Grantee Key Staff- Web Survey

Primary and Behavioral Health Care Integration Program

0990-0371Attach 10 Web Survey.DOC

Grantee Key Staff- Web Survey

OMB: 0930-0340

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Download: doc | pdf

Form Approved

OMB No. 0990-0371

Exp. Date XX/XX/20XX


ATTACHMENT 10

Web Survey


Note: There will be appropriate skips so that only certain groups of individuals are asked certain groups of questions.


A. Your Role in PBHCI


1) Which of the following best describes your role in the PBHCI program?

Administrator (Group 1)

Program manager

Medical director

CFO

Evaluator

Data manager

Other administrator

GROUP 1 SKIPS TO B1

Mental health provider (Group 2)

Psychologist

Psychiatrist

Social worker

Case Manager

Other mental health provider

Primary care provider (Group 3)

Nurse practitioner

Physician Assistant

Supervising physician

RN or LPN

Other primary care provider

Care coordinator (Group 4)

Care coordinator


2) What is the average number of PBHCI clients you see in person per week?

1-5 clients

6-10

11-15

16-20

More than 20 clients

GROUPS 2, 3, 4 SKIP TO B3


B. Cooperation/collaboration across Mental Health (MH) and Primary Care (PC)


1) What is the collaborative service agreement between MH and PC?

No formal agreement

Informal, unwritten agreement

MOA/MOU

Letter of commitment

Other (Please specify:_________________________)


2) What are the components of the service agreement? (Check all that apply.)

Guidelines on how rapidly patients will be seen

Policies detailing communication between primary care and mental health (i.e. sharing of clinical information about patients in a timely fashion)

Policies detailing coordination between primary care and mental health (e.g., scheduling MH and PC visits on the same day, which group is responsible for providing certain services, etc.)

Specific instructions on the proper procedure for scheduling a PC consult

Other (Please specify:____________________________)


3) How often do MH and PC providers meet (in person or via phone)?

Three times or more per week

Twice per week

Once a week

Once every 2 weeks

Once a month

Less than once a month


4) Are there regularly scheduled team meetings?

Yes

No


5) How often is information shared between MH and PC providers?

Always

Often

Sometimes

Rarely

Never


6) Are there separate treatment plans for MH and PC, or is there a single integrated treatment plan?

Separate treatment plans

SKIP TO B8

Single, integrated treatment plan


7) To what extent do MH and PC providers work together in constructing the integrated treatment plan?

They do not work together in constructing treatment plans

A little collaboration on the plan

Some collaboration

Close collaboration

SKIP TO B9


8) How often do MH and PC consult with each other as they develop individual treatment plans?

Always

Often

Sometimes

Rarely

Never


9) How often do PC and MH providers work together on achieving specific goals (e.g., behavior change that impacts physical health)?

Always

Often

Sometimes

Rarely

Never


10) Are patient records integrated between MH and PC?

Yes

No


11) Regarding the appointment system, how often are appointments coordinated so that patients can see multiple providers in a single clinic visit?

Always

Often

Sometimes

Rarely

Never


12) Are walk-in appointments available?

Yes

No


13) Are regularly planned visits for integrated care utilized? (e.g., regular visits for PH care management, wellness, etc.)

Yes

No


GROUPS 2, 3, 4 SKIP TO C5


C. Structure


1) Which of the following best describes the distance between PC and MH service facilities?

PC and MH services are co-located in the same building

PC and MH services are located in different buildings in the same block or in the same office park

PC and MH services are located within a half (.5) mile of one another

PC and MH services are located within one (1) mile of one another

PC and MH services are located within five (5) miles of one another

PC and MH services are located greater than five (5) miles apart


2) Please indicate the number of each type of staff funded by the PCBHI program. (Do not count staff in more than 1 category.)

0 1 2 3 4 5+

Nurse practitioner or PA located in MH setting      

PC physicians located in MH setting      

Embedded NCM      

Other care manager      

Other PBHCI staff (Specify:____________)      


3) How many hours per week do staff spend in each of the various program areas?


0 1-5 6-10 11-15 16-20 21-30 31-40

Screening and referral

Nurse practitioner/PA located in MH

setting       

PC physician located in MH setting       

Embedded NCM       

Other care manager       

Other PBHCI staff (Specify:____________)       


Care management

Nurse practitioner/PA located in MH setting       

PC physician located in MH setting       

Embedded NCM       

Other care manager       

Other PBHCI staff (Specify:____________)       


Wellness/prevention/early intervention

Nurse practitioner/PA located in MH setting       

PC physician located in MH setting       

Embedded NCM       

Other care manager       

Other PBHCI staff (Specify:____________)       


Other PBHCI activity (Specify:________)

Nurse practitioner/PA located in MH setting       

PC physician located in MH setting       

Embedded NCM       

Other care manager       

Other PBHCI staff (Specify:____________)       


4) How much difficulty has the program had in recruiting appropriate PC staff?

No difficulty

Little difficulty

Moderate difficulty

Great difficulty


5) How much provider education/training in integrated care is provided?

No special training in integrated care is provided

SKIP TO C7

1-5 hours

6-10 hours

11-20 hours

21-30 hours

31-40 hours

more than 40 hours


6) How would you characterize the education/training for integrated care?

Didactic education only (i.e., instruction that is not hands-on)

Hands-on training only (i.e., on-the-job training)

Both didactic and hands-on


7) Is there ongoing supervision for integrated care activities?

Yes

No

GROUP 2 SKIP TO E1

GROUP 3 SKIP to C11

GROUP 4 SKIP TO D1


8) What kinds of providers are trained in integrated care? Check all that apply.

Psychiatrists

Psychotherapists

Case managers

Nurse care managers

PC physicians

Nurse practitioners/PAs

Other (Please specify:____________________)


9) To what extent have there been issues with staff turn-over?

No issues with staff turn-over

Staff turn-over is a minor issue

Staff turn-over is a major issue


10) What hours/days are various services available for patients? Check all that apply.


Mon Tues Wed Thurs Fri Sat Sun

Outpatient mental health services Day Day Day Day Day Day Day

Eve Eve Eve Eve Eve Eve Eve


Primary care services Day Day Day Day Day Day Day

Eve Eve Eve Eve Eve Eve Eve


Wellness/prevention services Day Day Day Day Day Day Day

Eve Eve Eve Eve Eve Eve Eve


Care management Day Day Day Day Day Day Day

Eve Eve Eve Eve Eve Eve Eve


Urgent care Day Day Day Day Day Day Day

Eve Eve Eve Eve Eve Eve Eve


Other (Specify:__________) Day Day Day Day Day Day Day

Eve Eve Eve Eve Eve Eve Eve


11. Have there been issues related to malpractice insurance?

Yes

No


D. Screening and referral


1. Which patients are screened for PH conditions? Choose all that apply.

ALL seriously mentally ill (SMI) patients on current caseload

Only new SMI patients who present for services

All SMI patients with certain known physical health conditions

All SMI patients receiving psychotropic medication

Other (Specify:_______________)


2. When are initial screenings provided?

When patients first enter the clinic

Within the first week after referral to PBHCI program

Within the first month after referral to the PBHCI program

No set time

At some other time (Specify:___________________)


3a. What PH screening tools do you use? Check all that apply.

Blood pressure

Height

Weight

Waist circumference

Carbon monoxide (breath CO)

Cholesterol (blood)

Glucose or A1C (blood)

Triglycerides (blood)

Other (Specify:________________)


3b. What MH screening tools do you use? Check all that apply.

LOCUS IV

Beck Depression Inventory

PHQ-9

PANAS

SF-36

BASIS-32

CESD

Other (Specify:________________)


3c. What SUD screening tools do you use? Check all that apply.

AUDIT

FTND

CAGE

DAST

ASSIST

DAP

Other (Specify:________________)



4. Does the practice have a system for managing receipt of information on tests and results?

Yes

No SKIP TO D6


5. How effective is the system in ensuring that information on tests and results is received on a timely basis?

Not effective

Somewhat effective

Moderately effective

Very effective


6. Is it possible to order and view lab test and imaging results electronically, with electronic alerts?

Yes

No


7. How often are referrals tracked, with follow-up?

Always

Often

Sometimes

Rarely

Never


8. For what proportion of clients is follow-up screening conducted at regular intervals?

None (0%)

1-25%

25-50%

51-75%

75-99%

All (100%)


9. How often are patients linked to outside resources (e.g., community organizations offering housing, legal services, etc.)?

Always

Often

Sometimes

Rarely

Never


E. Registry/tracking


1. Is there a clinical registry for documenting PC and/or MH conditions?

No SKIP TO E5

Yes


2. Is the clinical registry searchable? That is, does it allow your program to systematically monitor and track the care of all individual patients in your program who meet criteria for a specific physical health diagnosis?

No SKIP TO E5

Yes, we organize patient-population data using an electronic system that includes searchable information.


3. Is the electronic registry used to manage patient care? (e.g., from information about relevant subgroups of patients needing services)

No

Yes, our data system includes searchable clinical patient information that is used to manage patient care.


4. Are the data fields used in the electronic clinical registry consistently used in patient records?

No

Yes, the practice uses the data fields listed above consistently in patient records.


5. Are charting tools used to document clinical information in the medical record?

No

Yes, the practice uses electronic or paper-based charting tools to organize and document clinical information in the medical record.


6. a) What are the top 3 clinically important diagnoses, risk factors, or conditions being treated by the PBHCI program? ____________ ______________ ____________

b) Do you have a system in place that enables you to track these diagnoses, risk factors, and conditions?

No

Yes


7. Is your electronic clinical registry used to generate reminders (i.e., automated “ticklers”) for patients or clinicians (e.g., about services or medications needed, follow-ups, etc.)?

No

Yes, we use electronic information to generate patient lists and remind patients or clinicians about necessary services, such as specific medications or tests, preventive services, pre-visit planning, and follow-up visits.


8. Who uses electronic medical records (EMRs)? Check all that apply.

MH providers

PC providers

Care managers

Other (Specify________________)


9. How often is attendance at external appointments (e.g., specialist appointments) tracked?

Always

Often

Sometimes

Rarely

Never (not tracked)

10. How often is registry data checked for completion and accuracy?

Always

Often

Sometimes

Rarely

Never


GROUP 2 SKIP TO H1

GROUP 4 SKIP TO G1


11. Regarding the current medication list, are there procedures in place to avoid polypharmacy?

No

Yes


GROUP 3 SKIP TO H1


F. Performance monitoring


1. Does the practice measure performance (e.g., service data, outcomes data, etc.)? If so, what factors are measured?

No

Yes, we measure or receive performance data by physicians or across the practice regarding: [Check all that apply.]

Clinical process

Clinical outcomes

Service data

Patient safety


2. Does the practice collect data on patient experience?

No

Yes, the practice collects data on patient experience with: [Check all that apply.]

Access to care

Quality of physician communication

Patient/family confidence in self-care

Patient/family satisfaction with care


3. Does the practice share performance data and patient experience data with providers?

No

Yes


4. Is performance data used to set goals based on measurement results?

No

Yes


5. Is performance data used to improve performance of individual physicians or of the practice as a whole?

No

Yes


6. Are performance measures electronically reported to external entities?

No

Yes


G. Care management


1. Do you have written processes for scheduling appointments and communicating with patients?

No

Yes


2. Do you have preventive service reminders for clinicians?

No

Yes, the practice uses reminders to prompt physicians about a patient’s preventive care needs at the time of the patient’s visit.


3. Does the practice use a team approach to managing patient care?

No

Yes


4. How often is care coordinated with external organizations and other physicians?

Always

Often

Sometimes

Rarely

Never


5. Considering appointments in the last 60 days for all PCBHI patients in your program, how long does it typically take a patient who meets the criteria to get an initial appointment to see a care manager? [Check one choice below.]

Same day

1-7 days

8-14 days

15-30 days

31-60 days

61 days or more

Never


6. In a typical two-week period, what percentage of patients in the PCBHI program see more than one member of the treatment team?

 ≤ 20% of PBHCI patients

21-40%

41-60%

61-80%

 ≥ 80%


7. How frequently do PBHCI program staff (within or across sites) meet to plan and review services for each client?

Once a month or less

2-3 times per month

4-7 times per month

 ≥ 8 times per month


8. What is the average caseload for a full-time PBHCI care manager?

< 20 patients

21-40 patients

41-60 patients

61-80 patients

81-100 patients

Over 100 patients


9. How often do care managers assess for and coordinate services to address needs beyond clinical care (e.g., SSI/SSDI, Medicaid, housing, income support, vocational rehabilitation, legal, etc.)?

Always

Often

Sometimes

Rarely

Never


10. How often does the care manager interface with other organizations in the community to address needs beyond clinical care?

Always

Often

Sometimes

Rarely

Never

GROUP 4 SKIP TO K1


H. Evidence-based practices


1. a) What are the top 3 clinically important diagnoses, risk factors, or conditions being treated by the PBHCI implementation? ____________ ______________ ____________

b) Do you use evidence-based guidelines in treating [CONDITION 1]?

No

Yes

Do you use evidence-based guidelines in treating [CONDITION 2]?

No

Yes

Do you use evidence-based guidelines in treating [CONDITION 3]?

No

Yes


2. Which evidence-based practices are you using? (Check all that apply.)

SBIRT

CBT

DBT

IPT

Integrated dual diagnosis treatment

Coordinated case management

Motivational Interviewing

Peer support

Other (Specify:______________)

Other (Specify:______________)

Other (Specify:______________)


GROUP 2 SKIP TO J1


I. Wellness/prevention/early intervention


1. What do the wellness programs consist of? Are they provided in individual or group format? [Check all that apply]

Individual Group

Peer facilitators/ Peer supports  

Nutrition  

Exercise  

Social support  

Linkages to support groups  

Stress management/ relaxation training  

Vaccinations  

Sexual health  

Other [Specify:_______________]  

Other [Specify:_______________]  

Other [Specify:_______________]  


2. Where are the wellness programs located? [Check all that apply]

MH/integrated site PC site Community site

Peer facilitators/ Peer supports   

Nutrition   

Exercise   

Social support   

Linkages to support groups   

Stress management/ relaxation training   

Vaccinations   

Sexual health   

Other [Specify:_______________]   

Other [Specify:_______________]   

Other [Specify:_______________]   


3. How many hours per week are wellness services available? Please indicate the number of hours/week for each program.

0 1-2 3-5 6-10 11-15 16+

Peer facilitators/ Peer supports      

Nutrition      

Exercise      

Social support      

Linkages to support groups      

Stress management/ relaxation training      

Vaccinations      

Sexual health      

Other [Specify:_______________]      

Other [Specify:_______________]      

Other [Specify:_______________]      


J. Self-management support


1. Self-management support services help patients/families better handle self-care tasks while ensuring that effective medical, preventive and health maintenance interventions take place. Other than the wellness programs discussed above, are other self-management support services available through your program? Which services are available? [Check all that apply]

Self-management support groups (other than AA and other 12-step programs)

Individual self-management support sessions

Health education materials with personalized feedback

Interactive instruction given by computer

Other [Specify]


2. a) To what extent does the practice work to facilitate self-management of care for patients with [CONDITION 1]?

No self-management support services for this condition

Minimal self-management support services for this condition

Some self-management support services for this condition

Extensive self-management support services for this condition

b) To what extent does the practice work to facilitate self-management of care for patients with [CONDITION 2]?

No self-management support services for this condition

Minimal self-management support services for this condition

Some self-management support services for this condition

Extensive self-management support services for this condition


b) To what extent does the practice work to facilitate self-management of care for patients with [CONDITION 3]?

No self-management support services for this condition

Minimal self-management support services for this condition

Some self-management support services for this condition

Extensive self-management support services for this condition


3. How often is patient self-management education a key component of the care plans for patients with chronic conditions?

Always

Often

Sometimes

Rarely

Never


K. Consumer involvement


1. To what extent are consumers involved in the development, execution, and/or evaluation of the PBHCI program?

Not involved

Slightly involved

Somewhat involved

Very involved


2. To what extent are consumers and their families involved in care (e.g., goal-setting, decision-making)?

Not involved

Slightly involved

Somewhat involved

Very involved


3. What tools and methods are used to involve consumers in their care? Check all that apply.

Patient access to health records

Patient portals

Medical report cards

Charts and graphs to visually show progress

WRAPs

MH advance directives

Other (Specify:_______________)

Other (Specify:_______________)

Other (Specify:_______________)



GROUP 2 SKIP TO M1


L. Electronic capabilities


1. Is electronic prescribing used?

No

Yes


2. Are electronic drug safety alerts used when prescribing?

No

Yes


3. Is cost taken into account when prescribing?

No

Yes


4. Is an interactive website used to support patient access and self-management?

No

Yes


5. Are emails used to notify patients about specific needs or clinical alerts?

No

Yes


6. Is email communication used to support care management for patients with the clinically important conditions you previously identified?

No

Yes


M. Women’s and minority health cultural competency


1. Is there a specialized women's health program at your site?

No

Yes


2. Does your program have a committee to address culture-related issues in treatment?

No

Yes


3. Does your clinic offer programs to train staff in cultural competence?

No

Yes, cultural competence training is available pertaining to… (check all that apply)

Gender

Country of origin

Race/ethnicity

Age

LGBT

Religion


4. Is cultural competency training required?

No

Yes


5. What is the minimum number of hours of cultural competency training required?

None (0 hours)

1-5 hours

6-10 hours

11-20 hours

21-30 hours

31-40 hours

more than 40 hours


GROUP 4, SKIP TO N6


6. What are the most prevalent non-English languages encountered in dealing with patients at your site? Indicate up to 3 commonly encountered languages.

Language(s)

1. ________________

2. ________________

3. ________________

IF NO LANGUAGES INDICATED, GROUP 1 SKIP TO N1, GROUPS 2 AND 3 SKIP TO N6


7. What language services are available for the non-English languages most commonly encountered by your staff? [For each language, indicate if the following services are currently available. Check all that apply.]

LANGUAGE 1

Bilingual staff

Interpreter services

Key forms (privacy, informed consent) available in non-English languages

Patient educational brochures available in non-English languages

LANGUAGE 2

Bilingual staff

Interpreter services

Key forms (privacy, informed consent) available in non-English languages

Patient educational brochures available in non-English languages

LANGUAGE 3

Bilingual staff

Interpreter services

Key forms (privacy, informed consent) available in non-English languages

Patient educational brochures available in non-English languages


GROUPS 2 AND 3 SKIP TO N6


N. Implementation


1. In what areas of PBHCI implementation has your program had the greatest successes to date? Check all that apply.

Screening and referral

Registry/tracking

Care management

Wellness/prevention/early intervention

Other PBHCI activity (Specify:________)

Other PBHCI activity (Specify:________)


2. What aspects of the PBHCI program is your site still working toward implementing? Check all that apply.

Screening and referral

Registry/tracking

Care management

Wellness/prevention/early intervention

Other PBHCI activity (Specify:______________)

Other PBHCI activity (Specify:______________)


3. What contextual factors (i.e., characteristics of your community or state, including funding availability) affected how you implemented the PBHCI program? Please check all that apply.

Changes in reimbursement policy

Changes in payor mix

Tax breaks

Major state or county budget cuts

Other (Specify:_______________________________)

 

4. Was PBHCI program implementation affected by any initiatives (other than PBHCI) that provide funding for medical/health homes or behavioral-physical health integration (e.g., medical home / health home or similar initiatives)?

Yes

No

  

IF NO SKIP TO N6

 

5. Indicate which initiatives impacted your program. Please check all that apply.

Medicaid Health Home State Option

Other Medical Home initiatives (Specify:______________________________)

Other integration initiatives (Specify:______________________________)

Other (Specify:______________________________)


6. a) What barriers has your program faced in implementing the integration? (INSERT OPEN-ENDED

TEXT BOX)


b) What strategies have your program used to overcome these barriers? (TEXT BOX)


7. What have we missed? What else do we need to know about the PBHCI program that we haven’t asked you? For instance, are there particularly unique or innovative components that have been implemented? (TEXT BOX)



 

 

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