Att 4 Clincal Partner Needs Assessment.Revised

Form Approved

OMB No. 0920-xxxx

Exp. xx/xx/xxxx

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).

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:

3. Which of the following best describes the health center? Check all that apply.

	Family practice		City health department
	Pediatric practice (age range: )		Community health center
	Adolescent clinic (age range: )		Community college
	Obstetrics and gynecology only		Four-year college
	Publicly funded family planning		School-based health center
	Hospital-based ambulatory care (teaching)		School-linked health center
	Hospital-based ambulatory care (non-teaching)		Job Corps
	Mobile clinic		Foster care
	State health department		Substance abuse treatment center
	County health department
			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…	YES	NO
Provide reproductive/sexual health care services to adolescent females?
Provide reproductive/sexual health care services to adolescent males?

SECTION II: REFERRALS AND LINKAGES

6. Please indicate the number of existing formal and informal linkages¹ 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	Formal Linkages		Informal Linkages
		Total	New	Total	New
A	Community-Based Organization (please specify)________________
B	High School
C	Middle School
D	Community college
E	Four-year college
F	After School Program
G	Foster Care Program
H	GED Program
I	Juvenile Detention
J	Family practice
K	Pediatric practice
L	Community health center
M	Mental health/Counseling Agency
N	Other (specify: )

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		Informal Linkages
		Total	New	Total	New
A	Community-Based Organization (please specify)________________
B	Substance Abuse
C	Mental Health
D	Intimate Partner Violence
E	After School Program
F	Foster Care Program
G	GED Program
H	Family Medicine or Pediatric Practice
I	Other (specify: )

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.

	Type of Material/Strategy	Available		Tailored Specifically for Adolescents		Number of Youth who indicate this as source of referral (if available)
		YES	NO	YES	NO
A	Referral Guide
B	Website
C	Hotline or Informational Call Center
D	Health Center Brochure
E	Flyer
F	Community Outreach/Education
G	Social Media (e.g., Twitter, Facebook, etc.)
H	Referral network for services not offered by health center
I	Other (specify: )

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 Revenue	Number of 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: ]

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/Reproductive 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: ]

SECTION IV: STAFF TRAINING

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

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

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.

	In the past two years, clinical staff received training on…	Number	Percentage of clinical staff
A	Contraceptive Services for Adolescents
B	Use of the Quick Start method for initiation of hormonal contraception
C	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
J	STI testing for adolescents
K	HIV testing for adolescents
L	Male sexual and reproductive health services
M	Continuous Quality Improvement
N	Youth Friendly Services
O	Adolescent development
P	Addressing the needs of Lesbian, Gay, Bisexual, Transgender ,and Queer (LGBTQ) Youth
Q	Social determinants of health

Section V: Implementation of Evidence-Based Reproductive Health Practices

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

	Are the following services available on-site at your health center?	YES	NO
A	Pregnancy testing
B	Chlamydia screening for all adolescent females at least annually, or based on diagnostic criteria, consistent with USPSTF and CDC recommendations
C	Chlamydia screening for adolescent females utilizing a urine or vaginal swab specimen
D	Chlamydia screening for adolescent males utilizing a urine specimen
E	Gonorrhea screening for both adolescent females and males
F	Expedited patient delivered partner therapy (EPT) as an option for the treatment of uncomplicated chlamydial infection
G	HIV rapid testing for adolescent females and males

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

	Does the health center provide the following forms of contraception (via prescriptions and/or dispense on-site) to adolescents?	Prescriptions		Dispense On-site
		YES	NO	YES	NO
A	Emergency contraception for females
B	Emergency contraception for males
C	IUDs
D	Hormonal Implants (Implanon)
E	Hormonal Contraceptive Pills
F	Hormonal Injection (Depo-provera)
G	Patch
H	Ring
I	Condoms

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

	How often does your health center…	YES	NO
A	Offer adolescents the availability of hormonal contraception or IUD at every visit that the adolescent makes to the clinical provider?
B	Offer adolescents the option of initiating hormonal contraception using the Quick Start method (starting birth control the day of the visit)?
C	Offer Quick Start initiation of hormonal contraception after an adolescent client has a negative pregnancy test?
D	Offer Quick Start initiation of hormonal contraception when an adolescent client is provided with Emergency Contraception where the pregnancy test is negative?
E	Offer adolescents the option of having an IUD inserted using the Quick Start method?
F	Provide Emergency Contraception (EC) to female adolescents for future use (advance provision)?
G	Provide Emergency Contraception to male adolescents?
H	Provide adolescents with time alone with a health care provider at every visit?
I	Take or update a reproductive/sexual health history or assessment at every visit?
J	Follow current guidelines for Pap screening (routine Pap screening begins at age 21 or 3 years after initiation of sexual intercourse)?
K	Offer “fast track” or streamlined visits with limited waiting time that includes access to hormonal contraception for adolescents?

15. Which of the following services does the health center require an adolescent patient to receive prior to prescribing or dispensing hormonal contraception?

	Service is required prior to dispensing hormonal contraception	YES	NO
A	Pap Smear
B	Pelvic Exam
C	Breast Exam
D	STD Testing
E	HIV Testing
F	Blood Pressure
G	Weight

SECTION VI: ACCESSIBILITY OF SERVICES FOR ADOLESCENTS

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

	Does the health center…	YES	NO
A	Require adolescent clients to make an appointment to access care?
B	Offer same day appointments for adolescent clients?
C	Offer appointments after school hours?
D	Offer appointments during the weekend?
E	Accept adolescent clients who walk-in for service?

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

	Is the health center…	YES	NO
A	Easily accessible by public transportation (within 1 mile of a bus stop, subway stop, etc.)?
B	Within close proximity (within 1-2 miles) of places where adolescents spend their free time?
C	Less than 10 miles from area schools?

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

	Does the health center…	YES	NO
A	Involve adolescents in designing services to provide reproductive health care to adolescents?
B	Involve adolescents in evaluating services to provide reproductive health care to adolescents?
C	Clearly display its hours and services?
D	Produce flyers or pamphlets that advertise its services for adolescents?
E	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?

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.

	Does the health center…	YES	NO
A	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?
D	Have an examination room specifically for adolescent clients that provides visual and auditory privacy?
E	Have teen-focused magazines or posters on the walls?
F	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?
G	Provide videos or TV programs showing health related information? (Please specify: )
H	Provide brief evidence-based or evidence-informed video Interventions designed for adolescents (e.g. “What Could You Do?”)? (Please specify: )
I	Provide other evidence-based interventions designed for adolescents? (Please specify: )

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	NO
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?
D	Have systems in place to facilitate billing third party payers for contraceptive and reproductive health care services provided?

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…	YES	NO
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:
Have a set of performance measures that are collected on a regular basis (e.g., quarterly, monthly) for monitoring the delivery of contraceptive, reproductive, or sexual health services for adolescents?
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		IHI Model for Improvement including Plan Do Study Act (PDSA)
B		Run Collaboratives
C		Clinical Quality Improvement Initiatives (specify/describe initiatives: )
D		Performance Measures
E		Using Data for Program Planning, Monitoring, and Evaluation (Data Dashboard)
F		Other (specify: )
G		None that I am aware of

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.

FEMALES	# Adolescent Clients (Unduplicated)	# Adolescent Visits2	# Adolescent Visits at which Contraceptive, Reproductive, or Sexual Health Services are Provided3
Hispanic/Latina – All Races4
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

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

MALES	# Adolescent Clients (Unduplicated)	# Adolescent Visits5	# Adolescent Visits at which Contraceptive, Reproductive or Sexual Health Services are Provided6
Hispanic/Latino – All Races7
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

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	# Adolescent Clients (Unduplicated)
All Unduplicated Clients (Total)
12-14 years
15-17 years
18-19 years
Total
Provided Hormonal Contraception8 (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
15-17 years
18-19 years
Total
Provided Emergency Contraception (EC)9
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	# Adolescent Clients (Unduplicated)
All Unduplicated Clients (Total)
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
Provided Hormonal Contraception10 (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
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
Provided Emergency Contraception (EC)11
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.)

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.

2 Any visit where an adolescent is seen by a healthcare team member – not only visits designated as reproductive/sexual health visits.

3 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

5 Any visit where an adolescent is seen by a healthcare team member – not only visits designated as reproductive/sexual health visits.

6 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

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

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

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

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

23