CCOE Client Survey

NATIONAL COMMUNITY CENTERS OF EXCELLENCE

(CCOE) IN WOMEN’S HEALTH

NATIONAL EVALUATION: ROUND II

CCOE Center Director and Program Coordinator Survey

You have been selected to participate in Round II of the National Evaluation of the National Community Centers of Excellence in Women’s Health (CCOE) program. The Department of Health and Human Services (DHHS) Office on Women’s Health (OWH) is conducting this evaluation. Your response is vital to helping OWH understand what community resources the CCOE programs leverage and how. Additionally, your responses will help OWH learn how services are integrated between each CCOE and their community partners.

Data gathered from this evaluation will be aggregated at a national level and the individual CCOE-level. CCOE-level information will be used for program improvement purposes. Your responses will be kept confidential.

The following topic areas are covered in this survey:

• CCOE General Information

• Health Service Delivery

• Training Health Care Providers

• Community-Based Research

• Public Education and Outreach

• Leadership Development

• Technical Assistance

• Community Awareness

Your feedback is critical in helping us obtain the necessary data that could influence future decisions about the CCOE program. It is estimated the survey will take approximately 30 to 45 minutes to complete. Please complete a working draft of this survey on paper prior to completing the actual online survey. This draft will assist you in filling out the Internet survey. (Note: You must complete the entire Internet survey at one time. Any data entered but not submitted will not be saved. Partially completed surveys cannot be accepted.)

The information you provide will be kept confidential, and will not be disclosed to anyone but the Department of Health and Human Services (DHHS) Office on Women’s Health (OWH) in the aggregate form only, except as otherwise required by law. If you have any questions on how to complete this survey please contact: Fatima Riaz at (240) 314-5675 or at 1101 Wootton Parkway, Suite 9246, Rockville, MD 20852.

Thank you in advance for your participation!

DR_GI_01_2006. Please select your CCOE.

• 01-Christiana Care Health System

• 02-Great Plains of Greeley County

• 03-Griffin Health Services Corporation

• 04-Hennepin County Department of Primary Care / North Point Health and Wellness Center

• 05-Jefferson Health System

• 06-Kokua Kalihi Valley Comprehensive Family Services

• 07-Mariposa Community Health Center

• 08-Morton Plant Hospital / Turley Family Health Services

• 09-Northeastern Vermont Area Health Education Center

• 10-Northeast Missouri Health Council, Inc.

• 11-NorthEast Ohio Neighborhood Health Services, Inc.

• 12-Oakhurst Medical Centers

• 13-St. Barnabas Hospital and Healthcare System

• 14-Women’s Health Services

DR_GI_01.1_2006. Provide a demographic breakdown of CCOE patients using the categories below.

Racial/Ethnic Category	Percent (%)
01.1A-American Indian or Alaska Native
01.1B Asian
01.1C Black or African American
01.1D Native Hawaiian or Other Pacific Islander
01.1E White
01.1F Other, please specify: _________________
01.1G Other, please specify: _________________
01.1H Other, please specify: _________________
Total:	100%

DR_GI_01.2_2006. Approximately how many women are currently enrolled/served by your CCOE? _______

DR_GI_01.3_2006. Has CCOE participant enrollment increased/decreased since your CCOE program’s inception? ______

DR_GI_02_2006. How many intake points does your CCOE have?

• One

• Two

• Three

• Four

• Five or more

DR_GI_03_2006. Please select the non-clinical services offered to CCOE participants that help improve access to care and other CCOE programs. Select all that apply.

• 01-Case management

• 02-Child care

• 03-Translation services

• 04-Materials available in languages other than English

• 05-Transportation assistance

• DR_GI_03A_2006-Other, please specify: _________________________________________

DR_GI_04_2006. Select the language(s) spoken by the CCOE’s target population.

• 01-English

• 02-Spanish

• 03-Chinese

• DR_GI_04A_2006-Other, please list all: _____________________________

DR_GI_06_2006. What mechanisms do you have in place for quality and overall program improvement? Select all that apply.

• 01-Patient surveys

• 02-Suggestion box

• 03-Hotline/telephone line

• 04-Monitoring patient outcomes

• 05-Benchmarking best practices

• 06-Monitoring staff turnover

• 07-Measuring employee satisfaction/staff surveys

• 08-Providing continual training and educational opportunities to all staff

• DR_GI_06A_2006-Other, please specify: _____________________________________

• 10-None

DR_GI_06B_2006. Please provide some examples on how these mechanisms helped improve service at the CCOE. Include any suggestions or lessons learned that would be helpful for newly designated CCOE programs. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DR_GI_07_2006. Please describe how the CCOE designation has impacted your organization and its ability to provide services to women.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DR_GI_08_2006. If your organization has graduated from the CCOE program and is now part of the Ambassadors for Change program, please describe how your ability to provide services has changed as a result of the change in status and in funding?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DR_GI_08_2006. Is there value to having a program with reduced funding and level of effort?

• Yes

• No

DR_GI_10_2006. Please explain why there is or is not value to having the Ambassadors for Change program.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DR_STF_01_2006. For each category listed, please indicate how many full-time equivalent (FTE) non-clinical CCOE program staffs are currently dedicated to providing service to CCOE participants (e.g., 1 full-time family care coordinator = 1 FTE). Decimals are acceptable. Please provide a description of key activities for each Program Staff position in the last year, and the amount of Office on Women’s Health (OWH) funds spent annually to maintain those staff. If your organization is a part of the AFC program, please provide the same information for staff that are dedicated to the AFC and provide services to CCOE—AFC participants.

CCOE Program Staff	# of FTEs	Was Position created since 2003 (Y/n)? (Note: If the CCOE was established after 2003, use column to describe key activities performed by each staff position listed)	OWH funds per year
Example: Director	1		$65,000
Center Director	01	1C_2006	$1B
Program Coordinator	02	2C_2006	$2B
Office Manager	03	3C_2006	$3B
Family Care Coordinator	04	4C_2006	$4B
Health Educator	05	5C_2006	$5B
Medical Advisor/ Director	06	6C_2006	$6B
Nurse Manager	07	7C_2006	$7B
Research Director	08	8C_2006	$8B
Administrative Assistant	09	9C_2006	$9B
Other: ___________	10	10C_2006	$10B

DR_STF_02_2006. Have the Program Staff roles evolved since 2003?

• Yes

• No

• Not sure

DR_STF_02A_2006. If yes, how are they different than in 2003?

DR_STF_02B_2006. If no, how could staff roles change to make the CCOE more efficient and/or effective in the community?

DR_STF_03_2006. If your program has graduated and become part of the AFC program, can you please describe how staff roles have changed as a result of the change in status and in funding?

If you received funding (including grants) from sponsors other than the Office on Women’s Health, please complete the following table.

DR_SP_01_2006. Indicate funding received since the end of 2003. For each funding award indicate the month and year during which the funding was received, the name of the funding sponsor, the total funding amount, and the reason or purpose of the funding.

MONTH/YR FUNDING RECEIVED		name of funding sponsor	amount	purpose for funding
March 1A-5A	2002 1B-5B	Example: March of Dimes 1-5	$5000 1C-5C	To conduct community based research related to folic acid 1D-5D
			$
			$
			$

DR_SP_06_2006. Do you know or believe that having the CCOE grant positively influenced or contributed to the award of these funds to your program?

• Yes

• No

DR_SP_06A_2006. Has a written plan or goals been established for the sustainability of the CCOE programs?

• Yes

• No

DR_SP_06B_2006. If yes, please describe the plan and describe which components will be continued and which will not and why those decisions were made.

DR_SP_07A_2006. Has the CCOE established local community financial support for the CCOE program?

• Yes

• No

DR_SP_07B_2006. If yes, please describe the types of support that are in place that will help with future sustainability of the CCOE program.

DR_SP_08_2006. If your program has graduated and become part of the AFC program, can you please describe whether and how your services have changed as a result of the change in status and in funding?

DR_PTR_01_2006. For current community partners, list their name; circle the type of arrangement (such as Memorandums of Understanding (MOU), Inter-Agency Agreement (IAA), formal contract, or other formal or informal agreement); and list the point of contact’s (POC) name, address, phone number, and email address. In the last column, list the main service(s) provided by the partner.

community partner name 1-7	type of arrangement 1A-7A	POC name, address, PHONE & email 1B-7B	service provided 1C-7C
E xample: Baptist Hospital	MOU IAA Contract Other: Formal Other: Informal	Stella Smith, 1000 Baptist Road Arlington, VA 11111 555.555.5555 [email protected]	Mammograms
	MOU IAA Contract Other: Formal Other: Informal
	MOU IAA Contract Other: Formal Other: Informal
	MOU IAA Contract Other: Formal Other: Informal
	MOU IAA Contract Other: Formal Other: Informal
	MOU IAA Contract Other: Formal Other: Informal
	MOU IAA Contract Other: Formal Other: Informal

DR_PTR_06_2006. What has contributed to the success of your partnerships? Select all that apply:

• Contract

• Length of relationship

• Physical location of the partner

• Interpersonal relationship between coordinators

• CCOE board membership and involvement

• Mutual benefit to both organizations

• Other, please specify ________________________

DR_PTR_07_2006. Has a written plan or goals been established for the sustainability of the CCOE partnerships?

• Yes

• No

DR_PTR_07A_2006. If yes, please describe how partnerships will be sustained.

DR_PTR_08_2006. If your program has graduated and become part of the AFC program, can you please describe whether and how your relationships with your partners have changed as a result of the change in status and in funding?

DR_PTR_09_2006. If your program has graduated and become part of the AFC program, and you are sustaining any of your CCOE partnerships, what role, if any, has the contribution of funds or lack of contribution of funds from OWH played in your ability to sustain those partnerships?

DR_SRV_001_2006. For each health professional listed, please indicate how many current full-time equivalents (FTEs) provide care to CCOE participants (e.g., part time nurse practitioner = 0.5 FTE). Decimals are acceptable. For each health professional, estimate the number of female staff and the number of multilingual staff. Please also indicate languages spoken by health professionals.

health professional	# of FTE’s providing care	# of female staff	# of MULTILINGUAL staff (languages spoken)
Example: Community Health Worker/ Outreach Worker	5	4	1 (Spanish)
Community Health Worker/ Outreach Worker
Family Physician or General Practitioner
Health or Peer Educator
Internist or Internal Medicine Physician
Mental Health Professional (e.g., Licensed Counselor, Psychiatrist, Psychologist, Social Worker)
Nurse Midwife
Nurse Practitioner (NP)
Nutritionist
Obstetrician or Gynecologist
Pediatrician
Physician’s Assistant (PA)
Registered Nurse (RN)
Substance Abuse Counselor
Other: __________________

DR_HD_08_2006. Does your clinical care center(s) have procedures for tracking women served by the CCOE program?

• Yes

• No

DR_HD_08A_2006. If yes, how do you track these women?

• Electronic medical record system

• Paper record

• Stand alone database

• Other: ______________________________

DR_HD_09A_2006. If yes, what types of information do you track?

• Cost of services

• Services rendered by CCOE

• Services rendered by Partner Organizations

• Non-health care services rendered by CCOE

• Non-health care services rendered by Partner Organizations

• CCOE patient referrals

• CCOE patient referral compliance

• Wellness check compliance

• Number of women receiving health care services

• DR_HD_09B_2006Other: ______________________________

DR_HD_09C_2006. If you track the number of women receiving health care services, can you provide an estimate of how many women received these services in the last year? _________

DR_HD_09D_2006. If you track referrals, what percent of CCOE participants use the referrals they receive?

• 25% or less

• 26-50%

• 51-75%

• 76-100%

• Not Sure

DR_HD_09E_2006. Does the CCOE utilize electronic health/medical records?

• Yes

• No

DR_HD_09F_2006. Do you share your patients’ clinical data with your partners (within the confines and in compliance of HIPAA and any other statute or regulation governing privacy)?

• Yes

• No

DR_HD_11_2006. Please describe how health care service delivery is integrated with other components of the CCOE program?

DR_HD_12A_2006. What are the best practices related to health service delivery provided by your CCOE? DR_HD_12B_2006. What are your lessons learned?

DR_HD_12C_2006. What are the biggest issues or concerns related to health service delivery?

DR_HD_13_2006. If your program has graduated and become part of the AFC program, can you please describe whether and how your delivery of health services has changed as a result of the change in status and in funding?

DR_HD_14_2006. If your program has graduated and become part of the AFC program, what role, if any, has the contribution of funds or lack of contribution of funds from OWH played in your ability to sustain the delivery of health services at your organization?

DR_TR_13_2006. Please describe how training is integrated with other components of the CCOE program.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DR_TR_15_2006. How is the CCOE program fostering interest in health sciences/service provider disciplines?

DR_TR_16_2006. What information or metrics does the CCOE collect regarding the impact and effectiveness of programs designed to foster interest in these disciplines? Please indicate if data is available on the metrics described. The evaluation team may request samples of data during the National Evaluation Round II: Site Visit.

DR_TR_17_2006. Does your CCOE track the number of individuals who go on from CCOE training to receive formal training in the health sciences/service provider disciplines?

• Yes

• No

DR_TR_17A_2006. If yes, can you provide an estimate of the number of women who participated in CCOE training and have gone on to receive formal training in the health sciences/service provider disciplines in the last year?

DR_TR_18_2006. Does your CCOE offer programs that help service providers complete their requirements for Continuing Medical Education (CMS)/Continuing Educational Units (CEU)?

• Yes

• No

DR_TR_18A_2006. If yes, does your CCOE track the number of providers who participate in such programming who successfully met their CMS/CEU requirements in the last year?

• Yes

• No

DR_TR_18B_2006. If yes, can you provide an estimate of the number of service providers who met their CMS/CEU requirements in the last year through their participation in CCOE-sponsored programming?

DR_TR_14A_2006. What are the best practices related to implementation of training services offered by your CCOE? DR_TR_14B_2006. What are your lessons learned?

DR_TR_14C_2006. What are the biggest issues or concerns related to implementation of training services offered?

DR_TR_15_2006. If your program has graduated and become part of the AFC program, can you please describe whether and your how training services have changed as a result of the change in status and in funding?

DR_TR_16_2006. If your program has graduated and become part of the AFC program, what role, if any, has the contribution of funds or lack of contribution of funds from OWH played in your ability to sustain training services?

DR_CR_15_2006. What community resources are involved in the research development process? Select all that apply.

• CCOE Advisory Board

• Other Advisory Board

• Partner organizations

• Centers of Excellence (CoE)

• Patients

• DR_TR_15A_2006. Other, please specify: _______________________________________________

DR_CR_16_2006. How are research results communicated to the public? Please select all that apply.

• Internet

• Newspaper

• Internal newsletter

• Journal or magazine advertisements

• Published in a journal or magazine

• Television/radio

• Lectures

• Educational materials/brochures

• During an office visit (staff or doctor communicate results)

• DR_CR_16A_2006. Other, please specify: _______________________________________________

DR_CR_17_2006. Please describe how research results are integrated into the CCOE program and/or the local community.

DR_CR_18A_2006. What are the best practices related to implementation of community-based research activities at the CCOE? DR_CR_18B_2006. What are your lessons learned?

DR_CR_18C_2006. What are the biggest issues or concerns related to implementation of community-based research activities at the CCOE?

DR_CR_19_2006. If your program has graduated and become part of the AFC program, can you please describe whether and how your community-based research activities have changed as a result of the change in status and in funding?

DR_CR_20_2006. If your program has graduated and become part of the AFC program, what role, if any, has the contribution of funds or lack of contribution of funds from OWH played in your ability to sustain community-based research activities?

DR_EO_19_2006. Please describe the CCOE’s goals and/or mission statement for public education and outreach.

DR_EOT_01_2006. What topics of interest are included in your public education and outreach program? Check all that apply:

01-Teen Health	02-Post-partum depression	03-Aging
Bullying	Diet, Exercise, Nutrition	Living Wills/Advanced Health Directives
Fertility	Breast, Ovarian, Cervical Cancer	Osteoporosis
Pregnancy	Urinary Tract Infections/Yeast Infections	Menopause
Contraception/Safe Sex	Domestic Violence	Estrogen Replacement Therapy
STDs	Depression or Other Mental Health Disorders	Medicare/Prescription Drug Benefit
Sex and Gender	Stress	Bridging the Gap Between Religion and Health Care
Sex/Sexuality	Body Image/Eating Disorders	Bridging the Gap Between Cultures and Health Care
Family Planning/ Parenting	Sleep Disorders	Other (please list)
CPR/Babysitter Training	Accessing Health Information on the Internet	_________________________
		_________________________
		_________________________
		_________________________

DR_COM_01_2006. List any non-CCOE community organizations that have contributed resources (in-kind donations) to your CCOE for the production and dissemination of educational materials during the last year. Describe what the resources and/or services were. (Partners should be excluded.)

MONTH/YR DONATION RECEIVED 1a-4a		Community organization 1B-4B	resources/services contributed 1C-4C
June	2002	Kinko’s	100 free copies of one-page brochure

Please rate the extent to which you agree with each of the following statements.

Educational materials distributed by the CCOE…	Strongly Agree	Agree	Neither agree nor disagree	Disagree	Strongly Disagree
• DR_EO_20_2006. …are available in large font	O	O	O	O	O
• DR_EO_21_2006. …are available in language(s) other than English	O	O	O	O	O
• DR_EO_22_2006. …are appropriate to the reading level of the targeted audience	O	O	O	O	O
• DR_EO_23_2006. …address important issues in the community	O	O	O	O	O
• DR_EO_24_2006. …are geared toward prevention (i.e., smoking cessation, drug avoidance, nutrition guidance, etc.,)	O	O	O	O	O
• DR_EO_24A_2006. …help patients improve their health literacy	O	O	O	O	O
• DR_EO_24B_2006. …are aimed at empowering patients to manage their own health	O	O	O	O	O

DR_EO_25_2006. Who does the CCOE partner with in conducting education and/or outreach?

• Partner organizations

• Non-CCOE community resources

• Both

• None

DR_EO_26_2006. How does your CCOE choose health topics for education and outreach? Select all that apply.

• Local health concerns/issues

• National health concerns/issues (e.g., Healthy People 2010, CDC warnings)

• Input from CCOE women

• Partner input

• CCOE staff input

• Polling the local community

• DR_EO_26A_2006. Other, please specify: _____________________________________________

DR_EO_27_2006. What percentage of health topics covered through education and outreach are initiated from community input? ____%

DR_EO_27.1_2006. Does your CCOE track the number of women participating in your education and outreach activities?

• Yes

• No

DR_EO_27.1A_2006. If yes, can you provide an estimate of the number of women participating in these activities over the last year? If you have estimates by type of activity participated in, please provide this information. This information will be cross referenced with information provided in your quarterly reports to OWH.

DR_EO_27.2_2006. Does your CCOE track the number of women using your resource center?

• Yes

• No

DR_EO_27.2A_2006. If yes, can you provide an estimate of the number of women who used the resource center over the last year? If you have estimates by type of resources used, please provide this information.

DR_EO_28_2006. Please describe how education and outreach activities are integrated with other components of the CCOE program.

DR_EO_28.1A_2006. How does the CCOE measure the success of one method of outreach versus another?

DR_EO_28.1B_2006. What are the top three most successful methods?

1.

2.

3.

DR_EO_29A_2006. What are the best practices related to public education and outreach at the CCOE? DR_EO_29B_2006. What are your lessons learned?

DR_EO_29C_2006. What are the biggest issues or concerns related to public education and outreach at the CCOE?

DR_EO_30_2006. If your program has graduated and become part of the AFC program, can you please describe whether and how your public education and outreach activities have changed as a result of the change in status and in funding?

DR_EO_31_2006. If your program has graduated and become part of the AFC program, what role, if any, has the contribution of funds or lack of contribution of funds from OWH played in your ability to sustain public education and outreach activities services?

DR_LD_30A_2006. When conducting leadership, mentoring, and/or skills development activities for young girls, minorities, or women in the community what does your CCOE hope to accomplish?

Young Girls:

DR_LD_30B_2006. Minorities:

DR_LD_30C_2006. Women:

DR_LD_31A_2006. What leadership opportunities does the CCOE offer women?

DR_LD_31B_2006. How do these activities support the promotion of minorities to leadership positions?

DR_LD_31C_2006. Please describe the opportunities and any successes or lessons learned.

DR_LD_32_2006. Do other organizations, besides the CCOE and its partners, provide free or low cost leadership training and/or skills development opportunities to women in the community?

• Yes

• No

DR_LD_32A_2006. If yes, please describe what the opportunities are and the community organizations that provide them.

DR_LD_33_2006. Please describe how leadership development activities are integrated with other components of the CCOE program.

DR_LD_34A_2006. What are the best practices related to implementation of leadership development activities at the CCOE? DR_LD_34B_2006. What are your lessons learned?

DR_LD_34C_2006. What are the biggest issues or concerns related to implementation of leadership development activities at the CCOE?

DR_LD_35_2006. If your program has graduated and become part of the AFC program, can you please describe whether and how your leadership development activities have changed as a result of the change in status and in funding?

DR_LD_36_2006. If your program has graduated and become part of the AFC program, what role, if any, has the contribution of funds or lack of contribution of funds from OWH played in your ability to sustain leadership development activities?

DR_TA_35_2006. Does your CCOE provide on-going technical assistance to another community (so as to help the community replicate the CCOE model)?

• Yes

• No

DR_TA_35A_2006. If yes, how long (in months) has this relationship existed? ______

If you have more than one on-going relationship, list the length of time your relationship with each community has existed.

DR_TA_36_2006. Please describe how technical assistance activities are integrated with other components of the CCOE program.

DR_TA_37A_2006. What are the best practices related to technical assistance activities at the CCOE? DR_TA_37B_2006. What are your lessons learned?

DR_TA_37C_2006. What are the biggest issues or concerns related to technical assistance activities at the CCOE?

DR_TA_38_2006. If your program has graduated and become part of the AFC program, can you please describe whether and how your technical assistance activities have changed as a result of the change in status and in funding?

DR_TA_39_2006. If your program has graduated and become part of the AFC program, what role, if any, has the contribution of funds or lack of contribution of funds from OWH played in your ability to sustain technical assistance activities?

DR_AWR_01_2006. There are several mechanisms that can be used to create an awareness of the CCOE’s existence and services to the community. Please list all mechanisms your CCOE used during the last year. For each communication mechanism, list the type of topic covered, how often or the frequency of the communication mechanism, and the approximate number in the targeted audience.

communication mechanisms	types of topics 1-7	frequency in past year 1A-7A	# in targeted audience 1B-7B
Example: Newspaper	Community Research Educational Events	6 2	3000 100
Newspaper
Radio
Television
Website
Church relationships: (please describe) ________________
Community Center relationships
Other: ___________________

DR_CA_38_2006. Please describe the impact or outcome of your current community awareness efforts, including any increases in service utilization.

DR_CA_39A_2006. What are the best practices related to raising community awareness about the CCOE and its services? DR_CA_39B_2006. What are your lessons learned?

DR_CA_39C_2006. What are the biggest issues or concerns related to raising community awareness about the CCOE and its services?

DR_CA_40_2006. If your program has graduated and become part of the AFC program, can you please describe whether and how your community awareness efforts have changed as a result of the change in status and in funding?

DR_CA_40_2006. If your program has graduated and become part of the AFC program, what role, if any, has the contribution of funds or lack of contribution of funds from OWH played in your ability to sustain community awareness efforts?

1