Phila Standard of Care Survey

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Cooperative Re-Engagement Controlled Trial (CoRECT)

Attachment #10

Philadelphia Standard of Care Survey

Public reporting burden of this collection of information is estimated to average 45 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)

Philadelphia’s Standard of Care Survey

Facility and Patient Services

1. What is the name of your facility?

2. Please indicate how many staff provide medical care to HIV patients at your facility. Pleased do not include interns, fellows, and residents in your tally.

Number of staff

2a._________MD/DO

2b._________PA

2c._________NP

2d.________Pharmacist

2e.________RN

2f.________LPN

2g.________Medical Assistant

2h._____________Other (please specify)

3. Please indicate how many staff at your facility provide mental health and supportive services on site to patients who are HIV positive. Please do not include interns, fellows, and/ or residents in your tally.

3a._________Number of staff

3b._________Psychiatrist

3c._________Psychologist

3d._________Behavioral Health

3e._________Consultant

3f._________Social Worker

3g._________Medical Case Manager

3h._________General Case Manager

3i._________Linkage Coordinator

3k._________Nutritionist

3l. ______________We do not have any mental health or support staff at this facility

4. What administrative support staff are employed at your facility? (Please check all that apply.)

4a. Other (please specify)

4b. Office Manager

4c. Medical Billing Staff

4d. Scheduling Staff

4e. None of these

5. What clinical services are available for patients with HIV on site at your facility?

Please indicate any other services you offer below. ---OR--- If you do not offer any additional clinical services please indicate that in the space below.

5a. Phlebotomy (Please answer questions 6 and 7 if you check this option)

5b. Pharmacy

5c. Radiology

5d. Substance Abuse Treatment

5e. Mental Health Treatment

6. (Skip to question 8 if you do not draw blood on site at your facility).

Please indicate where you draw blood at your facility for patients who are HIV positive. (Please check all that apply)

6a. In the same office where patients have their clinical appointments.

6b. In a separate building associated with the facility (i.e. main hospital, lab across the street from the building, etc.)

6c. In the same building on a separate floor from where patients have their clinical appointments.

6d. Please indicate here any other location at your facility where you draw blood.

7. Please list circumstances when you may not be able to draw blood on-site.

_____________________________________________________________

8. What ancillary/ support services are available for patients with HIV at your facility? (Please check all that apply.)

If you offer other services not listed above please list them here.

8a. Support Groups

8b. Health Education

8c. Adherence Counseling

8d. Food Banks

8e. Congregate Meals

8f. Transportation

8g. We do not offer any ancillary/support services to patients at our facility.

Patient Barriers to Care

* 9. How frequently do you think the following issues/challenges/barriers keep a patient from initially linking to treatment for their HIV?

(1)Never (2) rarely (3) Sometimes (4) Most of the Time (5) Always (6) I don't know

____9a. Homelessness

____9b. Incarceration

____9c.Transportation

____9d.Mental health

____9e.Substance Use

____9f.Other Health Problems

____9g.Lack of Insurance

____9h.Inability to pay insurance co-pays

____9i.Conflicts with work schedule

____9j.Unemployment

____9k.Childcare

____9l.Intimate partner violence

____9m.Too busy with other social service appointments

____9n.Inability to organize life activities

____9o.Stigma or disclosure fears

____9p.Patients feel healthy

____9q.Religious objections

________________(specify)9r.Other

10. How frequently do you think the following issues/challenges/barriers keep a patient from staying in treatment for their HIV?

(1)Never (2) rarely (3) Sometimes (4) Most of the Time (5) Always (6) I don't know

____10a.Homelessness

____10b.Incarceration

____10c.Transportation

____10d.Mental health

____10e.Substance Use

____10f.Other Health Problems

____10g.Lack of Insurance

____10h.Inability to pay insurance co-pays

____10i.Conflicts with work schedule

____10j.Unemployment

____10k.Childcare

____10l.Intimate partner violence

____10m.Too busy with other social service appointments

____10n.Inability to organize life activities

____10o.Stigma or disclosures fears

____10p.Patients feel healthy

____10q.Religious objections

_______________________(specify)10r. Other (please specify)

* 11. How frequently do patients report the following issues as a barrier to initially linking to treatment for their HIV?

(1)Never (2) rarely (3) Sometimes (4) Most of the Time (5) Always (6) I don't know

____11a.Homelessness

____11b.Incarceration

____11c.Transportation

____11d.Mental health

____11e.Substance Use

____11f.Other Health Problems (specify)

____11g.Lack of Insurance

____11h.Inability to pay insurance co-pays

____11i.Unemployment

____11j.Childcare

____11k.Intimate partner violence

____11l.Too busy with other social service appointments

____11m.Inability to organize life activities

____11n.Stigma or disclosure fears

____11o.Patients feel healthy

____11p.Religious objections

_____________11q.Other (please specify)

* 12. How frequently do patients report the following issues as a barrier to staying in treatment for their HIV?

(1)Never (2) rarely (3) Sometimes (4) Most of the Time (5) Always (6) I don't know

____12a.Homelessness

____12b.Incarceration

____12c.Transportation

____12d.Mental health

____12.eSubstance Use

____12f.Other Health Problems

____12g.Lack of Insurance

____12h.Inability to pay insurance co-pays

____12i.Unemployment

____12j.Childcare

____12k.Intimate partner violence

____12l.Too busy with other social service appointments

____12m.Inability to organize life activities

____12n.Stigma or disclosure

____12o.Patients feel healthy

____12p.Religious objections

__________12q.Other (please specify)

Re-linkage Practices and Protocol

13. In the last year, what methods has your practice used to re-link HIV patients back to care? (Please check all that apply.)

13a. Other (please specify) ___________________________________

13b. Called the patient after a missed medical office visit

13c. Made a field visit to the patient after a missed medical office visit

13d.Sent letters to the patient after a missed medical visit

13e.Sent the patient a text message

13f.Sent the patient a message via your health system’s secure patient portal

14. Which staff at your facility contact HIV patients when you are attempting to re-link them to care? (Please check all that apply.)

14a. Other (please indicate staff member(s) not listed)

14b. Receptionist

14c.Scheduling Staff

14d.Medical Assistant

14e.Nurse

14f.Linkage Coordinator

14g.Social Worker

14h.Behavioral Health Consultant

14i.Medical Director

14j.Physicians

14k.Physician's Assistant

15. Does your facility have a protocol for re-linking HIV patients back to care?

1 Yes we have a written protocol

2 Yes but it is not a written protocol

0 No

7 I don't know.

16. (Skip to question 20 if you answered NO to question 15.)

Briefly describe your facility's protocol for re-linking HIV patients who have been lost to care?

_____________________________________________________________________________________

17. Are there segments of your HIV patient population that are prioritized differently for re-linkage to care (i.e.

Pregnant women, patients with high viral loads etc.)?

Please indicate below how and why patients are prioritized differently for re-engagement.

1 Yes (please indicate below how and why patients are prioritized differently)

_____________________________________________________________________________________

0 No

7 I don't know.

18. Who monitors your facility's protocol for re-linkage to care?

_____________________________________________________________________________________

19. How often is your facility's protocol for re-linkage practices modified?

Other (please specify) _________________________________________

0 Never

1 Every 3-6 mos

2 Every 6-12 mos

3 Every 1-2 yrs

20. Would your facility be interested in receiving training from the health department on developing and/or

implementing a protocol for re-linking HIV patients back to care?

1 Yes

0 No

9 We may be interested but we'd like to learn more first.

Data Collection and Management

21. What Electronic Medical Record system do you use to collect data on your patients?

1 Epic

2 Allscripts

3 NextGen

4 eClinical Works

5 Cerner

6 Other , (please specify) ________________________________________________________

22. What other computerized systems do you use to collect data on your patients? (Please check all that apply.)

1 CAREWare

2 Electronic Scheduling System

3 In-house database system

4 Other (please specify) ___________________________________________________

23. How frequently do you update your CAREware database?

1 I don't use CAREWare.

2 Weekly

3 Monthly

4 Quarterly

5 Yearly

6 Other (please specify) _______________________________________

24. (Skip to question 25 if you DO NOT use CAREWare.)

How soon after a patient visit do you update their record in your CAREWare database?

1 Within 1 day

2 Within 1 week

3 Within 1 month

4 Within 3 months

5 Within 6 months

6 Other (please specify) _________________________________

25. What data systems could your facility use to identify patients who have not had a visit within the last 6 months? (Please check all that apply.)

1 CAREWare

2 Electronic Scheduling System

3 Electronic Medical Record

4 In-house database system

5 Other (please specify)

26. Is your facility able to capture a history of missed visits for HIV patients in your scheduling system?

If missed visits are not captured in the scheduling system, please indicate below where they are captured.

1 Yes

0 No

2 No, but we capture this elsewhere (indicate where it is captured below).

7 I don't know

27. Is your facility able to identify new patient appointments in your scheduling system?

1 Yes

0 No

7 I don't know

28. Is your scheduling system able to capture when a new patient appointment is for an individual who is HIV positive?

1 Yes

0 No

7 I don't know

29. Do you have a process for creating a list of patients from your data system (i.e. list of pts w/ HIV, list of pts not seen in last 6 mos.)?

1 Yes

0 No

7 I don't know

30. Do you have to request permission from a compliance office or some other entity within your organization to run reports or retrieve data from any of your data systems?

1 Yes

0 No

7 I don't know

31. (Skip to question 32 if you answered NO to question 30).

Which of your data systems require permission from a compliance office or other entity prior to retrieving data or running reports? (Please check all that apply.)

1 Please enter any additional systems not listed above.

2 Electronic Scheduling System

3 Electronic Medical Record

4 CAREWare

5 In-house database

32. Are any of your computer or data systems scheduled to undergo replacement, upgrades or development?

Please indicate below WHICH systems are scheduled to undergo change and WHEN the change is expected to occur.

_____________________________________________________________________________

33. Are any of your computer or data systems currently undergoing replacement, upgrades or development?

Please indicate WHICH systems are undergoing change below.

______________________________________________________________________________

34. Please indicate how competent you and/or your staff are at the following:

(1)Not Competent

(2)We rarely if ever do this and would need training.

(3)Somewhat Competent

(4)We do this occasionally but we may still need training.

(5)Competent we do this all the time and would not need training.

(6) N/A

____34a. Submitting data through a secure FTP site

____34b. Creating an excel spreadsheet

____34c.Entering data into a created Excel spreadsheet

____34d.Extracting data from a created Excel spreadsheet

____34e.Creating new reports from your Electronic Medical Record

____34f.Running canned reports from your Electronic Medical Record

____34g.Creating new reports in CAREWare

____34h. Running canned reports in CAREWare

Provider Concerns

35. When a patient returns to care, what are you most interested in finding out?

1 The patient's reasons for being out of care

2 The reasons the patient returned to care

3 The patient's willingness to continue engaging in care

If you'd like to share anything more about your answer to this question please indicate that here.

______________________________________________________________________________

36. Do you have any concerns about participating in CoRECT that you'd like to share with us?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________