Form 0920-0952 Attachment 4 (electronic)

Form Approved
OMB No. 0920-0952
Exp. 12/31/2015

Community and Clinical Partner
Clinical Partner Needs Assessment

Public reporting burden of this collection of information is estimated to average 60 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

ID: _____

Clinical Partner Needs Assessment (CPNA)
Reducing Teen Pregnancy: Integrating Services, Programs, and Strategies
through Community-wide Initiatives

The purpose of this assessment is to help your organization identify current services, as well as areas of potential
growth, related to the provision of health care services to support adolescent reproductive health. Information
gathered through this assessment will be used to track health center progress in improving youth access to
contraceptive and reproductive health services.
Please complete this ASSESSMENT on the provision of health care services for adolescents at your health center.
Please note that for the purposes of this ASSESSMENT, the term “adolescents” refers to all young women and men
between the ages of 12-19 years.

SECTION I: CLINICAL PROVIDER PROFILE – GENERAL INFORMATION
1. Please provide the following information for your health center.
Health center Name:
Mailing Address:
City:
State:
Zip Code:
Phone:
Fax:
E-mail:
2. Please provide contact information for yourself (Contact 1), as well as other “key contacts” at your
health center who have responsibilities for managing or overseeing health center practices, policies,
and procedures.
Contact 1

Contact 2

Contact 3

Contact 4

First Name:
Last Name:
Title/Position:

Phone:
Fax:
E-mail:

2

3. Which of the following best describes the health center? Check all that apply.
Family practice
Pediatric practice (age range:
Adolescent clinic (age range:

City health department
)
)

Community health center
Community college

Obstetrics and gynecology only

Four-year college

Publicly funded family planning

School-based health center

Hospital-based ambulatory care (teaching)
Hospital-based ambulatory care (nonteaching)

School-linked health center

Mobile clinic

Foster care

State health department
County health department

Substance abuse treatment center

Job Corps

Other (specify:

)

4. Which of the following best describes the service area for the health center? Check all that apply.
Urban
Suburban
Rural
Other (specify:

)

5. Please answer the following questions about your health center by checking the appropriate box.
Does the health center…
Provide reproductive/sexual health care services to
adolescent females?
Provide reproductive/sexual health care services to
adolescent males?

YES

NO

3

SECTION II: REFERRALS AND LINKAGES
6. Please indicate the number of existing formal and informal linkages 1 and new formal linkages
developed during this past year with each of the following types of organizations, providers,
programs, and/or institutions, for the purposes of linking at-risk adolescents to contraceptive and
reproductive health services.
Organization/Provider/ Program Type
A

Community-Based Organization (please
specify)________________

B
C
D
E
F
G
H
I
J
K
L

High School
Middle School
Community college
Four-year college
After School Program
Foster Care Program
GED Program
Juvenile Detention
Family practice
Pediatric practice
Community health center

Formal Linkages
Total
New

Informal Linkages
Total
New

M Mental health/Counseling Agency
N Other (specify:
)

1

By “formal linkages” we mean written agreements to work with these providers or organizations to
enhance access to contraceptive or reproductive health services that your health center provides; by
“informal linkages” we mean no written agreement exists.

4

7. Please indicate the number of formal and informal linkages you have developed with each of the
following types of organizations, providers, and/or programs for the purposes of referring youth to
care and social support for services not provided by your agency.
Organization/Provider/ Program Type

Formal Linkages
Total
New

A

Community-Based Organization (please
specify)________________

B
C
D
E
F
G
H
I

Substance Abuse
Mental Health
Intimate Partner Violence
After School Program
Foster Care Program
GED Program
Family Medicine or Pediatric Practice
Other (specify:
 )

Informal Linkages
Total
New

8. Please indicate the types of materials and strategies used to increase awareness of health center
services, and which of these are tailored specifically for adolescents, by checking the appropriate box.
Available
Type of Material/Strategy
YES
A
B
C
D
E
F
G
H
I

NO

Tailored
Specifically for
Adolescents
YES

Number of Youth who
indicate this as source of
referral (if available)

NO

Referral Guide
Website
Hotline or Informational Call
Center
Health Center Brochure
Flyer
Community
Outreach/Education
Social Media (e.g., Twitter,
Facebook, etc.)
Referral network for services
not offered by health center
Other (specify:
)

5

SECTION III: HEALTH INSURANCE BILLING PRACTICES AND REVENUE
The following tables ask about billing practices for adolescent patients between the ages of 12-19
years.
9a. Please indicate both the percentage of revenue the health center receives for adolescent visits by
source and the number of visits per revenue source. If none, then enter “0” for the item. Please note
that by “visits” we mean any clinic visit where an adolescent is seen by a health care team member –
not only visits where contraceptive or reproductive health services are provided.
% of
Number Source of Revenue
Revenue of Visits
Medicaid Fee for Service
Medicaid Family Planning Waiver
Medicaid Managed Care
Commercial Insurance
Sliding Fee Scale (Patient pays for a portion of the charges out-of-pocket)
Full Pay (Patient pays for the full cost of service out-of-pocket)
No pay (services are covered by grants, e.g., Title X, Title V, 330, Private
Foundation, etc.)
Uninsured (health center absorbs costs of services)
Other [Please describe:
]
9b. Please indicate both the percentage of revenue by source the health center receives for
adolescent visits at which contraceptive or reproductive health services are provided, and the number
of visits at which contraceptive or reproductive health services are provided per revenue source. If
none, then enter “0” for the item.
% of Revenue

Number of
Contraceptive/Repro
ductive Health Visits

Source of Revenue
Medicaid Fee for Service
Medicaid Family Planning Waiver
Medicaid Managed Care
Commercial Insurance
Sliding Fee Scale (Patient pays for a portion of the charges
out-of-pocket)
Full Pay (Patient pays for the full cost of service out-of-pocket)
No pay (services are covered by grants, e.g., Title X, Title V,
330, Private Foundation, etc.)
Uninsured (health center absorbs costs of services)
Other [Please describe:
]

6

SECTION IV: STAFF TRAINING

10. Please indicate the number and percentage of ALL health center staff (e.g., all clinical and nonclinical staff that have direct contact with adolescent clients) that have received training in the
following areas in the past two years.

A
B
C
D
E
F
G
H
I

In the past two years, staff received training
on…
Stages of Adolescent Development
State- specific Minors' Rights to Consent and
Confidentiality laws or provisions
State-specific laws related to Immigrant
Minors’ Rights to Confidentiality (as relevant)
State-specific sexual abuse and reporting laws
Cultural Competency
Continuous Quality Improvement
Youth Friendly Services
Strategies for serving non-English speaking
populations (includes interpreter)
Addressing the needs of Lesbian, Gay, Bisexual,
Transgender ,and Queer (LGBTQ) Youth

Number of
Staff

Percentage of
all staff

11. Please indicate the number and percentage of the clinical staff (e.g., MDs, advance practice
clinicians, nurse-extenders) that have been trained in the following areas in the past two years.

A
B

In the past two years, clinical staff received
training on…
Contraceptive Services for Adolescents

C

Use of the Quick Start method for initiation of
hormonal contraception
Use of Quick Start method for initiation of IUD

D

IUDs for Adolescents

E

Hormonal Implants

F

Emergency Contraception

G

Pap Smear Guidelines

H

Breast Exam Guidelines

I

Conducting a sexual health assessment/history
for an adolescent
STI testing for adolescents
HIV testing for adolescents
Male sexual and reproductive health services
Continuous Quality Improvement
Youth Friendly Services
Adolescent development

J
K
L
M
N
O

Number

Percentage of
clinical staff

7

P
Q

In the past two years, clinical staff received
training on…
Addressing the needs of Lesbian, Gay, Bisexual,
Transgender ,and Queer (LGBTQ) Youth
Social determinants of health

Number

Percentage of
clinical staff

SECTION V: IMPLEMENTATION OF EVIDENCE-BASED REPRODUCTIVE HEALTH PRACTICES
12. Please answer the following questions about your health center by checking the appropriate box.
A
B
C
D
E
F
G

YES

Are the following services available on-site at your health center?

NO

Pregnancy testing
Chlamydia screening for all adolescent females at least annually, or
based on diagnostic criteria, consistent with USPSTF and CDC
recommendations
Chlamydia screening for adolescent females utilizing a urine or vaginal
swab specimen
Chlamydia screening for adolescent males utilizing a urine specimen
Gonorrhea screening for both adolescent females and males
Expedited patient delivered partner therapy (EPT) as an option for the
treatment of uncomplicated chlamydial infection
HIV rapid testing for adolescent females and males

13. Please answer the following questions about your health center by checking the appropriate box.

A
B
C
D
E
F
G
H
I

Does the health center provide the following forms of
contraception (via prescriptions and/or dispense on-site)
to adolescents?
Emergency contraception for females
Emergency contraception for males
IUDs
Hormonal Implants (Implanon)
Hormonal Contraceptive Pills
Hormonal Injection (Depo-provera)
Patch
Ring
Condoms

Prescriptions
YES

NO

Dispense On-site
YES

NO

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14. Please indicate if the health center performs the following activities by checking the appropriate
box.

A
B
C
D
E
F
G
H
I
J
K

How often does your health center…
Offer adolescents the availability of hormonal contraception or IUD
at every visit that the adolescent makes to the clinical provider?
Offer adolescents the option of initiating hormonal contraception
using the Quick Start method (starting birth control the day of the
visit)?
Offer Quick Start initiation of hormonal contraception after an
adolescent client has a negative pregnancy test?
Offer Quick Start initiation of hormonal contraception when an
adolescent client is provided with Emergency Contraception where
the pregnancy test is negative?
Offer adolescents the option of having an IUD inserted using the
Quick Start method?
Provide Emergency Contraception (EC) to female adolescents for
future use (advance provision)?
Provide Emergency Contraception to male adolescents?
Provide adolescents with time alone with a health care provider at
every visit?
Take or update a reproductive/sexual health history or assessment
at every visit?
Follow current guidelines for Pap screening (routine Pap screening
begins at age 21 or 3 years after initiation of sexual intercourse)?
Offer “fast track” or streamlined visits with limited waiting time that
includes access to hormonal contraception for adolescents?

YES

NO

15. Which of the following services does the health center require an adolescent patient to receive
prior to prescribing or dispensing hormonal contraception?
A
B
C
D
E
F
G

Service is required prior to dispensing hormonal contraception
Pap Smear
Pelvic Exam
Breast Exam
STD Testing
HIV Testing
Blood Pressure
Weight

YES

NO

9

SECTION VI: ACCESSIBILITY OF SERVICES FOR ADOLESCENTS
16. Please answer the following questions about your health center by checking the appropriate box.

A
B
C
D
E

Does the health center…

YES

NO

Require adolescent clients to make an appointment to access care?
Offer same day appointments for adolescent clients?
Offer appointments after school hours?
Offer appointments during the weekend?
Accept adolescent clients who walk-in for service?

17. Please answer the following questions about your health center by checking the appropriate box.

A
B
C

Is the health center…
Easily accessible by public transportation (within 1 mile of a bus stop,
subway stop, etc.)?
Within close proximity (within 1-2 miles) of places where adolescents
spend their free time?

YES

NO

Less than 10 miles from area schools?

18. Please answer the following questions about your health center by checking the appropriate box.

A
B
C
D
E

Does the health center…
Involve adolescents in designing services to provide reproductive
health care to adolescents?
Involve adolescents in evaluating services to provide reproductive
health care to adolescents?
Clearly display its hours and services?
Produce flyers or pamphlets that advertise its services for
adolescents?
Advertise its services within the target community (e.g., through radio,
local print media, etc.)?

F

Use the Internet (including social media) for education, appointment
reminders, and/or communication with clients?

G

Offer low or no cost contraceptive and reproductive health care
services?

H

See adolescents for confidential reproductive health services without
parental/caregiver consent?

I

Use materials that address the needs of lesbian, gay, bisexual,
transgender, and queer (LGBTQ) adolescents?

J

Use materials that address the needs of non-English speaking
adolescents?

YES

NO

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SECTION VII: HEALTH CENTER ENVIRONMENT
This section collects information that describes the physical health center environment along with the
use and application of evidence-based clinic practices.
19. Please answer the following questions about the health center environment.

A

Does the health center…
Have a separate space/area to provide services for adolescent clients?

B

Have a separate waiting room for adolescent clients?

C

Have a counseling area specifically for adolescent clients that provides
both visual and auditory privacy?
Have an examination room specifically for adolescent clients that
provides visual and auditory privacy?
Have teen-focused magazines or posters on the walls?

D
E
F
G
H
I

YES

NO

Display information (pamphlets, posters, flyers, fact sheets) about an
adolescent’s ability to access confidential contraceptive and reproductive
health care without parental or caregiver consent?
Provide videos or TV programs showing health related information?
(Please specify:
)
Provide brief evidence-based or evidence-informed video Interventions
designed for adolescents (e.g. “What Could You Do?”)?
(Please specify:
)
Provide other evidence-based interventions designed for adolescents?
(Please specify:
)

11

SECTION VIII: HEALTH CARE CENTER INFRASTRUCTURE
This section collects information about the health center infrastructure in place to support the provision
of adolescent contraceptive and reproductive health services.
20. Please answer the following questions about your health center by checking the appropriate box.
Does the health center…

YES

A

Participate in the federal 340B drug discount purchasing program?

B

Have a pharmacy on-site that dispense hormonal contraception?

C

Have access to the Internet for all staff?
Have systems in place to facilitate billing third party payers for
contraceptive and reproductive health care services provided?

D

NO

21. Which Electronic Medical Records (EMR) system(s) does your health center use? Check all that
apply.
eClinical Works (eCW)
Centricity
Epic
NextGen
Other (specify:
None

)

22. Please answer the following question about your health center by checking the appropriate box.
Does the health center…

YES

NO

Have staff especially trained and dedicated to quality improvement
initiatives?
23. Please answer the following question about your health center by checking the appropriate box.
Where indicated, please list the measures used.
Does the health center…
Have a set of performance measures that are collected on a regular
basis (e.g., quarterly, monthly) for monitoring the utilization of health
care services for adolescents?
Please list measures used:

YES

NO

Have a set of performance measures that are collected on a regular
basis (e.g., quarterly, monthly) for monitoring the delivery of
12

Does the health center…
contraceptive, reproductive, or sexual health services for adolescents?

YES

NO

Please list measures used:

24. Please indicate your health center’s experience using the following performance improvement or
continuous quality improvement methods to plan, monitor, and evaluate health care delivery
systems. Check all that apply.
Continuous Quality Improvement (CQI) Method
A
B
C
D
E
F
G

IHI Model for Improvement including Plan Do Study Act (PDSA)
Run Collaboratives
Clinical Quality Improvement Initiatives (specify/describe initiatives:
Performance Measures
Using Data for Program Planning, Monitoring, and Evaluation (Data Dashboard)
Other (specify:
None that I am aware of

)

)

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SECTION IX: USE OF HEALTH CARE SERVICES BY ADOLESCENTS
NOTE: The following data may be collected via billing records, EMRs, and other methods. We are open
to suggestions for other data collection methods based on your familiarity with your health center
partners and your ability to collect data from your partners. It is recommended that you collect these
data for each month.
Please note that by “visits” we mean any visit where an adolescent is seen by a health care team
member – not only visits designated as reproductive/sexual health visits.
Please note that by “adolescent visits where contraceptive, reproductive, or sexual health services are
provided” we mean any health center visit where contraceptive, reproductive, or sexual health services
are provided to the adolescent patient, regardless of the primary reason for the visit.
25. Please complete the following tables (or use the attached Microsoft Excel worksheets).Complete
Table 1 for FEMALE adolescents and Table 2 for MALE adolescents.
Table 1. FEMALE Adolescent Clients (Unduplicated) and Visits by Race/Ethnicity and Age Group.
# Adolescent Clients
(Unduplicated)

FEMALES

# Adolescent Visits

2

# Adolescent Visits at which
Contraceptive, Reproductive, or
Sexual Health Services are
3
Provided

4

Hispanic/Latina – All Races
12-14 years
15-17 years
18-19 years
Total
Black or African American (Non-Hispanic)
12-14 years
15-17 years
18-19 years
Total
White (Non-Hispanic)
12-14 years
15-17 years
18-19 years
Total
Other (Non-Hispanic)
12-14 years
15-17 years
18-19 years
Total
Unknown Race and Ethnicity

2

Any visit where an adolescent is seen by a healthcare team member – not only visits designated as reproductive/sexual health visits.
Includes any health center visit where contraceptive , reproductive, or sexual health services are provided to the adolescent patient,
regardless of the primary reason for the visit.
4
Count data for all clients that indicated Hispanic/Latino(a) ethnicity, regardless of race
3

14

FEMALES

# Adolescent Clients
(Unduplicated)

# Adolescent Visits

2

# Adolescent Visits at which
Contraceptive, Reproductive, or
Sexual Health Services are
3
Provided

12-14 years
15-17 years
18-19 years
Total
All Races and Ethnicities
12-14 years
15-17 years
18-19 years
Total

15

Table 2. MALE Adolescent Clients (Unduplicated) and Visits by Race/Ethnicity, Age Group.

# Adolescent Clients
(Unduplicated)

MALES

Hispanic/Latino – All Races

# Adolescent Visits

5

# Adolescent Visits at which
Contraceptive, Reproductive or
Sexual Health Services are
6
Provided

7

12-14 years
15-17 years
18-19 years
Total
Black or African American (Non-Hispanic)
12-14 years
15-17 years
18-19 years
Total
White (Non-Hispanic)
12-14 years
15-17 years
18-19 years
Total
Other (Non-Hispanic)
12-14 years
15-17 years
18-19 years
Total
Unknown Race and Ethnicity
12-14 years
15-17 years
18-19 years
Total
All Races and Ethnicities
12-14 years
15-17 years
18-19 years
Total

5

Any visit where an adolescent is seen by a healthcare team member – not only visits designated as reproductive/sexual health visits.
Includes any health center visit where contraceptive, reproductive, or sexual health services are provided to the adolescent patient, regardless
of the primary reason for the visit.
7
Count data for all clients that indicated Hispanic/Latino(a) ethnicity, regardless of race
6

16

25a. Please specify the data source used to complete Tables 1 and 2 above. (Potential data sources:
Billing, pharmacy management, electronic medical records (EMR), or other administrative and/or
reporting databases.)

SECTION X: USE OF HORMONAL CONTRACEPTION AND IUD BY ADOLESCENTS
26. Please complete the following tables (or use the attached Microsoft Excel worksheets).
Table 3. FEMALE Adolescent Clients (Unduplicated) and Number Provided Hormonal Contraception or
IUD, by Age Group
FEMALES
All Unduplicated Clients (Total)
12-14 years
15-17 years
18-19 years
Total
8
Provided Hormonal Contraception (not including IUDs or Implants)
12-14 years
15-17 years
18-19 years
Total
Provided the Pill
12-14 years
15-17 years
18-19 years
Total
Provided Injectable Contraception (e.g., Depo Provera)
12-14 years
15-17 years
18-19 years
Total
Provided IUD
12-14 years
15-17 years
18-19 years
Total
Provided Contraceptive Implants (e.g., Implanon)
12-14 years

8

# Adolescent Clients (Unduplicated)

Hormonal contraception here includes the pill, patch, ring, and injectable contraception

17

15-17 years
18-19 years
Total
9
Provided Emergency Contraception (EC)
12-14 years
15-17 years
18-19 years
Total

Table 4. FEMALE Adolescent Clients (Unduplicated) and Number Provided Hormonal Contraception or
IUD, by Race/Ethnicity
FEMALES
All Unduplicated Clients (Total)
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
10
Provided Hormonal Contraception (not including IUDs or
Implants)
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
Provided the Pill
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
Provided Injectable Contraception (e.g., Depo Provera)
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
9

# Adolescent Clients (Unduplicated)

Including the provision of EC as a backup method along with another contraceptive method
Hormonal contraception here includes the pill, patch, ring, and injectable contraception

10

18

Provided IUD
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
Provided Contraceptive Implants (e.g., Implanon)
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
11
Provided Emergency Contraception (EC)
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total

26a. Please specify the data source used to complete Tables 3 and 4 above. (Potential data sources:
Billing, pharmacy management, electronic medical records (EMR), or other administrative and/or
reporting databases.)

Save File as

11

Submit Form

Including the provision of EC as a backup method along with another contraceptive method

19