2 Pre_and_post_test

APPENDIX A-2

HIV Clinician Workforce Study
Practice Survey
Draft Questionnaire
POST-PRETEST VERSION
September 13, 2011

Submitted to
The HIV/AIDS Bureau
Health Resources and Services Administration
by
Mathematica Policy Research
and
The Lewin Group

Public Statement

INTRODUCTION
The purpose of this survey. The HIV/AIDS Bureau (HAB) within the U.S. Department of Health and Human Services’
Health Resources and Services Administration (HRSA) is conducting a national study to better understand the size and
characteristics of the health profession workforce currently providing medical care to people living with HIV or AIDS in the
United States. HRSA will use the information to assess the capacity of HIV clinicians to meet the health care needs of
individuals living with HIV or AIDS and to develop strategies to address potential workforce shortages in the future.
Why your participation is critical. From an initial review of medical and pharmacy claims data, as well as an
administrative list of organizations funded under the Ryan White HIV/AIDS Program, we identified your practice or clinic
as one of a small number nationwide that provide direct outpatient medical care to a significant number of patients with
HIV or AIDS. HRSA needs the information that only you can provide to better understand the factors influencing the
capacity and productivity of the HIV clinician workforce and the implications of those factors for the capacity of the HIV
clinician workforce in the future.
What is your “practice or clinic?” All questions in this survey are about your practice or clinic, that is, the place (it may
be public or private, part of a hospital or health care system, a community health center or health department clinic, a solo
or group practice, etc.) that provides outpatient medical services to patients with HIV or AIDS. For brevity, we refer to this
place as “your practice.”
Questionnaire Sections
Page
Eligibility Screener ........................................................................................................................................................... 1
A.

Practice Management ............................................................................................................................................. 3

B.

Practice Staffing ...................................................................................................................................................... 6

C.

Recruitment and Retention...................................................................................................................................... 8

D.

Practice Capacity .................................................................................................................................................. 11

E.

Perception about HIV Clinician Capacity .............................................................................................................. 14

F.

Patient Characteristics .......................................................................................................................................... 16

G.

Contact Information ............................................................................................................................................... 19

Completing the questionnaire. We estimate the survey will take you or your designee about 30 minutes to complete.
Your best guess estimate on questions that ask for quantitative responses is fine. Several questions in the survey refer to
the past 12-month period. Please feel free to use the most recent reporting period for which the information is readily
available, including the 2010 Ryan White HIV/AIDS Program Data Report (RDR), if applicable.
• If there is no “Go To” instruction, proceed to the next question.
• If there is a “Go To” instruction, go to the question indicated.
• There are notes to guide you in your responses. They appear in italics.
If you need help answering any questions, please call Katie Morrison at Mathematica’s Washington, DC office toll-free at
1-866-xxx-xxxx or email her at [email protected]. Katie will be happy to help in any way. When you finish
the survey, please put it in the pre-paid Federal Express envelope included with the questionnaire and return it to
Mathematica Policy Research.

Prepared by Mathematica Policy Research

ii

ELIGIBILITY SCREENER
S1.

Does your practice currently provide outpatient medical care to patients with HIV or AIDS?

□
0□
1

S2.

Yes
No

GO TO S5

How would you describe your practice setting? (Mark only one.)

□
2□
3□
4□
5□
6□
7□
1

Private clinic or office

GO TO S2a

Hospital or university-based outpatient clinic

GO TO S2b

Publicly funded health center or clinic
Other community-based health center
GO TO S3

AIDS service organization
Public health department clinic

Other (Please specify) ___________________________

GO TO S5

S2a. Is the private clinic or office a…? (Mark only one.)

□
2□
3□
1

Solo practice
Group practice, single-specialty

GO TO S3

Group practice, multi-specialty

S2b. Is the hospital operated by…? (Mark only one.)

□
2□
3□
1

S3.

A federal, state, county, or city government
A private nonprofit organization
A private for-profit organization

Is your practice part of an integrated health care system composed of multiple provider
organizations that share resources and offer a comprehensive continuum of care?

□
0□
1

Yes
No

GO TO S4

S3a. Does this integrated health care system include any of the following? (Mark all that apply.)

□
2□
3□
4□
5□
1

S4.

HIV/AIDS specialty ambulatory care clinic
Multi-specialty ambulatory clinic(s)
Hospital inpatient department(s)
Substance abuse and/or mental health counseling and treatment centers
Clinical pharmacy

Does your practice receive Ryan White HIV/AIDS Program funding?

□
0□
1

Yes
No

Prepared by Mathematica Policy Research

1

S5.

Because your practice is not currently providing medical care to patients with HIV or AIDS or your
practice setting is outside the scope of the study, you are ineligible to participate in this survey.
However, we still need to hear this from you! Please put this paper questionnaire in the pre-paid
envelope we provided and mail it back to us so we will know to remove you from our respondent
follow-up list. Thank you for your help.

Prepared by Mathematica Policy Research

2

A. PRACTICE MANAGEMENT

1.

Does your practice use a computerized or electronic medical record (EMR) system?)

□
0□
d□
1

1a.

2

3

4

5

6

7

8

9

10

11

GO TO Q.2

Don’t know

□

To review patient records

□

To increase adherence to clinical guidelines

□

To share clinical information with providers internal to your practice

□

To share clinical information with providers external to your practice

□

To share clinical information with patients

□

To write and order prescriptions (also called e-prescribing)

□

To order laboratory, radiology, or other diagnostic tests

□

To receive laboratory, radiology, or other diagnostic test results

□

To make referrals for specialty care

□

To track patient enrollment, appointments, and/or referrals?

□

To monitor quality of care?

Has your practice implemented any appointment scheduling procedures or policies intended to
increase the number of patients you can see or expedite the flow of patients through your clinic?

□
0□
d□
1

2a.

No

Does your practice use the EMR system for any of the following? (Mark all that apply.)
1

2.

Yes

Yes
No
Don’t know

GO TO Q.3

Do these scheduling procedures or policies include any of the following? (Mark all that apply.)

□ Expediting intake and eligibility and medical screening appointments
2 □ Contacting patients to remind them of their appointments
3 □ Double-booking appointments
4 □ Maintaining open appointments for walk-ins
5 □ Maintaining cancellation lists
1

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3

□ Offering group appointments
7 □ Providing medical case managers to help patients navigate health care system
8 □ Providing peer counselors to help patients understand and adhere to treatment
9 □ Coordinating appointments so that patients see multiple clinicians during one visit
6

3.

Does your practice delegate clinical tasks and responsibilities from health professionals with more
advanced degrees to those with less training (such as from physicians to nurse practitioners or
from nurse practitioners to registered nurses)?

□
0□
d□
1

3a.

Yes
No
Don’t know

GO TO Q.4

To whom are these clinical tasks and responsibilities delegated? (Mark all that apply.)

□ Nurse practitioners
2 □ Physician assistants
3 □ Other advanced practice nurses
4 □ Registered nurses
5 □ Licensed practical nurses
6 □ Medical assistants
7 □ Medical case managers
8 □ Pharmacists
1

4.

Does your practice share the clinical management of your HIV patients with non-HIV physicians or
other clinicians, some of whom may be outside your practice? Sharing management of HIV
patients may involve providing telephone consultation or using other forms of telemedicine.

□
0□
d□
1

4a.

Yes
No
Don’t know

GO TO Q.5

With which type of clinicians does your practice share the management of HIV patients?

□ General practitioners
2 □ Infectious disease specialists
3 □ Clinical Pharmacists
4 □ Nurse practitioners
5 □ Physician assistants
1

Prepared by Mathematica Policy Research

4

5.

Does your practice offer services specifically designed to promote the long-term management of
HIV disease, including medication therapy management, patient education, and peer counseling?

□
0□
d□
1

6

Yes
No
Don’t know

Does your practice use an integrated team approach where multiple clinicians (such as physicians,
nurses, and medical assistants) work together to augment and enhance the physician visit by
providing previsit, postvisit, and between-visit contact with the patient?

□
0□
d□
1

Yes
No
Don’t know

Prepared by Mathematica Policy Research

5

B. PRACTICE STAFFING
For this section, 40 hours per week in your clinic = 1 full-time equivalent (FTE). For example, if you have
one physician working 40 hours per week in your clinic and another physician working 20 hours per week
in your clinic, you should report them as 1.50 FTEs.
7.

In your practice, how many FTEs of the following types of clinicians are spent providing medical
services to your patients? In Column A, record the number of FTEs spent providing total patient
care. In Column B, record the number of FTEs spent providing HIV patient care.
(The number of FTEs reported in Column B should not be greater than the number of FTEs
reported in Column A. If all of the clinicians in your practice treat only patients with HIV or AIDS, the
number of FTEs in Columns A and B will be the same. If no FTEs to report for a given type of
clinician, please record as zero.)

1

2

3

4

8.

Column A

Column B

Number of FTEs in
Total Patient Care

Number of FTEs in
HIV Patient Care

□ Infectious disease specialist

|

||

|.|

|

|

|

||

|.|

|

|

□ Physician (other than infectious disease specialist)

|

||

|.|

|

|

|

||

|.|

|

|

□ Nurse practitioner

|

||

|.|

|

|

|

||

|.|

|

|

□ Physician assistant

|

||

|.|

|

|

|

||

|.|

|

|

On average, how many HIV patient visits per week is a full-time HIV clinician of the following types
expected to provide in your practice? (If no visits to report for a given type of clinician, please
record as zero.)
Average Number of HIV Patient
Visits Per Week Per Full-Time HIV
Clinician

1

2

3

4

9.

□ Infectious disease specialist

|

|

|

|

□ Physician (other than infectious disease specialist)

|

|

|

|

□ Nurse practitioner

|

|

|

|

□ Physician assistant

|

|

|

|

On average, how many HIV patients is a full-time HIV clinician of the following types expected to
manage on an ongoing basis at your clinic? (By “manage,” we mean the clinician is responsible for
independently overseeing or coordinating a medical care for a panel of patients at your clinic. By
“ongoing basis” we mean active patients seen in the practice within the past year. For clinician
types that do not manage patient care at your clinic, please record as zero.)
Average Number of HIV Patients
Per One FTE Clinician

1

□ Infectious disease specialist

Prepared by Mathematica Policy Research

|

6

|

|

|

2

3

4

□ Physician (other than infectious disease specialist)

|

|

|

|

□ Nurse practitioner

|

|

|

|

□ Physician assistant

|

|

|

|

Prepared by Mathematica Policy Research

7

C. RECRUITMENT AND RETENTION

10.

1

2

3

4

In Column A, record the number of HIV-related clinical vacancies (by FTE) filled in your practice in
the past 12 months. In Column B, record the average length of time (in months) it took to fill each
type of position. (Include only positions for clinicians who treat patients with HIV or AIDS. If no filled
vacancies to report for a given type of clinician, please record as zero in Columns A and B.)

2

3

4

12.

Column B

Number of HIVRelated Vacancies
Filled in Past 12
Months
(in FTEs)

Average Length of
Time HIV-Related
Position was
Vacant
(in Months)

□

Infectious disease specialist

|

||

|.|

|

|

|

||

|

□

Physician (other than infectious disease specialist)

|

||

|.|

|

|

|

||

|

□

Nurse practitioner

|

||

|.|

|

|

|

||

|

□

Physician assistant

|

||

|.|

|

|

|

||

|

11.

1

Column A

In Column A, record the number of funded but currently vacant HIV-related clinical positions (by
FTE) in your practice. In Column B, record the average length of time (in months) these positions
have been vacant. (Include only positions for clinicians who treat patients with HIV or AIDS, and
only those positions with funding support. If no vacancies to report for a given type of clinician,
please record as zero in Columns A and B.)
Column A

Column B

Currently
Funded
HIV-Related
Vacancies
(in FTEs)

Average Length of
Time HIV-Related
Position Has
Been Vacant
(in Months)

□

Infectious disease specialist

|

||

|.|

|

|

|

||

|

□

Physician (other than infectious disease specialist)

|

||

|.|

|

|

|

||

|

□

Nurse practitioner

|

||

|.|

|

|

|

||

|

□

Physician assistant

|

||

|.|

|

|

|

||

|

In your practice, how difficult is it to recruit the following types of clinicians to provide HIV-related
medical care? (Mark only one in each row. If you do not use a given type of clinician in your
practice, please check Not Applicable.)
Very
Easy

Prepared by Mathematica Policy Research

Somewhat
Easy

8

Somewhat
Difficult

Very
Difficult

Not
Applicable

1

2

3

4

□

Infectious disease specialist

1

Physician (other than infectious
disease specialist)

1

□

Nurse practitioner

1

□

Physician assistant

1

□

□
□
□
□

2

2

2

2

□

3

□

3

□

3

□

3

□

4

□

4

□

4

□

4

□

0

□

0

□

0

□

0

□
□
□
□

12a. In your practice, how big a challenge is each of the following factors to recruiting HIV clinicians
generally? (Please indicate if each factor is a big challenge, a small challenge, or not a challenge at
all. Mark only one in each row.)
BIG
CHALLENGE
1

2

3

4

5

6

7

8

9

□

Low pay scale or lack of reimbursement for HIV
care

1

□

Lack of clinicians in the geographic area

1

□

Lack of clinicians with HIV experience

1

□

Lack of clinicians willing to work with HIV patients

1

□

Lack of interest in HIV clinical specialty

1

□

Lack of funds to hire new staff

1

□

Lack of J1 visas or other immigration problems

1

Workload is perceived as being too heavy or
burdensome

1

Other (Please specify)_____________________

1

□
□

13.

2

3

4

□

2

□

2

□

2

□

2

□

2

□

2

□

2

□

2

□

2

NOT A
CHALLENGE

□

3

□

3

□

3

□

3

□

3

□

3

□

3

□

3

□

3

□
□
□
□
□
□
□
□
□

In your practice, how difficult is it to retain each of the following types of clinicians who provide HIV
care? (Mark only one in each row. If you do not use a given type of clinician in your practice, please
check Not Applicable.)
Very
Easy

1

SMALL
CHALLENGE

□

Infectious disease specialist

1

Physician (other than infectious
disease specialist)

1

□

Nurse practitioner

1

□

Physician assistant

1

□

Prepared by Mathematica Policy Research

□
□
□
□

Somewhat
Easy
2

2

2

2

□
□
□
□

9

Somewhat
Difficult
3

3

3

3

□
□
□
□

Very
Difficult
4

4

4

4

□
□
□
□

Not
Applicable
0

0

0

0

□
□
□
□

13a. In your practice, how big a challenge is each of the following factors to retaining HIV clinicians
generally? (Please indicate if each factor is a big challenge, a small challenge, or not a challenge at
all. Mark only one in each row.)
BIG
CHALLENGE
1

2

3

4

5

6

7

8

9

□

Low pay scale or lack of reimbursement for HIV
care

1

Lack of clinicians in the geographic area

1

Lack of qualified HIV clinicians (i.e., lack of HIV
experience)

1

Lack of clinicians willing to work with HIV
patients

1

□

Lack of interest in HIV clinical specialty

1

□

Lack of funds to hire new staff

1

□

Lack of J1 visas or other immigration problems

1

Workload is perceived as being too heavy or
burdensome

1

Other (Please specify) ____________________

1

□
□
□

□
□

14.

1

2

3

4

SMALL
CHALLENGE

□

2

□

2

□

2

□

2

□

2

□

2

□

2

□

2

□

2

NOT A
CHALLENGE

□

3

□

3

□

3

□

3

□

3

□

3

□

3

□

3

□

3

□
□
□
□
□
□
□
□
□

In your practice, what is the average annual salary offered for the following full-time positions? In
Column A, please provide average annual salaries for full-time newly hired clinicians with
experience treating patients with HIV. In Column B, please provide average annual salaries for
full-time newly hired clinicians without experience treating patients with HIV. (If you do not use a
given type of clinician in your practice, please record as zero in Columns A and B.)

□

Column A

Column B

Average Annual Salary
With Experience Treating
HIV Patients

Average Annual Salary
Without Experience
Treating HIV Patients

$|

|

|

|,|

|

|___|

$|

|

|

|,|

|

|___|

disease specialist)

$|

|

|

|,|

|

|___|

$|

|

|

|,|

|

|___|

□

Nurse practitioner

$|

|

|

|,|

|

|___|

$|

|

|

|,|

|

|___|

□

Physician assistant

$|

|

|

|,|

|

|___|

$|

|

|

|,|

|

|___|

Infectious disease specialist

□ Physician (other than infectious

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10

D. PRACTICE CAPACITY

15.

In a typical week, about how many total patient visits does your practice conduct? (Please count
visits for both HIV and non-HIV patients.)
|___|___|___| VISITS

16.

In a typical week, about how many of your total patient visits are for patients with HIV or AIDS?
|___|___|___| VISITS

17.

Assuming no change in current your resource levels, such as funding or staffing, how many
additional visits (in addition to those you are currently providing) for patients with HIV or AIDS
could your practice currently absorb without compromising the quality of care provided?
|

18.

|

|

| VISITS

For each type of patient, what is the average waiting time for a non-regularly scheduled
appointment in your practice? (Mark only one in each row.)
Average Waiting Time
Less
Than
1 Week
1

2

3

19.

□
□
□

Patients newly diagnosed with HIV

1

HIV patients new to your practice,
but not newly diagnosed

1

Existing HIV patients at your
practice engaged in care

1

□
□
□

1
Week
2

2

2

□
□
□

2
Weeks
3

3

3

3
Weeks

□

4

□

4

□

4

4
Weeks

□

5

□

5

□

5

□
□
□

More
Than
4 Weeks
6

6

6

□
□
□

For each of type of patient, what is the average length of a typical visit with a primary clinician in
your practice? (If no patients to report in for a given type of patient, please record as zero.)
Minutes
1

2

3

20.

□
□
□

Patients newly diagnosed with HIV

|

|

|

|

HIV patients new to your practice, but not newly
diagnosed

|

|

|

|

Existing HIV patients at your practice engaged
in care

|

|

|

|

Is your practice currently accepting new Medicaid patients with HIV for medical care? (For patients
with multiple sources of coverage, please consider their primary payer source only. Mark only one.)

Prepared by Mathematica Policy Research

11

1

2

0

□

Yes, with no limitations on care provision

□

Yes, with some limitations on care provision

□

No, completely closed to all new Medicaid patients with HIV

GO TO Q.21

20a. How important were the following factors in the decision to limit or close your practice to new
Medicaid patients with HIV? (Mark only one in each row.)

Very
Important
1

2

3

4

21.

□

Administrative requirements

1

□

Complex needs of HIV patients

1

□

Overall HIV patient load

1

Inadequate reimbursement of
funding for HIV care

1

□

□

Moderately
Important
2

□

2

□

2

□

2

□
□
□
□

Not Very
Important
3

3

3

3

□
□
□
□

Not
Important
At All
4

4

4

4

□
□
□
□

Is your clinic or practice currently accepting new Medicare patients with HIV for medical care? (For
patients with multiple sources of coverage, please consider their primary payer source only. Mark
only one.)
1

2

0

□

Yes, no limitations

□

Yes, some limitations

□

No, completely closed to all new Medicare patients with HIV

GO TO Q.22

21a. How important were the following factors in the decision to limit or close your practice to new
Medicare patients with HIV? (Mark only one in each row.)

Very
Important
1

2

3

4

□

Administrative requirements

1

□

Complex needs of HIV patients

1

□

Overall HIV patient load

1

Inadequate reimbursement of
funding for HIV care

1

□

Prepared by Mathematica Policy Research

□

Somewhat
Important
2

□

2

□

2

□

2

12

□
□
□
□

Not Very
Important
3

3

3

3

□
□
□
□

Not
Important
At All
4

4

4

4

□
□
□
□

22.

Is your clinic or practice currently accepting new commercially insured patients with HIV for
medical care? (For patients with multiple sources of coverage, please consider their primary payer
source only. Mark only one.)
1

2

0

□

Yes, no limitations

□

Yes, some limitations

□

No, completely closed to all new commercially insured patients with HIV

GO TO Q.23

22a. How important were the following factors in the decision to limit or close your practice to new
commercially insured patients with HIV? (For patients with multiple sources of coverage, please
consider their primary payer source only. Mark only one in each row.)

Very
Important
1

2

3

4

23.

□

Administrative requirements

1

□

Complex needs of HIV patients

1

□ Overall HIV patient load
□

Inadequate reimbursement of
funding for HIV care

1

1

□

Somewhat
Important
2

□

2

□

2

□

2

□
□
□
□

Not Very
Important
3

3

3

3

□
□
□
□

Not
Important
At All
4

4

4

4

□
□
□
□

Is your clinic or practice currently accepting new uninsured patients with HIV for comprehensive
primary medical care? (Mark only one.)
1

2

0

□

Yes, no limitations

□

Yes, some limitations

□

No, completely closed to all new commercially insured patients with HIV

GO TO Q.24

23a. How important were the following factors in the decision to limit or close your practice to new
uninsured patients with HIV? (Mark only one in each row.)

Very
Important
1

2

3

4

□

Administrative requirements

1

□

Complex needs of HIV patients

1

□

Overall HIV patient load

1

Inadequate reimbursement of
funding for HIV care

1

□

Prepared by Mathematica Policy Research

□

Somewhat
Important
2

□

2

□

2

□

2

13

□
□
□
□

Not Very
Important
3

3

3

3

□
□
□
□

Not
Important
At All
4

4

4

4

□
□
□
□

E. YOUR PERCEPTION ABOUT HIV CLINICIAN CAPACITY

24.

In your opinion, the supply of clinicians providing direct medical care to patients with HIV or AIDS in
your community is currently…? (Mark only one.)

□
2□
3□
1

25.

Greater than demand (clinician surplus)
Balanced with demand
Less than demand (clinician shortage)

Using a scale of 1 – 5, where 1 means you strongly disagree with the statement and 5 means you
strongly agree with it, please rate this statement: I am concerned about a shortage in the number of
clinicians providing direct medical care to patients with HIV or AIDS in my community over the next
5 years. (Mark only one in each row.)
Strongly
Disagree

1

2

3

4

Strongly
Agree

Infectious disease specialists

1

□

2

□

3

□

4

□

5

□

Physicians (other than infectious disease
specialists)

1

□

2

□

3

□

4

□

5

□

□

Nurse practitioners

1

□

2

□

3

□

4

□

5

□

□

Physician assistants

1

□

2

□

3

□

4

□

5

□

□
□

26.

On a scale of 1 to 5 where 1 is least effective and 5 is most effective, please rate the effectiveness
of the following strategies for meeting a future increase in the demand for HIV-related medical
services without compromising the quality of care provided.
Least
Effective

1

2

3

4

5

□
□
□
□

□

Most
Effective

Training more medical and other health
profession students to go into HIV/AIDS
care

1

□

2

□

3

□

4

□

5

□

Increasing professional opportunities for
clinicians currently providing HIV/AIDS
care

1

□

2

□

3

□

4

□

5

□

Increasing the use of nurse practitioners
and physician assistants in managing
care for patients with HIV or AIDS

1

□

2

□

3

□

4

□

5

□

Increasing the use of social workers,
counselors, and patient educators to
improve linkages with and engagement,
adherence, and retention in HIV/AIDS
care

1

□

2

□

3

□

4

□

5

□

1

□

2

□

3

□

4

□

5

□

Reducing the amount of time spent
completing paperwork and meeting other

Prepared by Mathematica Policy Research

14

regulatory requirements
6

7

8

9

□

□
□
□

10

Increasing the adoption of health
information technology, including sharing
medical records, ordering prescriptions,
and ordering and receiving lab tests

1

□

2

□

3

□

4

□

5

□

Increasing the use of telemedicine for
treating patients in care settings without
adequate HIV expertise

1

□

2

□

3

□

4

□

5

□

Expanding the government loan
forgiveness program for clinicians
providing care to patients with HIV/AIDS

1

□

2

□

3

□

4

□

5

□

Increasing the use of non-HIV primary
care physicians for the treatment of
patients with HIV or AIDS

1

□

2

□

3

□

4

□

5

□

1

□

2

□

3

□

4

□

5

□

1

□

2

□

3

□

4

□

5

□

1

□

2

□

3

□

4

□

5

□

1

□

2

□

3

□

4

□

5

□

1

□

2

□

3

□

4

□

5

□

□ Increasing the use of advanced primary
care practice models intended to
promote the management of HIV
disease, including medication therapy
management

11

□ Increasing public funding and/or
reimbursement rates for HIV-related
health care services

12

□ Implementing appointment scheduling
changes intended to increase the
number of patients who can be seen

13

□ Creating incentives for currently
practicing clinicians to delay retirement
or prevent them from shifting out of HIVrelated medical care

14

□ Other (Please specify)
________________________________

Prepared by Mathematica Policy Research

15

F. PATIENT CHARACTERISTICS
Questions in this section refer to your practice’s most recent 12-month reporting period. If you submitted a
2010 RDR to HRSA, please feel free to use the information presented in that report. Please count each
patient once only, regardless of how many times he or she was seen during the reporting period. Your
best estimate of patient and visit counts is fine.

27.

During your most recent 12-month reporting period, how many total patients in each of the
following HIV status categories did your practice serve? (If no patients in a give category to report,
please record as zero.)
Number of Patients Served
in 12-Month Reporting Period
1

2

3

4

□

HIV negative

|

|

|

|

| PATIENTS

□

HIV positive, without an AIDS diagnosis

|

|

|

|

| PATIENTS

□

HIV positive, with an AIDS diagnosis

|

|

|

|

| PATIENTS

□

HIV status unknown

|

|

|

|

| PATIENTS

|

|

|

|

| PATIENTS

TOTAL

28.

Of those with HIV or AIDS, what percentage is in each of the following patient categories? (The
total percentage must add up to 100 percent. If no patients to report in a given category, please
record as zero.)
Percent of HIV/AIDS Patients
1

2

3

□
□
□

Patients newly diagnosed with HIV

|

|

|

|%

HIV patients new to your practice, but not newly
diagnosed

|

|

|

|%

Existing HIV patients at your practice engaged in care

|

|

|

|%

TOTAL

29.

100%

Of those with HIV or AIDS, what percentage also had each of the following comorbidities?
(Percentages do not need to add up to 100 percent. If no patients in a given category to report,
please record as zero.)
Percent of HIV/AIDS Patients
1

2

3

□

Serious mental illness

|

|

|

|%

□

Substance abuse disorder

|

|

|

|%

□

Hepatitis B or C

|

|

|

|%

Prepared by Mathematica Policy Research

16

4

30.

□

Other significant comorbidities

|

|

|

|%

Of those with HIV or AIDS, what percentage was in each of the following antiretroviral therapy
categories? (The total percentage must add up to 100 percent. If no patients in a given category to
report, please record as zero.)
Percent of HIV/AIDS Patients
1

2

3

4

□

None

|

|

|

|%

□

HAART

|

|

|

|%

□

Other (mono or dual therapy)

|

|

|

|%

□

Unknown

|

|

|

|%

TOTAL

31.

100 %

Of those with HIV or AIDS, what percentage was in each of following age categories? (The total
percentage must add up to 100 percent. If no patients in a given category to report, please record
as zero.)
Percent of HIV/AIDS Patients
1

2

3

4

5

6

7

□

Under 2 years

|

|

|

|%

□

2-12 years

|

|

|

|%

□

13-24 years

|

|

|

|%

□

25-44 years

|

|

|

|%

□

45-64 years

|

|

|

|%

□

65 and older

|

|

|

|%

□

Unknown

|

|

|

|%

TOTAL

32.

100 %

Of those with HIV or AIDS, what percentage was in each of following gender categories? (The
total percentage must add up to 100 percent. If no patients in a given category to report, please
record as zero.)
Percent of HIV/AIDS Patients
1

2

3

□

Male

|

|

|

|%

□

Female

|

|

|

|%

□

Transgendered

|

|

|

|%

Prepared by Mathematica Policy Research

17

4

□

Unknown

|

TOTAL

33.

|

|%

100 %

Of those with HIV or AIDS, what percentage were Hispanic or Latino/a?
|

34.

|

|

|

| PERCENT

Of those with HIV or AIDS, what percentage was in each of the following race categories? (The
total percentage must add up to 100 percent. If no patients in a given category to report, please
record as zero.)
Percent of HIV/AIDS Patients
1

2

3

4

5

6

7

□

American Indian or Alaskan Native

|

|

|

|%

□

Asian

|

|

|

|%

□

Black or African American

|

|

|

|%

□

Native Hawaiian or Pacific Islander

|

|

|

|%

□

White

|

|

|

|%

□

More than one race

|

|

|

|%

|

|

|

|%

□. Unknown

TOTAL

35.

100 %

Of those diagnosed with HIV or AIDS, what percentage was in each of the follow health
insurance categories? (The total percentage must add up to 100 percent. If no patients in a given
category to report, please record as zero.)
Percent of HIV/AIDS Patients
1

2

3

4

5

6

7

8

□

Privately insured

|

|

|

|%

□

Medicaid only

|

|

|

|%

□

Medicare only

|

|

|

|%

□

Both Medicaid and Medicare

|

|

|

|%

□

Other public insurance (VA or Indian Health)

|

|

|

|%

□

Self pay or uninsured

|

|

|

|%

□

Other (Please specify)____________________

|

|

|

|%

□

Unknown

|

|

|

|%

TOTAL

Prepared by Mathematica Policy Research

100 %

18

G. CONTACT INFORMATION

In case we need to contact you to clarify any of your answers, please provide the following
information:

Name:
Title: _________________________________________________________________________
Address:
Phone Number: (| | | |)-|
Area Code

|

|

|-|

|

|

|

|

Email Address:

Prepared by Mathematica Policy Research

19