Immunizations – Immunizations remain an important aspect of public health and preventive care. ACIP guidelines should be followed.

• Children should be immunized with Hep B, DTaP, IPV, Hib, Prevnar, Rotavirus, Hep A, MMR, Varicella, and Influenza according to routine and catch-up schedules published by the CDC. Combination vaccines should be used when available and when appropriate. Annual flu vaccine should be encouraged starting at 6 months of age.
  • The health center reports immunization rates on the UDS report using the CMS 117v10 clinical quality measure. Documentation required: for all children prior to their 2^nd birthday, unless there is documented evidence of contraindication for the vaccine or a history of illness, ALL of the following need committed to the flowsheet: 4 DTP/DTaP, 3 IPV, 1 MMR, 3-4 Hib, 3 HepB, 1VZV (Varicella), 4 Prevnar 13, 2-3 Rotavirus, 2 Influenza vaccines, and one Hep A. Influenza can be offered through June 30^th of a calendar year. Note – the second Hepatitis A and 4^th Hib are ideal although not required for CMS 117v10.
• Adolescents should be immunized for meningococcal meningitis, dTap, and should be offered HPV and flu vaccination at age 11. At age 16-18, adolescents should receive an MCV4 booster and can be offered Influenza, Men B, and/or HPV if appropriate.
  • The health center reports through the HEDIS data set the percentage of 13 year old patients who have received 1 MCV4, 1 dTap, and have completed the HPV series.
• COVID vaccine can be offered to children and adolescents (as well as their families) as per ACIP recommendations.

Lead Screening: Lead is a toxic heavy metal present in the environment. Lead levels should be checked regularly. The Illinois Healthy Kids Handbook recommends lead levels at 9, 15, 24, and 36 months for those in Chicago.

• The health center reports through the HEDIS data set the percentage of children who are two years of age who have had at least two lead levels before their second birthday. Children with a lead level greater than 5 can be referred to early intervention.

Developmental screening is a way to identify children who may benefit from additional services at an early age. Both HEDIS and Healthy Kids recommend developmental screens in the first, second, and third year of life. At Family Christian Health Center we use the ASQ (Ages for Stages Questionnaire) at 9, 15, and 30 months. If a child has missed his previous screening, the ASQ should be performed.

• Documentation required – The ASQ scores need entered on the Pediatric Health Form and the provider interpretation clicked for children at 9-12 months, 15-24 months, and between 24 and 36 months

Autism screening should be performed at 18 and 24 months using the MCHAT-Revised. Early identification of children with autism can improve outcomes by the early initiation of services.

• Documentation required – The MCHAT assessment (normal or abnormal) needs entered on the Pediatric Health Form by the provider.

Weight Assessment and counseling for nutrition and physical activity for children and adolescents – The last decades have seen significant increases in childhood and adolescent obesity. Healthy lifestyle habits can lower the risk of becoming obese and developing related disease.

• The health center reports BMI% calculation rates, nutrition counseling rates, and physical activity counseling rates on the UDS report using the CMS 155v10 clinical quality measure for those patients seeing either a PCP or OB/GYN (although pregnancy is an exclusion). Documentation required – The BMI%ile for children 3-17 must be calculated. Nutrition counseling needs entered either through the Weight Management form or the FCHC Quality form. Similarly, physical activity counseling should be entered through the Weight Management form or the FCHC Quality form.

Sexually active woman and adolescents 16-24 should be screened yearly for Chlamydia and GC. Any who test positive should have follow up testing for HIV, syphilis, and Hepatitis B.

• The health center reports through the HEDIS data set the percentage of sexually active woman age 16-24 who had at least one test for chlamydia during the measurement year.

All patients ages 15-65 should be screened for HIV yearly on an opt-out basis when possible and appropriate. Those who screen positive should start treatment within 30 days. Patients with newly diagnosed HIV must be referred to case management and introduced to the case manager at the office visit whenever possible. HIV screening, pre-exposure prophylaxis (PreP), and HIV linkage to care are each reported within the UDS data set.

• The health center reports the percentage of patients 15-65 who are screened for HIV within the calendar year (CMS 349v4).
• Any patient newly diagnosed with HIV needs an office visit for treatment within 30 days with either a PCP who treats HIV or an Infectious Disease specialist and needs to initiate treatment. Once the patient follows with a treating provider, that date of treatment start should be entered (based on medication start date). When the initial appointment is scheduled, any labs that the ID specialist would like should also be ordered to facilitate start of treatment.
• The number of patients receiving PreP will be reported on table 6A.

Screening for depression is appropriate starting at age 12, and anyone whose screen is consistent with depression should have a documented follow up plan. The PHQ2 should be entered for all patients using the FCHC Quality form. Anyone who scores a 3 or higher (or has a history of depression or is being treated for depression) should have the PHQ9 completed. A follow up plan should also be documented. Likewise, those who are being treated for depression should have PHQ9 completed at each visit.

• The health center reports this metric on the UDS report using the CMS 2v11 clinical quality measure. Documentation required – the PHQ2 should be entered for all patients on the FCHC Quality Form. If the screen is positive, the PHQ9 and follow up plan (for instance refer to LCPC) should also be documented.
• Depression Remission at twelve months (CMS159v10) reports those patients 12 years and older diagnosed with major depression or dysthymia who have improvement in the PHQ9 to under 5 at 12 months (+ 60 days) of the index event. To comply with this metric, the PHQ9 should be recorded at a 12 month follow up visit for those being treated for depression.

Entry into prenatal care – If women enter care in their first trimester then the probability of adverse birth outcomes will be reduced. Whenever possible, the initial prenatal visit should occur during the first trimester.

• The health center reports through the UDS report the percentage of woman who enter prenatal care in the first trimester. Documentation required – the trimester of entry into prenatal care needs recorded in the Perinatal Case in the Case Management section.

Infant Birth Weights – Lower infant birth weights are a reflection of Health Care Disparities, and a low birth weight is defined by a weight under 2,500g (5# 8oz).

• The health center reports through the UDS report the percentage of infants born under 2500 grams. Documentation required – birth weights need entered in the Perinatal Case in the Case Management section.

HIV screening – All pregnant woman should receive HIV screening.

• The health center reports this metric on the UDS report as part of the CMS349v4 clinical quality measure and does not separate pregnant patients into a separate cohort.
• Any patient newly diagnosed with HIV needs an office visit for treatment within 30 days with either a PCP who treats HIV or an Infectious Disease specialist. Once the patient follows with a treating provider, that date of treatment start should be entered (based on medication start date). When the initial appointment is scheduled, any labs that the ID specialist would like should also be ordered to facilitate start of treatment.

Depression – Screening for depression is appropriate starting at age 12, and anyone whose screen is consistent with depression should have a documented follow up plan. The PHQ2 should be entered for all patients using the FCHC Quality form. Anyone who scores a 3 or higher (or has a history of depression or is being treated for depression) should have the PHQ9 completed. A follow up plan should also be documented. Likewise, those who are being treated for depression should have PHQ9 completed at each visit.

• The health center reports this metric on the UDS report using the CMS 2v11 clinical quality measure. Documentation required – the PHQ2 should be entered for all patients on the FCHC Quality Form. If the screen is positive, the PHQ9 and follow up plan (for instance refer to LCPC) should also be documented.
• Depression Remission at twelve months (CMS159v10) reports those patients 12 years and older diagnosed with major depression or dysthymia who have improvement in the PHQ9 to under 5 at 12 months (+ 60 days) of the index event. To comply with this metric, the PHQ9 should be recorded at a 12 month follow up visit for those being treated for depression.
• For pregnant patients specifically, the EPDS should also be completed as appropriate – ideally at intake, 20 weeks, and post-partum.

Adult BMI Screening and Follow Up – If clinicians routinely calculate and record the BMI for their adult patients and then identify patients with a BMI that is out of range and then develop a follow-up plan for overweight, obese, and underweight patients, then the likelihood of the debilitating consequences of serious weight problems can be reduced.

• The health center reports this metric on the UDS report using the CMS 69v10 clinical quality measure. Documentation required – Counseling and a follow up plan need documented on either the Weight Management form or the FCHC Quality form for any patients 18 or over with a BMI less than or equal to 18.5 or greater than or equal to 25. Telehealth visits are excluded although counseling may be appropriate at those visits as well.</span

Tobacco Use: Screening and Cessation Intervention – Any patient over the age of 18 needs a tobacco use assessment at least every year. Any patient identified as using tobacco should have cessation counseling at the time of screening. If tobacco users are provided with an effective mix of counseling and pharmacologic intervention then tobacco users will be more likely to quit smoking and will therefore have a lower incidence of cancer, asthma, emphysema, and other tobacco related illnesses.

• The health center reports this metric on the UDS report using the CMS 138v10 clinical quality measure. Documentation required – the tobacco assessment is recorded on the Risk Factors form including smokeless tobacco. If patients use tobacco, cessation counseling should be documented through the Risk Factors form also. The center reports the percentage of patients screened and those who screen positive and are counseled to quit (CMS 138v10).</span

Cervical Cancer Screening – If women receive Pap tests as recommended then they can be treated earlier and will be less likely to suffer adverse outcomes from HPV and cervical cancer. Pap smears are recommended, if normal, at a minimum of at least every 3 years for woman ages 21 to 30. Women 30 to 64 should have either a Pap smear every 3 years or a Pap smear every 5 years provided the co-tested HPV test was normal and is documented. Results from Pap tests done elsewhere should be obtained if possible and all results should appear in the flow sheet.

• The health center reports this metric on the UDS report using the CMS 124v10 clinical quality measure. Documentation required – The Pap smear needs recorded on the flow sheet as well as the HPV result if this was performed as a co-test. For women who are excluded because of a total hysterectomy, “total hysterectomy” needs entered under the PSHx section or the code of Z90.710 entered on the problem list.</span

Mammography recommendations vary in 2022. Screening may be offered as early as age 40 or mammography screening may start at age 50. Please note this does not apply to women who have a history of breast cancer who should have diagnostic, not screening mammography. The center will report screening rates for woman 50 to 74 who have had a mammogram within 27 months of 12/31/2022.

• The health center reports the percentage of woman 50-74 who have had a mammogram in the past 27 months (CMS125v10). Documentation required – The results from any mammogram completed should be obtained and entered onto the flow sheet.</span

Colorectal screening is recommended for all patients ages 50 to 75. Ideally this will be done via a colonoscopy. Alternatives include fecal occult blood testing within the measurement year, FIT-DNA testing within 3 years, or CT colonography within 5 years. If the colonoscopy (or alternate screening) has not been completed, the patient should be referred to gastroenterology or alternative screening ordered.

• The health center reports this metric on the UDS report using the CMS 130v10 clinical quality measure. Documentation required – the colonoscopy result (or alternative screening result) needs entered on the flow sheet. Results can be entered through the Risk Factors form.</span

HIV Screening – All patients ages 15-65 should be screened for HIV yearly on an opt-out basis when possible and appropriate. Those who screen positive should start treatment within 30 days. Patients with newly diagnosed HIV must be referred to case management and introduced to the case manager at the office visit whenever possible. HIV screening, pre-exposure prophylaxis (PreP), and HIV linkage to care are each reported within the UDS data set.

• The health center reports the percentage of patients 15-65 who are screened for HIV within the calendar year (CMS 349v4).
• Any patient newly diagnosed with HIV needs an office visit for treatment within 30 days with either a PCP who treats HIV or an Infectious Disease specialist and needs to initiate treatment. Once the patient follows with a treating provider, that date of treatment start should be entered (based on medication start date). When the initial appointment is scheduled, any labs that the ID specialist would like should also be ordered to facilitate start of treatment.
• The number of patients receiving PreP will be reported on table 6A.

Depression – Screening for depression is appropriate starting at age 12, and anyone whose screen is consistent with depression should have a documented follow up plan. The PHQ2 should be entered for all patients using the FCHC Quality form. Anyone who scores a 3 or higher (or has a history of depression or is being treated for depression) should have the PHQ9 completed. A follow up plan should also be documented. Likewise, those who are being treated for depression should have PHQ9 completed at each visit.

• The health center reports this metric on the UDS report using the CMS 2v11 clinical quality measure. Documentation required – the PHQ2 should be entered for all patients on the FCHC Quality Form. If the screen is positive, the PHQ9 and follow up plan (for instance refer to LCPC) should also be documented.
• Depression Remission at twelve months (CMS159v10) reports those patients 12 years and older diagnosed with major depression or dysthymia who have improvement in the PHQ9 to under 5 at 12 months (+ 60 days) of the index event. To comply with this metric, the PHQ9 should be recorded at a 12 month follow up visit for those being treated for depression.

Ischemic Vascular Disease – If clinicians ensure that patients with established ischemic vascular disease (IVD) use aspirin or another antithrombotic drug, then the likelihood of myocardial infarction and other vascular events can be reduced. Any patient 18 years or older who has a diagnosis of ischemic vascular disease or was discharged after an acute myocardial infarction, coronary bypass grafting, or angioplasty in the preceding year should be on an aspirin or other antithrombotic or a contraindication entered.

• The health center reports this metric on the UDS report using the CMS164v7 clinical quality measure. Documentation required – antithrombotic therapy needs recorded in the Medication List (even if patients are taking an aspirin over the counter).

Statin therapy for the prevention and treatment of atherosclerotic cardiovascular disease – If clinicians ensure that patients at risk for coronary artery disease receive lipid lowering therapy then the likelihood of CAD related clinical events will be reduced. Patients ages 20 or older with a history of ASCVD should receive statin therapy. Patients ages 20 or older with familial or pure hypercholesterolemia should receive a statin. Patients 20 or older with an LDL-C at or above 190 should receive statin therapy. Patients with diabetes who are 40 years or older should receive statin therapy if not pregnant, breastfeeding, or planning a pregnancy.

• The health center reports this metric on the UDS report using the CMS 347v5 clinical quality measure. Documentation required – a statin needs to appear on the active medication list or a script needs to have been written within the measurement year.

Controlling High Blood Pressure – All patients diagnosed with Hypertension aged 18 to 85 should be treated to a blood pressure under 140/90 although 130/80 may also an appropriate target for many patients. Patients with an initial pressure at or above 140/90 should have the pressure repeated using an averaged pressure from an automated outpatient blood pressure machine with further treatment as needed/indicated.

• The health center reports this metric on the UDS report using the CMS 165v10 clinical quality measure. Documentation required – the last recorded blood pressure should be under 140/90. Remote monitoring pressures are acceptable as well. If multiple pressures are taken on the same day, the lowest systolic and lowest diastolic are the accepted pressure for that visit.

Diabetes Mellitus – all patients with diabetes mellitus should have an A1c performed. Those with an A1c greater than 9 or without an A1c are considered uncontrolled. The ideal A1c will vary based on a patients age and comorbid conditions but optimal control should be sought. Comprehensive care for patients with diabetes includes controlling A1c values, controlling blood pressure, possible statin therapy for those over 40, yearly ophthalmology evaluation, nephropathy screening, depression screening, and neuropathy screening.

• The health center reports this metric on the UDS report using the CMS 122v10 clinical quality measure. Documentation required – the A1c value needs recorded within the flow sheet and the last A1c needs to be less than 9. Patients new to the practice or who have not previously had an A1c drawn should have the A1c the day of the visit either from point of care testing or drawn in the lab whenever possible.

Sealant Use – Any children ages 6-9 years with an annual oral or periodic exam should have a carries risk assessment and those at moderate or high risk should have sealants placed on their non-carious permanent first molars if this has not been done previously.

• The health center reports this metric on the UDS report using the CMS277 clinical quality measure. Children 6-9 should have the Dental Caries Risk Form completed in the Dental Office Visit. Those without caries should have sealants applied.

Oral health screening – Any patient ages 2-17 should have a comprehensive oral exam or yearly periodic oral exam during the calendar year.

• The health center reports this metric yearly as part of the 330 grant..