Survey of Administrators of Publicly-funded Health Cente

Evaluation of U.S. Family Planning Guidelines - Phase II

E1_Administrator Survey

Survey of non-Title X Clinic Administrators

OMB: 0920-0969

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Form Approved

OMB Number: 0920-XXXX

Exp. Date: XX/XX/XXXX

2012-2013 SURVEY FOR ADMINISTRATORS OF

PUBLICLY-FUNDED HEALTH CENTERS THAT PROVIDE FAMILY PLANNING

Public reporting burden of this collection of information is estimated to average 15 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx).


  1. Health Center Characteristics



1.

What type of organization is your health center? (Please select one)

Health department (local, county, state)

Hospital

Planned Parenthood

Federally-Qualified Health Center (e.g. community health center)

Private, non-profit organization

Other (please specify)______________


2.

What best describes your health center’s clinical focus?


Family planning/reproductive health


Primary (general health) care


Other (please specify) _____________


3.

What state or territory is your agency located in?

_____________________


4.

Which best describes the area that your health center serves?


Mostly urban/suburban


Mostly rural


Combination or rural & urban



5.

Approximately how many clients received any clinical services at your health center in the last year? (fiscal or calendar)


< 500


500 -999


1,000-4,999


5,000-9,999


10,000 – 49,000


50,000 +



6.

Approximately how many clients received family planning services at your health center in the last year? (fiscal or calendar)


< 500


500 -999


1,000-4,999


5,000-9,999


10,000 +



7.

What is the approximate age and gender breakdown of your health center’s family planning clients?


All clients (male and female)




< 20 years old

______%



20-29 years old

______%



30-44 years old

______%



45 years or older

______%


Males (all ages)

______%


9.

Is your health center a part of the following health care networks?



Yes

No

Don’t know


Accountable care organization


Medical home (PCMH or other)


Medicaid managed care


Other managed care network/PPO


Participating provider in one or more private insurance company networks

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II.

Questions about survey completion

10.

Which of the following best describes the primary role of the person or persons who completed this survey? (Select all that apply.)


Administrator


Medical director


Nurse/nurse practitioner manager


Other (please specify)__________


11.

If your health center is a part of a multi-site agency, did you consult your parent agency to complete this survey? (Select one.)


Yes, parent completed entire survey


Yes, parent completed or checked parts of the survey


No, parent did not help complete or check the survey


No, we are not part of a multi-site agency


No, we are the parent agency






III.

Clinical Services Provided






12.

In the past 3 months, about how often did your health center provide the following services?



Never

Rarely

Occasionally

Frequently


Pregnancy diagnosis & counseling


Contraceptive services for women


Contraceptive services for men


Basic infertility services for women


Basic infertility services for men


STD screening for women


STD screening for men


Preconception health care for women


Preconception health care for men



13. In the past 3 months, were the following contraceptive methods* provided on site to clients who requested them? Also, please note whether your health center ran out of supplies of that method in the last 3 months.


Provided on site,

last 3 months

Supplies ran out,

last 3 months


Yes, to all clients who requested it

Yes, to some clients who requested it

No

Yes

No

Sterilization (male)



Sterilization (female)



LNG-IUD (Mirena®)

Cu-IUD (ParaGard®)

Implant (Implanon® or Nexplanon®)

DMPA (Depo-Provera®)

Patch (Ortho Evra®)

Vaginal ring (NuvaRing®)

Combined Oral Contraceptives (COCs)

Progestin-only oral contraceptives

Emergency contraceptive pills

Male condom

Female condom

*Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.



14.

In the past 3 months, how often did your health center use the following referral practices?



Never

Rarely

Occasionally

Frequently


Provided a resource listing or directory to the client


Provided a documented referral to the client


Made an appointment for the client


Contacted the client directly about the referral outcome


Contacted the referral source to find out if the client was seen


Asked the client about the referral at his or her next visit

15.

The following questions refer to your health center’s clinical recommendations for on site, routine screening during initial or follow-up family planning visits. By screening, we mean the process of routinely asking questions about a client’s history or performing a physical exam or laboratory test in average-risk asymptomatic persons to help assess risk factors for, or the presence of, a specific disease or condition.



Is this standard of care for female clients?

Is this specified in a written protocol?

Is this standard of care for

male clients?

Is this specified in a written protocol?



Yes

No

Yes

No

Yes

No

Yes

No


Intimate partner and sexual violence


Substance abuse


Tobacco use


Depression


Immunizations


Unhealthy diet


Body-mass index (BMI)


High blood pressure


Diabetes


High cholesterol


Chlamydia


Gonorrhea


Syphilis


HIV


Breast cancer






Cervical cancer






Testicular cancer

























16.


The following questions relate to your health center’s clinical recommendations for contraceptive counseling.

Is this standard of care?

Is this specified in a written protocol?







Yes

No

Yes

No


Use open-ended questions


Assess the client’s reproductive life plan (i.e., ask about their intentions regarding the number and timing of pregnancies in the context of their personal values and life goals)


Presented information regarding potential contraceptive methods with the most effective methods presented first (tiered approach)


Help the client think about potential barriers to using their selected method correctly and develop a plan to deal with these barriers


Use method-specific consent forms


Inform adolescents that long-acting reversible contraceptives are safe and effective options







IV.

Health Center Infrastructure, Systems, and Community Education


17.

In the past 3 months, about how often did your health center make available the following services or materials to clients?



Never

Rarely

Occasionally

Frequently


Same-day appointments for clinical services


Weekend or evening hours for clinical services


Adolescent-only hours or days for clinical services


Educational materials (written or video) specifically designed for adolescents


Educational materials (written or video) in languages that match the needs of your client base


Language translation services that match the needs of your client base







18.

In the past 3 months, about how often did your health center do the following, related to adolescent clients?



Never

Rarely

Occasionally

Frequently


Offered time alone with a provider for adolescents who come with a parent or guardian


Required parental consent, for adolescents seeking contraceptive services


Actively encouraged communication between adolescents and parents/guardians about sex and reproductive health


Actively promoted the availability of confidential services to adolescents



19.

Does your health center use the following technologies?

No

Yes:

Limited use

Yes: Routinely


Electronic health records



Electronic system for billing



Email, phone, or text messages to clients for appointment reminders


Email, phone, or text messages to clients for test results (e.g., STD)


Website that allows clients to make appointments online




20. In the past 12 months, did your health center use any of the following methods for community education? (Not exclusively related to fund-raising)


21. In the past 12 months, did your health center conduct community education in the following places or groups?


Yes

No



Yes

No

TV


Schools

Radio


Colleges or universities

Websites or social media (e.g. Facebook)


Other youth-serving groups

Billboards


Parent groups

Newspapers or magazines


Faith-based organizations

Community events


Other health care services

Small group education (1 session)


Community health fairs

Small group education (2+ sessions with same group)


Other social service organizations





V.

Quality improvement


22.

How often does your health center formally review the following aspects of service delivery, to monitor the quality of family planning services? (They could be measured in various ways.)



Monthly or Quarterly

Annually

Every 2-3 years

As needed

Other frequency

Never/ not currently reviewed


Availability of contraceptive methods


Access to services


Clinic efficiency


Client satisfaction


Cultural competency


Referrals and/or care coordination


Contraceptive use


Cost of providing services


Unintended pregnancy


Birth spacing



23.

In the past 12 months, has your health center modified any clinical practices or other aspects of the health center, in response to a review of quality improvement data? Please note this question does not relate to any modification, but only those implemented in response to your center’s review of quality improvement data.



Yes

No


If yes, please briefly describe

what aspect of service delivery was changed:

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VI.

Referral Arrangements and Staff Training

24.

What kinds of partnerships does your health center have with providers who offer the following contraceptive methods and other services? (In each column, select all that apply.)



We offer this

on site

Co-located with those who do, or our parent organization provides this

Contract, or other written agreement

Informal relationships with provider(s) who do this

Referral only


Female sterilization


Male sterilization


IUD insertion/removal


Implant insertion/removal


Natural family planning









HIV treatment


Prenatal care


Primary care


Infertility treatment



25.

Please indicate whether all, some, or none of the health center’s staff have received training in the following areas:

Trained in past 2 years: All relevant staff

All staff

Some staff

No staff


Contraceptive counseling


Serving male clients

Ever trained: Clinical staff only





Inserting and removing copper IUD


Inserting and removing hormonal IUD


Inserting and removing contraceptive implants



Thank you for your time!

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Please add any additional comments here:





















Please mail the completed survey back or complete it online at:

<http://XXXXXinsert here >



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