CT Standard of Care Survey

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Cooperative Re-Engagement Controlled Trial (CoRECT)

Attachment #9

Connecticut Standard of Care Survey

Public reporting burden of this collection of information is estimated to average 30 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 NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Connecticut Standard of Care Clinic Assessment

CoRECT: Assessment of Clinic Standard of Care Practices

Point person at your clinic for CoRECT

Name:_____________________________ Phone:_____________________________

Email:______________________________

“Out of care” patients

1. Do you currently have a protocol in your clinic to contact patients who are out of care? 1 Yes 2 No

2. If so, how do you define “out of care” in your clinic? How do you identify those that are “out of care” (e.g., electronic records, paper)?________________________________________

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

3. Who is responsible for conducting outreach for patients that are out of care?

1 Receptionist 7 Practice manager

2 Medical assistant 8 Medical director

3 Nurse 9 Mid-level practitioners (APRN or PA)

4 Peer 10 Physician/ provider

5 Nurse case manager

6 DIS or Linkage Coordinator 11 Dedicated team member other than case manager

1 2 Other _________________________________

4. If you have a protocol, what type of outreach do you conduct for out of care patients? How often?

Process	Frequency (e.g., every missed appointment, if no appointment in six months, etc.). If you do not conduct this type of outreach, write “N/A”
4a. Telephone calls	1Yes 0No 6N/A Frequency_________________________
4b. Letters	1Yes 0No 6N/A Frequency_________________________
4c. Referral to case manager	1Yes 0No 6N/A Frequency_________________________
4d.Other: ____________________	1Yes 0No 6N/A Frequency_________________________
4e.Other: ____________________	1Yes 0No 6N/A Frequency_________________________

5. Has your protocol been revised or updated in the last six months? 1Yes 0No If Yes please explain: