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)
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?
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)
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0371. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
| File Type | application/msword |
| File Title | Technical Advisory Group (TAG) Conference Call |
| Author | IST |
| Last Modified By | IST |
| File Modified | 2011-07-01 |
| File Created | 2011-03-08 |