Form CMS-10485 MAPCP Provider Survey

Attachment D1: MAPCP Provider Survey

The Multi-payer Advanced Primary Care Practice Demonstration Provider Survey

Sponsored by:

U.S. Department of Health and Human Services,

Centers for Medicare & Medicaid Services

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Public Burden Statement: According to the Paperwork Reduction Act of 1995, a federal agency may not conduct, and a person is not required to respond to, an information collection request unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is [XXXX-XXXX]. The time required to complete this information collection is estimated to average 12 minutes per respondent, including the time to review instructions and complete and review the information collection. If you have comments concerning the accuracy of this burden estimate or any suggestions for reducing this burden, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1850.

OMB No.: [xxxx-xxxx]

Expires: [3 yrs from OMB approval date]

You can close this web survey and return to it at any time using your Respondent ID#, which acts as your password for this survey.

Your Respondent ID is: [#######]

Please write this number down in case you need to return to your survey.

Clicking “Next” on each page of this survey automatically saves your responses.

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Your Participation in this Survey

This survey is being fielded among all health care providers participating in the Centers for Medicare and Medicaid Services’ Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration, which includes providers participating in [state]’s [state-specific name of MAPCP demonstration].

This survey is designed to measure the extent to which the practice you work for engages in activities associated with the patient-centered medical home model of care.

There is no “passing grade” for this voluntary survey, nor will your responses have any consequences for payment. We are genuinely interested in your candid observations of the way your practice operates today.

Your responses will be linked to claims data using an encrypted identifier, and analyzed by researchers (at RTI International, The Urban Institute, and the National Academy for State Health Policy) contracted to evaluate this demonstration.  Researchers will report the results of this survey and their analyses in reports to CMS that will be made available to other federal agencies, state governments, and the general public in a non-identifiable, aggregated form.

We estimate that this survey will take 12 minutes to complete.

If you are willing to participate in this research, please complete this survey by [insert date that is 4.5 months after OMB approves this survey].

If you have difficulty or questions when completing this survey, please contact Stephen Zuckerman at [email protected] or 202-261-5679.

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The Questions in this Survey

This survey asks about how your practice currently manages your patients’ health needs. The questions are organized into two sections:

Section A: Practice Functions asks you to identify your practice’s care processes and approach to managing change and improving quality.

Section B: Provider Characteristics asks about your patient panel size, how long you’ve been with your practice, and basic demographic information.

Please complete all questions in the survey to the best of your knowledge. If your practice has multiple physical locations, please respond based on the practice site that is participating in [state]’s [state-specific name of MAPCP Demonstration initiative]. For practices with more than one physical location participating in [state]’s [state-specific name of MAPCP Demonstration], we will contact each location to complete the survey.

All medical doctors, doctors of osteopathy, nurse practitioners, and/or physician’s assistants in your practice have been asked to complete this survey. Input can be requested from other staff in the practice as needed but please complete as much of the survey as you can from your perspective.

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Appointment systems

…are limited to pre-scheduled appointments. 1 2 3

…have pre-scheduled appointments and the ability to schedule urgent visits. 4 5 6

… have pre-scheduled appointments, the ability to schedule urgent visits; and the capacity for walk-ins or same-day visits. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Respond to urgent problems

Clinician/practice team responds to urgent problems as time permits, and otherwise directs patients to the emergency department or urgent care centers. 1 2 3

Clinician/practice team has a system in place to triage patient problems, through phone or email communications or face-to-face visits, but with limited availability for same-day appointments. 4 5 6

Clinician/practice team has a system in place to triage patient problems though phone or email communications or face-to-face visits, with same-day appointments usually available. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

After-hours access (24 hours, 7 days a week) to practice team for urgent care

…is not available after-hours during evenings and/or weekends. Practice does not actively coordinate emergency department care nor does it follow-up with patients after visits to the emergency department. 1 2 3

…is available by phone for urgent care. 4 5 6

…is available by phone for urgent care, and in-person during some evenings and/or weekends. The practice actively participates in coordinating emergency department care, and follows-up with patients after visits to the emergency department. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Alternate types of contact (email, web-portal, text-message) with the practice team

…are not regularly available. 1 2 3

… are available but not encouraged, or selectively available, and responses are not provided within a timely and consistent timeframe. 4 5 6

… are a core component of patient-practice team communication, and responses are provided within a timely and consistent timeframe. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Patient-clinician continuity

For ambulatory/outpatient care, patients are not assigned to a specific clinician and care team. 1 2 3

For ambulatory/outpatient care, patients are assigned to a specific clinician and care team, and are encouraged to seek care from this designated clinician and practice team. There is limited practice involvement with patients’ care during hospital and post-acute care facility stays. 4 5 6

For ambulatory/outpatient care, patients are assigned to a specific clinician and care team, and are encouraged to seek care from this designated clinician and practice team. The practice monitors patients’ care during hospital and post-acute facility stays, and is involved as needed. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Registries (integrated in the EHR or free-standing)

…are not used by practice teams for pre-visit planning, reminders to providers, patient outreach, or population health monitoring. 1 2 3

…are used by practice teams for pre-visit planning, reminders to providers, patient outreach, or population health monitoring but only for a limited number of conditions and high risk patients. 4 5 6

…are available to practice teams and routinely used for pre-visit planning, reminders to providers, and patient outreach, and population health monitoring across a comprehensive set of diseases and high risk patients. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Visit focus

…is organized around the specific reason for a patient’s visit. 1 2 3

…is organized around the specific reason for a patient’s visit, but sometimes with attention to ongoing chronic care and prevention needs if time permits. 4 5 6

…is organized around the specific reason for a patient’s visit, but with consistent attention to ongoing chronic care and prevention needs (e.g., through the use of EHR care alerts). 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Medication review for patients on multiple medications

…is not routinely done. 1 2 3

…is done only during care transitions or when patients receive new medications. 4 5 6

...is done on a regular basis for patients during care transitions, when patients receive new medications and during all regularly-scheduled visits. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Care plans* for patients with chronic conditions

…are not routinely developed or recorded in patient medical records. 1 2 3

… are developed collaboratively with patients and families, and include self-management and clinical goals, but they are not routinely recorded in patient medical records nor used to guide subsequent care. 4 5 6

…are developed collaboratively with patients and families, recorded in patient medical records, include self-management and clinical goals, are used to guide ongoing care, and are given to the patient and family to support their care. 7 8 9

* A “care plan” summarizes a patient’s treatment goals and treatment plan, and identifies the responsibilities of each of the various health care providers involved in the patient’s care. A care plan is developed in collaboration with patients/families, and is based on a patient health risk assessment.

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Clinical care management for complex patients

…is not done. 1 2 3

… involves assisting patients with educational resources and self-management, but does not involve the use of any care management services by the practice. 4 5 6

…is accomplished by identifying patients for whom care management might be beneficial. The practice actively coordinates care management with other providers and caregivers; and provides educational resources and ongoing support to assist with self-management. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Preventive services (e.g., cancer screenings)

…are delivered at visits specifically scheduled for this purpose. 1 2 3

…are delivered at visits specifically scheduled for this purpose. Practice staff also identify needed preventive services at other visits. 4 5 6

…are delivered at visits specifically scheduled for this purpose. Practice staff also identify needed preventive services at other visits. In addition, registries or other clinical decision support tools are used to identify patients who have not received recommended preventive services, and reminders are given to patients to schedule these. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Assessing patient and family values and preferences (e.g., preferences for last-stage-of-life care, role in clinical decision-making)

…is not done systematically. 1 2 3

…is done for only some patients with significant health problems or who articulate values and preferences themselves. The practice team incorporates these patients’ preferences and values into planning and organizing care. 4 5 6

…is systematically done for all patients with significant health problems or who articulate values and preferences themselves. The practice team incorporates patient preferences and values into planning and organizing care. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Involving patients and caregivers in health care decision-making

…is not a priority. 1 2 3

…is recognized as important but practice does not use any systematic approach (e.g., decision aids) to support patients. 4 5 6

… is a priority and systematically done. Patients are supported to consider the likely outcomes of treatment options through the use of clinical decision aids, motivational interviewing, and/or teach-back techniques. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Patient self-management support for chronic conditions

…is accomplished by distributing information (e.g., pamphlets, booklets) or referring patients to self-management classes or educators. 1 2 3

…is provided through goal-setting and action planning with members of the practice team, with ad hoc ongoing support from other providers as needed. 4 5 6

…is provided through goal-setting and action planning with members of the practice team trained in patient education, empowerment and problem-solving methodologies. Ongoing support is available through individualized care or group interventions. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Tracking and follow-up with patients for important referrals

…is not generally done. 1 2 3

…is sometimes done. 4 5 6

…is consistently done. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Tracking and follow-up with patients about test results

…is not generally done. 1 2 3

…is done for some test results. 4 5 6

…is consistently done for all tests. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Relationships with commonly referred-to practices (i.e. cardiology, OB/GYN)

…are not formalized with practice agreements and referral protocols. 1 2 3

…are established through verbal understanding with some practices. 4 5 6

…are formalized with practice agreements and referral protocols. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Patient referral information to specialists, hospitals, and other medical care providers

…is transmitted by the patient. 1 2 3

…is usually transmitted by the practice, but referrals do not always contain reason for referral, relevant clinical information or other core patient information. 4 5 6

…is consistently transmitted by the practice. Referrals contain reason for referral, clinical information relevant to the referral (e.g., test results, medical history), and core patient information (e.g., medications, allergies). 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Patients in need of behavioral health support or community-based resources (e.g., social services)

…are only provided names of some organizations for patients to contact on their own. 1 2 3

…are referred to partners with whom the practice has established relationships and relevant patient information is communicated to these organizations. 4 5 6

…are referred to partners with whom the practice has established relationships, relevant patient information is communicated to them, and timely follow-up with patients occurs where necessary. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Follow-up with patients seen in the Emergency Department (ED) or hospital

…occurs only if ED, hospital, patient, or caregiver alerts the practice. 1 2 3

…generally occurs on an ad hoc basis. Practice has agreements with the hospitals and facilities patients most commonly use to alert them when their patients are seen there. 4 5 6

…is done routinely after receiving notification from the ED or hospital. Practice has agreements in place with the hospitals and facilities patients most commonly use. Practice tracks patients and follows up with them either by visit, phone or other forms of communication within a short and specified timeframe. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Electronic health records

…are not used. 1 2 3

…are used for basic functions such as documenting services rendered, using computerized provider order entry, printing information for patients, and e-prescribing. 4 5 6

…are used for basic functions plus more advanced functions such as clinical decision support (e.g., medication guides/ alerts, preventive services alerts, clinical guidelines) and generating quality measure data for quality improvement purposes. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Quality improvement activities

…are not organized or supported consistently. 1 2 3

…are conducted in reaction to specific problems and do not use systematic quality improvement approaches. 4 5 6

…are based on systematic quality improvement approaches (e.g., Plan-Do-Study-Act cycles, or tracking performance on quality measures) and are used in meeting organizational goals. 7 8 9

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General Instructions. Please select the point value that best describes the level of advanced primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented. Assign lower point values if some, but not all, of the actions described in that box have been implemented.

Feedback to the practice from patients and their families

…is not collected. 1 2 3

…is noted and incorporated into practice activities, but not in a systematic way. 4 5 6

…is regularly collected through a formal approach (e.g., patient survey, focus group), and through specific patients’ concerns, and is incorporated into practice improvements. 7 8 9

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What is the total number of different patients you, as a clinician, have in your patient panel, regardless of type of insurance coverage? Your best estimate is fine.

| | , | | | | total number of patients in your patient panel

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How many patient visits do you have in an average week, regardless of type of insurance coverage? Your best estimate is fine.

| | | | NUMBER OF PATIENTS PER WEEK

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Don’t know / Prefer not to say

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Which response best reflects how you are compensated for work performed at your primary practice location?

□ Salary only

□ Productivity incentives only

□ Salary with productivity incentives

□ Salary with quality incentives

□ Salary with both quality and productivity incentives

□ Capitation

□ Other

(specify)_____________________________________

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Don’t know / Prefer not to say

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If you reported using any productivity incentives in the previous question, which productivity measures does your practice use in calculating incentives? CHECK ALL THAT APPLY

□ Cash collections

□ Relative Value Units (RVUs)

□ Number of visits

□ Other

Specify:_______________________________

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Don’t know / Prefer not to say

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What is your gender?

□ Male

□ Female

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Are you of Hispanic or Latino origin?

□ Yes

□ No

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What is your race?

□ White

□ Black / African American

□ Asian

□ Native Hawaiian / Other Pacific Islander

□ American Indian / Alaska Native

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How long have you been with the practice?

□ Less than 1 year

□ Between 1 and 5 years

□ Between 5 and 10 years

□ More than 10 years

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In a typical week, how many hours are you scheduled to work at the practice?

□ Less than 20 hours

□ 20 to 29 hours

□ 30 to 39 hours

□ 40 to 49 hours

□ 50 hours or more

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Don’t know / Prefer not to say

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Thank you for completing this survey.