers are required in the "Results Posted" and "Follow-up to Abnormals" columns; indicate this column is not relevant by entering dashes [---].

Prostate Cancer Screening
Although not included in the clinical measure indicators, it is highly advisable that each health center include screening for prostrate cancer through PSA, rectal digital exam or both in routine preventative care services. It is also recommended that clinicians educate their patients on the risks of prostate cancer and the benefits of early detection and treatment.

Clinical Measure Indicators	Documentation Required	Management Plan Required If:
CARDIOVASCULAR RISK ASSESSMENT
Smoking	Smoking history initially on all patients and annually or at 50% of visits if under age 25 or if history of smoking within past 5 years	Any smoking
Hypertension	Blood pressure screening performed at amajority (>50%) of visits within the last two years	140/90 HG on two occasions or current anti-hypertensive prescription
Inactivity	Activity level assessed annually or at 50% if history of inactivity	Less than 20 minutes activity 3x/week
Excessive weight	Weight assessed once in past five years if normal or at a majority (>50%) of visits within the last two years if excessive	Greater than 20% above ideal weight; clinician assessment
Excess dietary fat: history	Dietary fat intake test performed once in last five years if intake is normal or once within last two years if excessive	Greater than 30% of calories from fat with >10% being saturated
Excess dietary fat: cholesterol	Cholesterol test performed once in last five years if intake is normal or once within last two years if excessive	Cholesterol level >200 mg/dl
EITHER dietary fat or cholesterol	Dietary fat intake or cholesterol test performed once in last five years if intake is normal or once within last two years if excessive	Greater than 30% of calories from fat with >10% being saturated; cholesterol level >200 mg/dl
Diabetes Screening	Screening in patients over 40 once in the past three years if risk factors of obesity or family history of diabetes are present	Two random glucose > 200 or two fasting blood sugar levels >126.
CANCER SCREENING
Colon Cancer Screening	Annual fecal occult blood testing performed in patients over 50	As appropriate

Domestic Violence:
Documentation is required that the patient was questioned about domestic violence at least once within the last two years or at each visit if there are signs of physical injury. Record in the performance column whether a domestic violence assessment was performed (Y), not documented as performed (N), refused (R), etc. within the last two years. Any identified risks require documentation of a management plan.

Cardiovascular Risk Assessment:
For each chart, document in the appropriate column whether each clinical indicator for cardiovascular risk assessment was performed (Y), not documented as performed (N), refused (R), etc. Performance of cardiovascular risk assessment includes documentation of the following annually or at 50% of visits if there is a history: smoking and inactivity. Any person who currently smokes, regardless of the amount of cigarettes smoked per day or the number of years smoking, requires a management plan. Inactivity is defined as less than 20 minutes of sustained, purposeful exercise three times per week. Management plans are required for inactive patients. Blood pressure should be monitored at a majority (greater than 50%) of patient visits within the last two years. Hypertension is defined as blood pressure readings of >140/90 mm Hg on two or more occasions or treatment for hypertension. Individuals with diastolic blood pressures exceeding this reading on two occasions and not already receiving medication for control of hypertension require a management plan. Individuals with diastolic blood pressures exceeding 90 mm Hg on two occasions and not already receiving medication for control of hypertension require a management plan. Ideally, individuals with elevated diastolic and/or systolic blood pressures, but who do not meet the definition of hypertension, will receive preventive management plans. The following should be assessed once in the past five years if they were found to be in the normal ranges: weight and dietary fat. Excessive weight is defined by provider assessment and documentation in the medical record. Excess dietary fat is measured in two ways: (1) dietary history - with >30% of calories reported from fat and >10% from saturated fat (as per USPHS clinical outcome measures guidance) and (2) cholesterol levels (as per CPCA/CIC recommendation). Documenting the use of cholesterol testing in addition to dietary histories is expected to result in a more accurate representation of clinician practices with respect to screening for excess dietary fat. Reports of saturated fat intakes >10% or cholesterol levels >200 mg/dl require management plans. Document the number of patients who have been screened for diabetes; tests are to be performed once every three years on all patients over 40 with risk factors of obesity or family history of diabetes. Abnormal results include two random glucose readings >200 or two blood sugar levels >126. Any abnormal results require a management plan.

Cervical Cancer Screening:
Document the number of women who had pap smear tests performed; Pap Smear tests are to be performed at least every two years on all women 20 - 64 years of age. Abnormal results include Class II, III, IV or lowgrade, highgrade SIL or squamous cancer. Any abnormal results require a management plan that includes follow-up within six weeks.

If a pap smear was not performed or refused, no answers are required in the "Results Posted" and "Follow-up to Abnormals" columns; indicate this column is not relevant by entering dashes [---].

Breast Cancer Screening:
Review each chart for performance of a clinical breast exam; performance of breast cancer screening requires a clinical breast exam at least once within the last two years. Any abnormal findings require a management plan consistent with CHC protocols. There are currently no recommendations for mammography screening in women 20- 39 years of age.

Document in the appropriate column, the number of women who had instruction in the performance of self breast examination. All women are to be instructed in the methods of self breast examination at least every two years.

Clinical Measure Indicators	Documentation Required	Management Plan Required If:
DOMESTIC VIOLENCE
Domestic violence assessment	Patient questioned about domestic violence at least once within the last two years or at each visit if there are signs of physical injury	Patient reports she is a victim, or at risk of, domestic violence; any sign of physical injury
CARDIOVASCULAR RISK ASSESSMENT
Smoking	Smoking history initially on all patients and annually or at 50% of visits if under age 25 or if history of smoking within past 5 years	Any smoking
Hypertension	Blood pressure screening performed at a majority (>50%) of visits within the last two years	Diastolic value >90 mm HG on two occasions or current anti-hypertensive prescription
Inactivity	Activity level assessed at a majority (>50%) of visits within the last two years	Less than 20 minutes activity 3x/week
Excessive weight	Weight assessed once in past five years if normal or at a majority (>50%) of visits within the last two years if excessive	Greater than 20% above ideal weight; clinician assessment
Excess dietary fat: history	Dietary fat intake test performed once in last five years if intake is normal or once within last two years if excessive	Greater than 30% of calories from fat with >10% being saturated
Excess dietary fat: cholesterol	Cholesterol test performed once in last five years if intake is normal or once within last two years if excessive	Cholesterol level >200 mg/dl
EITHER dietary fat or cholesterol	Dietary fat intake or cholesterol test performed once in last five years if intake is normal or once within last two years if excessive	Greater than 30% of calories from fat with >10% being saturated; cholesterol level >200 mg/dl
CANCER SCREENING
Pap Smear	Pap smear within the last two years	n/a1
Pap smear results posted1	If pap smear performed, results documented in the chart	Abnormal pap smear
Follow-up abnormal pap smears2	If pap smear performed and documented as abnormal (Class II, III, IV or lowgrade, highgrade SIL or squamous), follow-up documented within six weeks	n/a1
Clinical breast exam performed and results posted	Clinical breast exam performed within last two years and results documented	Abnormal clinical breast exam results
Clinical breast exam results posted2	Results documented in the chart	Abnormal clinical breast exam results
Self breast exam	Self breast examination instruction with the last two years	n/a1

¹ Although clinical outcome measures do not require a management plan, standard clinical practice would suggest that preventive/corrective action be taken if clinical indicator not performed.

² Only relevant if patient had procedure performed.

Domestic Violence:
Documentation is required that the patient was questioned about domestic violence at least once within the last two years or at each visit if there are signs of physical injury. Record in the performance column whether a domestic violence assessment was performed (Y), not documented as performed (N), refused (R), etc. within the last two years. Any identified risks require documentation of a management plan.

Cardiovascular Risk Assessment:
For each chart, document in the appropriate column whether each clinical indicator for cardiovascular risk assessment was performed (Y), not documented as performed (N), refused (R), etc. Performance of cardiovascular risk assessment includes documentation of the following at a majority (greater than 50%) of patient visits within the last two years: smoking, blood pressure, activity level, weight and dietary fat. Any person who currently smokes, regardless of the amount of cigarettes smoked per day or the number of years smoking, requires a management plan. Hypertension is defined as blood pressure readings of >140/90 mm Hg on two or more occasions or treatment for hypertension. Individuals with diastolic blood pressures exceeding this reading on two occasions and not already receiving medication for control of hypertension require a management plan. Individuals with diastolic blood pressures exceeding 90 mm Hg on two occasions and not already receiving medication for control of hypertension require a management plan. Ideally, individuals with elevated diastolic and/or systolic blood pressures, but who do not meet the definition of hypertension, will receive preventive management plans. Inactivity is defined as less than 20 minutes of sustained, purposeful exercise three times per week. Management plans are required for inactive patients. Excessive weight is defined by provider assessment and documentation in the medical record. Excess dietary fat is measured in two ways: (1) dietary history - with >30% of calories reported from fat and >10% from saturated fat (as per USPHS clinical outcome measures guidance) and (2) cholesterol levels (as per CPCA/CIC recommendation). Documenting the use of cholesterol testing in addition to dietary histories is expected to result in a more accurate representation of clinician practices with respect to screening for excess dietary fat. Reports of saturated fat intakes >10% or cholesterol levels >200 mg/dl require management plans. Document the number of patients who have been screened for diabetes; tests are to be performed once every three years on all patients over 40 with risk factors of obesity or family history of diabetes. Abnormal results include two random glucose readings >200 or two blood sugar levels >126. Any abnormal results require a management plan.

Cervical Cancer Screening:
Document the number of women who had pap smear tests performed; Pap Smear tests are to be performed at least every two years on all women 20 - 64 years of age. Abnormal results include Class II, III, IV or lowgrade, highgrade SIL or squamous cancer. Any abnormal results require a management plan that includes follow-up within six weeks.

If a pap smear was not performed or refused, no answers are required in the "Results Posted" and "Follow-up to Abnormals" columns; indicate this column is not relevant by entering dashes [---].

Breast Cancer Screening:
Review each chart for performance of a clinical breast exam and mammography screening; document performance status in the appropriate box. Performance of breast cancer screening requires a clinical breast exam at least once within the last two years. Women greater than 50 years of age should receive annual mammograms; CHC-specific protocols will determine whether women 40 - 50 years of age should receive biannual mammograms. Any abnormal findings require a management plan consistent with CHC protocols.

Document in the appropriate column, the number of women who had instruction in the performance of self breast examination. All women are to be instructed in the methods of self breast examination at least every two years.

Colon Cancer Screening:
Document the number of patients who have had Fecal Occult Blood Testing performed; Fecal Occult Blood test are to be performed annually all patients aged 50 and over. Any abnormal results require a management plan that includes follow-up within six weeks.

Clinical Measure Indicators	Documentation Required	Management Plan Required If:
DOMESTIC VIOLENCE
Domestic violence assessment	Patient questioned about domestic violence at least once within the last two years or at each visit if there are signs of physical injury	Patient reports she is a victim, or at risk of, domestic violence; any sign of physical injury
CARDIOVASCULAR RISK ASSESSMENT
Smoking	Smoking history initially on all patients and annually or at 50% of visits if history of smoking within past 5 years	Any smoking
Hypertension	Blood pressure screening performed at a majority (>50%) of visits within the last two years	140/90 HG on two occasions or current antihypertensive prescription
Inactivity	Activity level assessed annually or at 50% if history of inactivity	Less than 20 minutes activity 3x/week
Excessive weight	Weight assessed once in past five years if normal or at a majority (>50%) of visits within the last two years if excessive	Greater than 20% above ideal weight; clinician assessment
Excess dietary fat: history	Dietary fat intake test performed once in last five years if intake is normal or once within last two years if excessive	Greater than 30% of calories from fat with >10% being saturated
Excess dietary fat: cholesterol	Cholesterol test performed once in last five years if intake is normal or once within last two years if excessive	Cholesterol level >200 mg/dl
EITHER dietary fat or cholesterol	Dietary fat intake or cholesterol test performed once in last five years if intake is normal or once within last two years if excessive	Greater than 30% of calories from fat with >10% being saturated; cholesterol level >200 mg/dl
Diabetes screening	Screening in patients over 40 performed once in past three years if risk factors of obesity or family history of diabetes are present	Two random glucose >200 or 2 fasting blood sugar levels >126.
CANCER SCREENING
Pap Smear	Pap smear within the last two years	n/a1
Pap smear results posted2	Results documented in the chart	Abnormal pap smear
Follow-up abnormal pap smears2	If pap smear performed and documented as abnormal (Class II, III, IV or lowgrade, highgrade SIL or squamous), follow-up documented within six weeks	n/a1
Clinical breast exam performed and results posted	Clinical breast exam performed within last two years and results documented	Abnormal clinical breast exam results
Clinical breast exam results posted2	Results documented in the chart	Abnormal clinical breast exam results
Mammography	Screening or diagnostic mammography within the last two years	n/a1
Mammography results posted2	Mammography results documented	Abnormal mammography results
Self breast exam instruction	Self breast examination instruction with the last two years	n/a1
Colon Cancer Screening	Annual fecal occult blood testing performed in patients over 50	As appropriate

¹ Although clinical outcome measures do not require a management plan, standard clinical practice would suggest that preventive/corrective action be taken if clinical indicator not performed.

² Only relevant if patient had procedure performed.

Performance Standards and Recording Results

Audit results for patient charts within the Geriatric Lifecycle are recorded on the Geriatric Audit Form (attached). Each Audit Form provides space to record the performance results of clinical measures for up to ten (10) patients. Each horizontal line of the Audit Form records the performance of all clinical measures for one patient. Below are guidelines to facilitate determinations with respect to performance for Geriatric Lifecycle clinical measures.

Abuse Assessment:
Documentation is required that the patient was questioned about elder abuse and domestic violence at least once within the last two years or at each visit if there are signs of physical injury. Record in the performance column whether an abuse assessment was performed (Y), not documented as performed (N), refused (R), etc. within the last two years. Any identified risks require documentation of a management plan.

Functional Assessment:
For each chart, document whether the USPHS' clinical outcome measures guidance and/or clinician/CHC documentation were utilized to assess for functional status. The clinical outcome measures assessment includes documentation of clinician review of the following four questions: can you get out of bed yourself? can you dress yourself? can you make your own meals? and can you do your own shopping? Clinician/CHC functional assessments are generally progress notes or checklists assessing activities of daily living. Regardless of the specific approach, functional levels must be assessed at least once every two years in this target population. In the Management Plan column, indicate if a management plan was completed. A management plan is required if deficits in functional activity are noted.

Immunizations:
In the column under each of the three vaccines, indicate if the vaccine was administered (Y), not documented as given (N), refused (R), etc. Performance of geriatric immunizations includes documentation of annual influenza for the past two years, documentation of ever having received the pneumoccal vaccine, and documentation of tetanus vaccination within the last ten years.

Medication Profile:
Review the medical record for each of the six clinical indicators that comprise the Medication Profile clinical measure. Performance of medication profile indicators requires documentation of each indicator at every visit within the last two years. Record whether the patient's name and medical record number are documented on the medication sheet(s); it is recommended that CHCs not utilize the individual progress notes as the sole source for documenting the medication profile.

The Audit Form has two columns to indicate documentation with respect to whether medication names are listed. The first column documents whether the names of both current and discontinued medications are recorded in the medical record (as per USPHS guidance); the second column documents whether the medical record documents the name of only current medications (as per CPCA/CIC addition). Document performance status in both columns. (The second column was added in the belief that documenting only the USPHS guidance would underrepresent current practices with respect to documenting the names of geriatric medications. Both documentation methods require the inclusion of over-the-counter medications).

Record whether medication dosage, regime (when and how often to take) and the quantity of medication dispensed are documented. Medication allergies or intolerances must be noted in a prominent place in the chart.

Cardiovascular Risk Assessment:
Document the number of patients who have been screened for diabetes; tests are to be performed once every three years on all patients over 40 with risk factors of obesity or family history of diabetes. Abnormal results include two random glucose readings >200 or two blood sugar levels >126. Any abnormal results require a management plan.

Cervical Cancer Screening:
Document the number of women who had pap smear tests performed; pap smear tests are to be performed at least every two years on all women 20 - 64 years of age. Abnormal results include Class II, III, IV or lowgrade, highgrade SIL or squamous cancer. Any abnormal results require a management plan that includes follow-up within six weeks.

If a pap smear was not performed or refused, no answers are required in the "Results Posted" and "Follow-up to Abnormals" columns; indicate this column is not relevant by entering dashes [---].

Breast Cancer Screening:
Review each chart for performance of a clinical breast exam and mammography screening; document performance status in the appropriate box. Performance of breast cancer screening requires a clinical breast exam at least once within the last two years. Women greater than 50 years of age should receive annual mammograms. Any abnormal findings require a management plan consistent with CHC protocols.

Colon Cancer Screening:
Document the number of men who have had Fecal Occult Blood Testing performed; Fecal Occult Blood test are to be performed annually all patients aged 50 and over. Any abnormal results require a management plan that includes follow-up within six weeks.

Clinical Measure Indicators	Documentation Required	Management Plan Required If:
ABUSE ASSESSMENT
Abuse assessment	Patient questioned about elder abuse and domestic violence at least once within last two years or at each visit if there are signs of physical injury	Patient reports s/he is a victim, or at risk of, abuse; any signs of physical injury
FUNCTIONAL ASSESSMENT
ADL assessment	Assessment of ability to get out of bed, dress self, make own meals and do own shopping performed once every two years	Unable to perform activities of daily living (ADL)
IMMUNIZATIONS
Influenza	Annual Influenza vaccination	n/a1
Pneumoccal	Pneumococcal vaccination given once if administered >65 or two times, 5 years apart if first dose <65.	n/a1
Tetanus	Tetanus vaccination given once within last ten years unless indicated earlier	n/a1
MEDICATION PROFILE
Patient's name and MR#	Patient's name and medical record number on medication profile	n/a1
Medication names	Names of current and discontinued medications, including over-the-counter medications, documented on medication profile; and names of current only medications, including over-thecounter medications reviewed at every non-episodic visit	n/a1
Medication doses	Medication profile documents medication dosages for all medications updated at every non-episodic visit	n/a1
Medication regime	Medication profile indicates when and how often to take medication(s) updated at every non-episodic visit	n/a1
Allergies / Intolerance	Patient's allergies or intolerance to medications are documented; minimal documentation required is no known drug allergies ("NKDA")	n/a1
CARDIOVASCULAR RISK ASSESSMENT
Diabetes screening	Screening performed once in past three years if risk factors of obesity or family history of diabetes are present	Two random glucose >200 or 2 fasting blood sugar levels >126.
CANCER SCREENING
Pap Smear	Pap smear within the last two years	n/a1
Pap smear results posted2	If pap smear performed, results documented in the chart	Abnormal pap smear
Follow-up abnormal pap smears2	If pap smear performed and documented as abnormal (Class II, III, IV or lowgrade, highgrade SIL or squamous) , follow-up documented within six weeks	n/a1
Mammogram	Screening or diagnostic mammography within the last two years	n/a1
Mammography results posted2	Mammography results documented	Abnormal mammography results
Colon Cancer Screening	Annual fecal occult blood testing performed	As appropriate

¹ Although clinical outcome measures do not require a management plan, standard clinical practice would suggest that preventive/corrective action be taken if clinical indicator not performed.

² Only relevant if patient had procedure performed.

PART D

Summarizing and Reporting Audit Results

CHC Clinical Outcome Measures audit results and implementation experience are to be documented and reported annually. Results of Connecticut CHC clinical outcome measures audits are to be reported to the CPCA on the respective Audit Summary form for each of the eight target populations (that together comprise the five lifecycles) according to the schedule below.

In addition to Audit Summaries, on an annual basis CHCs are required to set One and Three Year Performance Goals and a narrative, outlining their experience in implementing clinical outcome measures and providing recommendations to removing any barriers and/or suggesting facilitators to implementation. Lastly, CHCs are to include a copy of their most recent Clinical Health Plans in the annual materials forwarded to the CPCA. For 330 funded health centers, this data will be forwarded (with audit data blinded) to the Regional Office.

Step I: Summarizing Audit Results

Summarize the data for each lifecycle sample on the respective Audit Summary form. This form differs from the Audit Forms for each lifecycle (which record data on individual medical records for each of the target populations) in that it summarizes the results of performance across the entire sample of patients for each target population. Shaded areas in the form designate areas that are not necessary to, or should not be, complete. Data entry issues specific to each lifecycle are as follows:

Perinatal Lifecycle

Use the Perinatal Lifecycle Audit Summary form to summarize the number of women from the sample who received prenatal care during their first, second and third trimester of pregnancy. Count the number of women who received a "Y" in the first trimester column; enter this number in the "First Trimester" box on the Summary form. Count the number of women who received a "Y" in the second trimester column; enter this number in the "Second Trimester" box. Count the total number of women who received a "Y" or yes for first receiving prenatal care during their third trimester; enter this number in the "Third Trimester" box on the Summary form.

Using the main table on the Perinatal Lifecycle Audit Summary form, enter the total number of women who scored a "Y", "N", "R", etc. for each indicator listed. In each box record the total number of charts as well as its corresponding percentage; place the percentage in parenthesis in the same box next to the actual number. For example, if 23 of the 25 Perinatal charts reviewed had documentation of assessment for preexisting medical risks, place the number 23 in the corresponding "Y" box with (92%) next to it (23/25 x 100% = 92%).

To determine Overall Performance for the sample of Perinatal Lifecycle medical records audited, simply add the percentages down the "Y" column for each indicator marked with an (*) and divide by the total number of indicators measured (the number of *'s). For the Perinatal lifecycle's "Y" column, you would add the percentage scores for five indicators (domestic violence, pre-existing medical risks, current medical problems, behavioral/ environmental risks and post-partum follow-up) and divide by five; the resulting number would be the overall performance for this column. Repeat this same process for the "N","R","X","O" and "L" columns.

Alternate - Perinatal Lifecycle

Use the Alternate Perinatal Lifecycle Audit Summary form to summarize the number of women from the sample who were referred to prenatal care during their first, second and third trimester of pregnancy. Count the number of women who received a "Y" in the first trimester column; enter this number in the "First Trimester" box on the Summary form. Count the number of women who received a "Y" in the second trimester column; enter this number in the "Second Trimester" box. Count the total number of women who received a "Y" or yes for first receiving prenatal care during their third trimester; enter this number in the "Third Trimester" box on the Summary form.

Using the main table on the Alternate - Perinatal Lifecycle Audit Summary form, enter the total number of women who scored a "Y", "N", "R", etc. for each indicator listed. In each box record the total number of charts as well as its corresponding percentage; place the percentage in parenthesis in the same box next to the actual number. For example, if 23 of the 25 Perinatal charts reviewed had documentation of assessment for pre-existing medical risks, place the number 23 in the corresponding "Y" box with (92%) next to it (23/25 x 100% = 92%).

To determine Overall Performance for the sample of Perinatal Lifecycle medical records audited, simply add the percentages down the "Y" column for each indicator marked with an (*) and divide by the total number of indicators measured (the number of *'s). For the Alternate - Perinatal lifecycle's "Y" column, you would add the percentage scores for five indicators (domestic violence, pre-existing medical risks, current medical problems, behavioral/ environmental risks and post-partum follow-up) and divide by five; the resulting number would be the overall performance for this column. Repeat this same process for the "N","R","X","O" and "L" columns.

Pediatric: Two Year Olds

Use the Pediatric Lifecycle: Two Year Olds Audit Summary form to summarize the domestic violence, immunization, growth and development and oral health status of two year olds in your sample. Enter the total number of infants who scored a "Y", "N", "R", etc. for each indicator listed. In each box record the total number of charts as well as its corresponding percentage; place the percentage in parenthesis in the same box next to the actual number. For example, if 23 of the 25 Pediatric Two Year Olds charts reviewed had documentation of a growth chart update, place the number 23 in the corresponding "Y" box with (92%) next to it (23/25 x 100% = 92%).

To determine Overall Performance for the sample of Pediatric Lifecycle: Two Year Old medical records audited, simply add the percentages down the "Y" column for each indicator marked with an (*) and divide by the total number of indicators measured (the number of *'s). For the Pediatric lifecycle's "Y" column, you would add the percentage scores for seven indicators (domestic violence, two year old immunizations, growth chart update, anemia screening, gross and fine motor skills, language skills, and BBTD) and divide by seven; the resulting number would be the overall performance for this column. Repeat this same process for the "N","R","X","O" and "L" columns.

Pediatric: Six Year Olds

Use the Pediatric Lifecycle: Six Year Olds Audit Summary form to summarize the domestic violence, immunization, growth and development and oral health status of six year olds in your sample. Enter the total number of children who scored a "Y", "N", "R", etc. for each indicator listed. In each box record the total number of charts as well as its corresponding percentage; place the percentage in parenthesis in the same box next to the actual number. For example, if 23 of the 25 Pediatric Six Year Olds charts reviewed had documentation of fluoridation assessment, place the number 23 in the corresponding "Y" box with (92%) next to it (23/25 x 100% = 92%).

To determine Overall Performance for the sample of Pediatric Lifecycle: Six Year Old medical records audited, simply add the percentages down the "Y" column for each indicator marked with an (*) and divide by the total number of indicators measured (the number of *'s). For the Pediatric Six Year Olds "Y" column, you would add the percentage scores for nine; indicators (domestic violence, DPT#5, OPV#4, TB screen, growth chart update, anemia screening, gross and fine motor skills, language skills, and oral health status) and divide by nine; the resulting number would be the overall performance for this column. Repeat this same process for the "N","R","X","O" and "L" columns.

Adolescent

Use the Adolescent Lifecycle Audit Summary form to summarize the domestic violence, substance abuse, and family planning performance for adolescents in your sample. Enter the total number of adolescents who scored a "Y", "N", "R", etc. for each indicator listed. In each box record the total number of charts as well as its corresponding percentage; place the percentage in parenthesis in the same box next to the actual number. For example, if 46 of the 50 Adolescent charts reviewed had documentation of a current substance abuse assessment, place the number 46 in the corresponding "Y" box with (92%) next to it (46/50 x 100% = 92%).

To determine Overall Performance for the sample of Adolescent medical records audited, simply add the percentages down the "Y" column for each indicator marked with an (*) and divide by the total number of indicators measured (the number of *'s). For the Adolescent's "Y" column, you would add the percentage scores for seven indicators (domestic violence, current substance abuse assessment, history/exposure to substance abuse, sexual history, HIV/STD prevention, last menstrual period - females only, and return visit) and divide by seven; the resulting number would be the overall performance for this column. Repeat this same process for the "N","R","X","O" and "L" columns.

Adult Lifecycle: Males

Use the Adult Lifecycle: Males 20-64 Years of Age Audit Summary form to summarize the cardiovascular risk assessment and cancer screening performance for adult males in your sample. Enter the total number of adult males who scored a "Y", "N", "R", etc. for each indicator listed. In each box record the total number of charts as well as its corresponding percentage; place the percentage in parenthesis in the same box next to the actual number. For example, if 23 of the 25 Adult Male charts reviewed had documentation of an assessment for hypertension place the number 23 in the corresponding "Y" box with (92%) next to it (23/25 x 100% = 92%).

To determine Overall Performance for the sample of Adult Male medical records audited, simply add the percentages down the "Y" column for each indicator marked with an (*) and divide by the total number of indicators measured (the number of *'s). For the Adult Males' "Y" column, you would add the percentage scores for seven indicators (smoking, hypertension, inactivity, excessive weight, dietary history or cholesterol, diabetes screening, colon cancer screening) and divide by seven; the resulting number would be the overall performance for this column. Repeat this same process for the "N","R","X","O" and "L" columns.

Adult Females: 20 - 39 Years of Age

Use the Adult Lifecycle: Females 20-39 Years of Age Audit Summary form to summarize the domestic violence, cardiovascular risk assessment and cancer screening performance for young adult females in your sample. Enter the total number of young adult females who scored a "Y", "N", "R", etc. for each indicator listed. In each box record the total number of charts as well as its corresponding percentage; place the percentage in parenthesis in the same box next to the actual number. For example, if 23 of the 25 young adult female charts reviewed had documentation of an assessment for domestic violence place the number 23 in the corresponding "Y" box with (92%) next to it (23/25 x 100% = 92%).

To determine Overall Performance for the sample of Adult Females: 20-39 Years Old medical records audited, simply add the percentages down the "Y" column for each indicator marked with an (*) and divide by the total number of indicators measured (the number of *'s). For the young Adult Females' "Y" column, you would add the percentage scores for nine indicators (domestic violence, smoking, hypertension, inactivity, excessive weight, dietary history or cholesterol, pap smear, clinical breast exam, and self breast exam instruction) and divide by nine; the resulting number would be the overall performance for this column. Repeat this same process for the "N","R","X","O" and "L" columns.

Adult Females: 40 - 64 Years of Age

Use the Adult Lifecycle: Females 40-64 Years of Age Audit Summary form to summarize the domestic violence, cardiovascular risk assessment and cancer screening performance for older adult females in your sample. Enter the total number of older adult females who scored a "Y", "N", "R", etc. for each indicator listed. In each box record the total number of charts as well as its corresponding percentage; place the percentage in parenthesis in the same box next to the actual number. For example, if 23 of the 25 older adult females charts reviewed had documentation of a clinical breast exam, place the number 23 in the corresponding "Y" box with (92%) next to it (23/25 x 100% = 92%).

To determine Overall Performance for the sample of Adult Females: 40-64 Years Old medical records audited, simply add the percentages down the "Y" column for each indicator marked with an (*) and divide by the total number of indicators measured (the number of *'s). For the older Adult Females' "Y" column, you would add the percentage scores for twelve indicators (domestic violence, smoking, hypertension, inactivity, excessive weight, dietary history or cholesterol, diabetes screening, pap smear, clinical breast exam, mammography and self breast exam instruction, colon cancer screening) and divide by ten; the resulting number would be the overall performance for this column. Repeat this same process for the "N","R","X","O" and "L" columns.

Geriatric

Use the Geriatric Lifecycle Audit Summary form to summarize the domestic violence, functional assessment, immunizations, and medical profile, cardiovascular risk assessment and cancer screening performance for geriatric patients in your sample. Enter the total number of geriatric records who scored a "Y", "N", "R", etc. for each indicator listed. In each box record the total number of charts as well as its corresponding percentage; place the percentage in parenthesis in the same box next to the actual number. For example, if 46 of the 50 geriatric charts reviewed had documentation of a clinical measures functional assessment, place the number 46 in the corresponding "Y" box with (92%) next to it (46/50 x 100% = 92%).

To determine Overall Performance for the sample of Geriatric medical records audited, simply add the percentages down the "Y" column for each indicator marked with an (*) and divide by the total number of indicators measured (the number of *'s). For the Geriatric's "Y" column, you would add the percentage scores for sixteen indicators (domestic violence, any ADL assessment, influenza, pneumoccal, tetanus, patient's name and medical record number on medical profile, medical names - current only, medication doses, medication regime, quantity of medication, allergies/intolerances, diabetes screening, pap smear, mammogram and colon cancer screening) and divide by sixteen; the resulting number would be the overall performance for this column. Repeat this same process for the "N","R","X","O" and "L" columns.

Step II: Projecting One and Three Year Performance Goals

One and Three Year Clinical Outcome Measures Performance Goals are to be set annually (January 15th). Determinations with respect to goal setting should be based upon results from the clinical outcome measures audit, as well as considerations as to CHC resources, staffing, patient mix, patient compliance and clinical systems and protocols. Space is provided on the bottom of the Audit Summary form to enter projections. Goals will provide markers to evaluate community health center progress with respect to implementing clinical outcome measures.

Step III: Documenting Clinical Outcome Measures Implementation Experience

On an annual basis (due October 15th), please provide a narrative of your community health center's experience in implementing clinical measures. Minimum documentation in this narrative includes:

1. How have you incorporated the clinical outcome measures within your CHC's quality assurance/improvement activities? Has this auditing process augmented existing work?
   1. Overall:
   2. Perinatal Lifecycle
   3. Pediatric Lifecycle
   4. Adolescent Lifecycle
   5. Adult Lifecycle
   6. Geriatric Lifecycle
2. What barriers does your CHC face to implementing the clinical outcome measures? to the annual audit?
   1. Overall:
   2. Perinatal Lifecycle
   3. Pediatric Lifecycle
   4. Adolescent Lifecycle
   5. Adult Lifecycle
   6. Geriatric Lifecycle
3. Describe the changes your health center has made as a result of implementing clinical outcome measures?
   1. Overall:
   2. Perinatal Lifecycle
   3. Pediatric Lifecycle
   4. Adolescent Lifecycle
   5. Adult Lifecycle
   6. Geriatric Lifecycle
4. What expectations do you have with respect to what the clinical outcome measures can or will achieve for your CHC?
   1. Overall:
   2. Perinatal Lifecycle
   3. Pediatric Lifecycle
   4. Adolescent Lifecycle
   5. Adult Lifecycle
   6. Geriatric Lifecycle
5. What technical assistance would you and/or your CHC like, if any, on clinical outcome measures?
   1. Overall:
   2. Perinatal Lifecycle
   3. Pediatric Lifecycle
   4. Adolescent Lifecycle
   5. Adult Lifecycle
   6. Geriatric Lifecycle

Step IV: Updating Institutional Clinical Health Plans

In addition to submitting Audit Summary tables and a narrative of your CHC's experience implementing the Clinical Outcome Measures, please submit the most recent copy of your CHC's Clinical Health Plan.

The Audit Summary forms are forwarded to the CPCA according to the schedule found on page thirty-two of this manual. One and Three Year Goals, along with a narrative regarding implementation of clinical measures and the most recent copy of your CHC's Clinical Health Plan are to be forwarded to the CPCA each January and October, respectively. For 330 funded health centers, your responses will provide the data which, blinded, will be forwarded to the Regional Office. All community health center data will be forwarded to the State Offices.