The performance of the Community Access Program will be evaluated by collecting, measuring and comparing certain preventive health care and visit data (numbers and type of clinic, hospital, emergency and other health visits) data on all CAP enrollees. Those enrollees having a diagnosis of diabetes, hypertension, depression or asthma (referred to collectively as the "CAP tracked chronic conditions") will have certain additional data collected, measured and compared.

The preventive care data results will be compared with West Virginia Healthy People 2010, Healthy People 2010 (federal) and other relevant sources. The chronic condition data will be compared with the appropriate collaborative. Within each chronic condition collaborative, only certain items will be  collected and evaluated. Each such item is discussed in this article. Only items related to "hypertension" (Cardiovascular Disease Collaborative) is collected and evaluated. Each clinic should report the preventive and chronic condition data items.

A)  Application for Primary Care Benefits 

This form authorizes the sharing of certain demographic and medical record information between and amongst the institutions and personnel associated with CAP. It remains with the health center enrolling the CAP member. See the Instructions for this form.

B) Health History

The Health History data may entered through the CAP Web site Database. A user name and password are required to access this program.

A paper Health History scan form is also provided. The scan form is sent to CAP IS Coordinator for incorporation into the CAP database.

At the time of enrollment, the relevant demographic, preventive care and diagnoses data is collected from each CAP enrollee. The CAP Enrollee self-reports the preventive care and chronic conditions data requested. A CAP Enrollee who reports that she or he has not been diagnosed with any of these chronic conditions marks "None". See the Instructions for this form.

C) Financial Eligibility Determination Forms

These forms are used determine the financial eligibility status of a CAP Enrollee for free or discounted services or health care (example: Pharmacy Assistance Program, free care at a hospital, etc.). The  Enrollment Coordinator completes these form in behalf of any CAP enrollee who proves eligible.

D) Adult Health Schedule

A Adult Health Schedule is placed in the CAP enrollees medical record. This Schedule records the values and dates of service of any preventive or chronic condition (i.e., diabetes, hypertension, depression or asthma) services which have been provided to the CAP Enrollee. Any action on the part of the Care Manager is also recorded. Any update to CAP data arising from a visit, service or test is recorded on the appropriate line on the Schedule form. See the Instructions for this form.

E)  Data Sheet 

In the near future, the data from the Adult Health Schedule may entered through the CAP Web site Database in place of the Data Sheet.. A user name and password are required to access this program.

A paper Data Sheet is also provided. The Data Flow Sheet allows the CAP IS Coordinator to update the preventive care, chronic condition care and the Care Manager intervention data taken from the Adult Health Schedule. See the Instructions for this form.

F) Tracking Sheet  

On a regular basis, each clinic will receive a Tracking Sheet created by CAP IS Coordinator from the data previously sent to him .The Tracking Sheet will have the CAP Enrollee names (alphabetical order) with the demographic, preventive care and chronic condition data. The Care Manager should review the Tracking Sheet to determine any further action. The Tracking Sheet will bear a closing (as of) date (i.e., updates of CAP data received as of this date are  reflected in the Tracking Sheet.

F) Re-enrollment Tracking Sheet (RETL) 

Re-enrollment is required annually on or before the CAP Enrollee's anniversary date (i.e., Enrollment/Re-enrollment date).. Any CAP enrollee whose name appears on this list is due for re-enrollment. CAP enrollee names appear on the list the month before the re-enrollment is due. See the Re-enrollment / Dis-enrollment Policy for further information.


Chronic health conditions were singled out by former President Clinton for his Health Disparities Initiative, and were chosen as the first clinical program to be addressed by BPHC’s Health Status and Performance Initiative. We will be addressing the chronic health conditions of diabetes, hypertension (one element of Cardiovascular Disease), depression and asthma.


Definitions of terms

One important shared national measure of every Health Disparities Collaborative is "patient self-management", since supporting self-care management is an integral part of the chronic care model. Examples of Patient Self-Management tools have been provided for diabetes, hypertension and asthma.

Typical levels

The Typical level is one of two targets used to evaluate progress toward the appropriate goal. For example, the recommendation is for all diabetics to have at least 2 hemoglobin A1c tests per year. Although this recommendation  is regarded as the "Gold Standard" for diabetes management, less that 25% of the nation’s diabetics have had one HbA1c reading in previous 12 months.

Target level

The Target level is the second of two measures used to evaluate progress for diabetes, hypertension and asthma (excluding depression). The Target level for diabetes with respect to hemoglobin A1c is to have more than 90% of all diabetics with at least one hemoglobin A1c test within the previous 12 months.

West Virginia recommends an increase the hemoglobin A1c (glycosylated hemoglobin) test rate to 85%. The Typical level in West Virginia is 15.9%, significantly lower than the nation as a whole. West Virginia has made glycosylated hemoglobin Objective 5.6, a Flagship Objective. West Virginia Health People 2010

Appropriate Goal

The term Appropriate Goal (not Target Level)  is used in reference to key measures to improve depression care. For Self-Management, the Appropriate Goal is >70% compared to a Typical level of <20%.

Please familiarize yourself with the Comparison Data sources used to evaluate CAP.