Form Approved

OMB No. 0920-0976

Exp. date 7/31/2016

Million Hearts® Hypertension Control Champion Nomination

Public reporting burden of this collection of information is estimated at 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, NE, M/S D74, Atlanta, GA 30333, ATTN: PRA 0920-0976.

Contact information (for individual submitting the nomination):

Name: ________________________________________________________________________

Business Address: _______________________________________________________________

City: ______________________ State: __________ Zip Code: ______________

Business Phone:____________________ Business E-mail: _______________________________

Nominee information: Please provide the following information for the provider or practice being entered into the Challenge.

Name: ________________________________________________________________________

Business Address: ______________________________________________________________

Business Phone:	_________________ Business E-mail: ____________________________

Check the box which best represents the nominee:

A healthcare system

A single clinician or group practice or clinic

Check the box which best represents the nominee’s practice:

Obstetrics/gynecology

Family practice

Internal medicine

Osteopathy

Cardiovascular care

Other ________________________

Population served

Number of patients enrolled in the practice or health system: _____________________

Number of patients seen at least once in the previous 12 months: ________________

Describe patient demographics that support the practice or health system’s care for a population with a high prevalence of hypertension:

Geographic region served __________________________________________________

Is this urban, rural, or both? __________________________________________

Percent of patients who belong to a racial/ethnic minority________________________

Percent of patients whose primary language is not English ________________________

Percent of patients who are enrolled in Medicaid________________________

Percent of patients: Age 18 – 39 __________

Age 40 – 59 __________

Age 60 + ____________

Other ___________________________________________________________________

Hypertension Control

Million Hearts® supports use of the National Quality Forum #0018 (insert link) or other nationally recognized measures for defining hypertension control. Please check the appropriate box below and provide the requested information:

The nominee uses NQF 18 guidelines for their controlling blood pressure measure. Describe the exclusions the nominee includes (e.g., pregnant women, patients with end-stage renal disease).
__________________________________________________________________________

The nominee uses another measure for controlling blood pressure. Describe how the nominee calculates the measure; including who is included in the denominator and what is considered adequate control.

Nominees are asked to provide two hypertension control rates: a current rate for a 12-month period and a rate for a 12 month period a year or more previous.

For the current Hypertension Control Rate:

What is the Reporting Period (e.g., 1/1/2013 to 12/31/2013)? ________________.

How many adult patients (18 – 85 years old) were seen at least once during the reporting period? ______________________

Of these, how many were diagnosed with hypertension? ________

Of these, how many are included in the control rate denominator (are not in an excluded category)? _____________

What is the Hypertension Control Rate for the practice or healthcare system’s adult hypertensive population during this reporting period? __________________

Using the same steps, what was the Hypertension Control Rate for the practice or healthcare system’s adult hypertensive population a year or more previous? ______________ Reporting period (e.g., 1/1/2012 to 12/31/2012):: ___________

Do you report hypertension control rate to any other federal or regulatory agency?

Which one?

Were the data obtained from an electronic health record system? ________.

If not, how were the data obtained? ________________________________________________

Clinical system supports

Please check the button before each sustainable process for providing care in the clinic or healthcare system that is used on a regular basis. Provide a brief description of as many “other” processes or systems as applicable to your practice or health system. You may also add details to many of the systems described below to support the nomination.

Written treatment protocols

Provider dashboards

Please describe: ______________________________________________________________
___________________________________________________________________________

Please describe: ______________________________________________________________
___________________________________________________________________________

Please describe: ______________________________________________________________
___________________________________________________________________________

Please describe: ______________________________________________________________
___________________________________________________________________________

Please describe: ______________________________________________________________
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Please describe: _____________________________________________________________

___________________________________________________________________________

Please describe: ______________________________________________________________
___________________________________________________________________________

Please describe: ______________________________________________________________
___________________________________________________________________________

Is there anything else you would like to add to support the nomination?
_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Agreement to Participate

Please enter your name below to indicate that you, as the nominee, agree to the following.

If you are not the nominee, please enter your name below assuring that you have consulted with the nominee, and the nominee agrees to the following:

All information provided is true and accurate to the best of your knowledge.

To participate in a data verification process if selected as a candidate for champion.

Consent to a background check if selected as a candidate for champion.

To be recognized by provider or practice name and location if selected as a champion, to participate in recognition activities, and to share best practices for the development of publically available resources.

To assume any and all risks and waive claims against the Federal Government and its related entities, except in the case of willful misconduct, for any injury, death, damage, or loss of property, revenue, or profits, whether direct, indirect, or consequential, arising from my participation in this prize contest, whether the injury, death, damage, or loss arises through negligence or otherwise.

To indemnify the Federal Government against third party claims for damages arising from or related to competition activities.”

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Thank you for participating.