Form #2 Pilot survey questionnaire

Form Approved
OMB No. 0935-0124
Exp. Date 5/31/2014

Survey of Behavioral Health Care in Primary Care Settings

About You and Your Practice

1. Your main practice location is where you spend a majority of time in direct patient care. What is the zip code of your main care practice location?

2. Are you a full- or part-owner, employee, or independent contractor of your main practice location?

Owner (full or part)

Employee

Contractor

3. What is your medical specialty?

Family/General Practice

Internal Medicine

Other  If Other, go to #35 on Page 8

4. Including yourself, how many physicians work at your main practice location? Please include all physicians regardless of how many hours they work.

One/solo practice

2-5

6-10

More than 10  If More than 10, go to #35 on Page 8

5. Including all physicians and other health care providers how many, including yourself, of each of the following health providers work at your main practice location? Please include all physicians and other health care providers regardless of how many hours they work.

	None	One	2 to 5	6 to 10	More than 10
Primary Care Providers
Family/General Practice
Internal Medicine
OB-Gynecology
Pediatrics
Other Health Care Providers
Registered Nurses
Nurse Practitioners
Medical Assistants
Physician Assistants
Care Managers/Coordinators
Behavioral Health Providers
Psychiatrists
Social Workers
Psychologists
Marriage and Family Therapists (MFT)
Psychiatric Nurse Practitioners
Other Clinicians: (Please specify)
Other Non-Clinicians: (Please specify)

6. How are medical records shared among all physicians and other health providers at your main practice location?

Separate paper records for each provider

Paper records shared across providers

An electronic data system accessible by all physicians and other health providers

7. In a typical week how many hours do you work at the main practice location in providing direct patient care?

8. Have you attended any workshops or participated in any continuing education on integrated or collaborative approaches to treating behavioral health in a primary care setting? Behavioral health includes mental health and substance abuse.

Yes

No If No, go to #10

9. If Yes, please indicate when was the most recent workshop or continuing education program?

In the last two years

Over two years ago but within five years

I cannot remember the timing of the workshop

About Patients Seen in Your Main Practice Location

When answering the following question please focus only on patients you see at your main practice location.

10. Thinking about all the patients you see in an average week, how many patient visits do you have?

11. Approximately what percentage of your patients are male and female?

|___|___| %Male

|___|___| %Female

12. Approximately what percentage of your patients are the following age groups?

|___|___| %under 18 years

|___|___| %18-64

|___|___| %65 and older

13. Approximately what percentage of your patients are the following:

|___|___| %Hispanic/Latino

|___|___| %Non-Hispanic White

|___|___| %Non-Hispanic Black/African American

|___|___| %American Indian or Alaska Native

|___|___| %Asian

|___|___| %Native Hawaiian or Pacific Islander

|___|___| %Multiracial

14. Which of the following type(s) of payment do you accept from your patients? Check all that apply.

Medicare

Medicaid or other state sponsored insurance

Private insurance, health plans, or HMO

Self-pay or uninsured

Workers compensation

No charge

Providing Care to your Patients at the Main Practice Location

When answering the following questions please focus only on protocols and systems you follow at your main practice location.

15. Do you have a systematic process to screen or assess your patients for the following chronic physical conditions?

	Yes	No	Don’t know	Not applicable
Diabetes
Cardiovascular disease
Asthma
Other chronic condition (do not include behavioral health conditions) Please Specify):____________________ _

16. Do you have a systematic process to screen and assess your patients for behavioral health conditions such as depression, anxiety, or substance abuse?

Yes

No  If No, go to #26 on Page 6

17. Do you have a systematic process to screen or assess your patients for the following behavioral health conditions?

	Yes	No	Don’t know	Not applicable
Depression
Anxiety
Substance Abuse
Other behavioral health condition (Please specify): _____________________

18. A registry is a list of patients with a particular condition associated with clinical data for each patient. Does your practice maintain a registry for the following conditions?

	Yes	No	Don’t know
Diabetes
Cardiovascular disease
Depression
Anxiety
Substance Abuse
Asthma
Other condition: (Please specify)

19. How do you follow up on patients you have diagnosed with having behavioral health conditions?

19a. I treat them with medication.

Yes

No

19b. I treat them with counseling.

Yes

No

19c. I refer them to a psychiatrist or other behavioral health provider.

	Onsite	Offsite	Both onsite and offsite	Neither
Referred to a psychiatrist
Referred to another behavioral health provider such as a psychologist, MFT, Social Worker, or Psychiatric Nurse Practitioner

20. Behavioral health providers include psychiatrists, psychologists, marriage and family therapists (MFTs), social workers, and psychiatric nurse practitioners. You may be working with an established network of such behavioral health providers who you regularly refer your patients to. This established network does not include the 800 number on the patient’s insurance card. Do you have such an established network of providers?

Yes

No

21. When you refer patients to behavioral health providers what is the system for care coordination and follow-up?

Patients are responsible for their own coordination and follow-up

A care manager or social worker is in place to coordinate needed care for patient

I coordinate the follow-up directly with the behavioral health provider

Not applicable

22. How do you receive feedback from the psychiatrist or other behavioral health provider?

No feedback

Telephone conversations with the psychiatrist or other behavioral health provider

Process notes from the psychiatrist or other behavioral health provider

Psychotherapy notes from the psychiatrist or other behavioral health provider

Telephone conversations and process or psychotherapy notes

Not applicable

23. There are many approaches and models to treating behavioral health conditions. The next three questions ask about the steps and treatment models you use when treating your patients.

23a. How often do you take any of the following steps in treating your patient’s behavioral health conditions?

	Never	Sometimes	Usually	Always	Not applicable
Repeat measurements or screen periodically during treatment
Follow clearly stated protocols to adjust the treatment approach depending on the patient's response to treatment
Involve behavioral health specialists in challenging cases that do not quickly respond to routine treatment
Follow U.S. Preventive Services Task Force guidelines for screening on depression
Follow U.S. Preventive Services Task Force guidelines for alcohol misuse
Follow U.S. Preventive Services Task Force guidelines for tobacco use
Do you collect data on patient outcomes over a longer term course of treatment e.g., 6 months, 12 months, or longer

23b. How often do you use the Screening, Brief Intervention and Referral to Treatment (SBIRT) model for treating alcohol and/or substance abuse?

Never

Sometimes

Usually

Always

I am not aware of SBIRT

23c. For treating behavioral health conditions there are a number of other standardized models. Do you use any standardized model?

Yes, please describe the model __________________________________________________________

No

24. How often do you and the behavioral health provider together involve the patient and/or patient’s family in making decisions about their treatment plan?

Never

Sometimes

Usually

Always

25. Patient self-management refers to all systems and processes you use to help your patients and their care givers manage their health conditions outside formal medical institutions. This may include discussions with your patient, their care givers, and their family members; use technologies; or use of educational materials. For which behavioral conditions do you have systems to encourage patient self-management? Check all that apply.

Depression

Anxiety

Substance Abuse

Other, please specify _______________________

Reimbursement

26. Are you reimbursed for specific chronic disease management/care management services?

Yes

No  If No, Go to #28

27. Please indicate how you are reimbursed for chronic disease management/care management services. Check all that apply.

Care-management fee

Fee per patient

Fee per service

Fee per episode of care

Global payment for all care

Other_______________________

28. Is your reimbursement for chronic behavioral health conditions the same as for other non-behavioral chronic conditions?

Yes, they are handled the same

No

Other, please specify:_______________________

I do not treat patients for behavioral health conditions  Go to #30 on Page 7

29. How are you currently funding behavioral care as part of primary care? Please feel free to ask your office manager or account manager when responding to this question. Check all that apply.

Payment arrangements with a managed care organization

Capitation arrangement

Shared risk arrangement

P4P – Pay for performance funding

Grant funding

Joint blending of funds with another health care/social service organization

Internal restructuring of funds

Community support/donations/fundraising

Billing through CPT codes for medical services (e.g., use of E & M codes)

Billing through CPT codes for behavioral health services

Billing through CPT codes for health and behavior codes (96150-96155)

Billing through Healthcare Common Procedure Coding System (HCPCS) codes for services

Billing screening codes, such as SBIRT, or PHQ 9

Quality assurance project – redistribution of funds

Self pay / sliding scale fee

Other (please specify)____________________________________

Not applicable

Working in Care Teams in Your Practice

30. Care teams are multidisciplinary teams of health care providers working together under the leadership of a physician; with each member of the team having specific responsibilities to provide care that spans from the exam room to the home.

Based on your experience working in care teams, indicate whether you agree or disagree with each statement.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly Agree	I do not work with care teams
The give and take within teams results in better decisions around patient care
The involvement of multiple team members increases the likelihood of medical errors
The team process burdens care
Primary care physicians are not responsible for behavioral care of patients

Quality Assurance and Improvement

When answering the following questions please focus on Quality Assurance and Improvement protocols followed by the main practice where you spend the majority of your time in patient care.

31. Does your main practice have a written plan with procedures and defined goals for accountability for measuring performance of individual physicians?

Yes

No

Don’t know

32. For each of the following conditions has your practice adopted written evidence-based standards?

	Yes	No	Don’t know	Not Applicable
Diabetes
Cardiovascular disease
Depression
Anxiety
Substance Abuse
Asthma
Other condition: Please specify

33. For patients with each of the following behavioral health conditions does your clinic provide data to individual physicians on the quality of their care?

	Yes	No	Don’t know	Not Applicable
Depression
Anxiety
Substance Abuse
Other condition: Please specify

34. Does your clinic conduct or participate in formal quality improvement activities?

Yes

No

Don’t know

Please Go to #37

Information on Larger Practices

Please answer these questions if you are not a family/general practitioner, not an internal medicine doctor, or if there are more than ten physicians at your main practice location.

35. Including full- and part-time physicians at the practice, how many physicians, including yourself, practice at your main practice location?

10 or fewer

11-20

21-50

51-100

More than 100

36. Who owns the practice?

Hospital

Physician or physician group

Other health care corporation

HMO

Other_______________________

Other Comments

37. What obstacles have you encountered as you manage behavioral conditions in your practice?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

38. What else have you done in your approach to managing patients who seek care for behavioral health conditions in your practice?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank You for completing the Survey.

Public reporting burden for this collection of information is estimated to average 10 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0124) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

July 20, 2012 – Attachment B – Pilot survey questionnaire