Form 1 Online_Questionnaire_for_Pre-Work_Profile_of_RWHAP

Instrument 1. Online Questionnaire for Pre-Work Profile of RWHAP Clinic Site

Public Burden Statement: 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. The OMB control number for this project is 0916-xxxx. Public reporting burden for this collection of information is estimated to average 0.5 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857.

Introduction

Thank you for being willing to participate in the HRSA/HAB Building Futures site visit. The purpose of the visit is to learn more about what affects outcomes related to retention in care and viral load suppression among HIV-positive youth served by the Ryan White HIV/AIDS Program.

We truly value your feedback, and are eager to gain insight into how you serve HIV-positive youth. This brief questionnaire will begin the feedback process. The next phase of the feedback process will be in approximately two weeks during an in-person site visit.

This questionnaire will ask you about strengths and challenges serving HIV-positive youth at your site in the following five areas: 1) Systems and infrastructure; 2) Community presence and linkages; 3) Clinical standards and models for care; 4) Provider Staff; and 5) Collaboration with youth and families.

This questionnaire should take you about 30 minutes to complete. Each member of the clinic staff that will participate in the site visit can assist you in completing this questionnaire in order to get multiple perspectives across your staff. This should include, where available/applicable: Program leader (i.e. Manager, Director); Clinical Director; 1-3 clinician/nurse practitioners; mental health worker; substance abuse counselor; case manager; peer coordinator; and an administrative staff member.

Your answers will help guide the site visit when you will have more time to elaborate and explain your responses.

If you prefer to complete this survey by phone, please contact X at [email protected].

Description of Site

1. Name of person completing questionnaire

___________________________________

2. Role at site (select all that apply):

• CEO

• Management

• Clinician

• Other _______________

3. Provider Type (select one):

• Community-based service organization (CBO)

• Health department

• Hospital or university-based clinic

• Publicly funded community health center

• Publicly funded community mental health center

• Other _____________

4. Number of clinicians¹ on team who provide services for HIV-positive youth:

__________

5. Number of non-clinicians/staff on team who provide services for HIV-positive youth:

___________

6. We will be interviewing the following key staff members at your clinic during the site visit. We would like to obtain more information on who they are: for each person please list their name, number of years at the clinic, and highest degree or licensure.

• Program leader (i.e. Manager, Director)

• Clinical Director

• 1-3 clinicians/nurse practitioners

• Case manager

• Mental health worker

• Substance abuse counselor

• Peer coordinator

• Administrative staff member

7. Please check off the RWHAP core medical services provided for HIV-positive youth at your site. (check all that apply)

• Outpatient/ambulatory medical care

• Early intervention services (Parts A and B)

• Home and community-based health services

• Home health care

• Hospice services

• Mental health services

• Medical case management

• Medical nutrition therapy

• Oral health care

• Outpatient substance abuse services

• Other: _______________________

8. Please check off any additional support services that your agency provides and/or has established linkages for: (check all that apply)

	Agency provides service	Agency has formal linkages to refer for this service	Agency does not provide or link for this service
Outreach (e.g. clinic-based, community-based, peer-based, street-based)			
Mental health services			
Substance abuse services			
ADAP enrollment			
Health insurance enrollment			
Cost sharing support			
Food support			
Transportation			
Peer support/navigation			
System navigation (e.g. accompanying patients to appointments, explaining procedures to new patients, scheduling appointments, other navigation assistance)			
Housing assistance			
Lawyers/legal assistance			
Client education (HIV services, life supports, life skills training)			
Remedial help with school/tutoring			

9. Use of Electronic Health Records (EHR) system at your site

• Yes

• No

• Don’t know

Systems & Infrastructure

Please describe the degree to which your site has the stated clinical systems and infrastructure in place to serve HIV-positive youth. Rank each statement as best as you can.

	Does not describe us	Just getting started	Almost there	Describes us well	Don’t know/NA
Clinic has youth friendly hours (e.g. nights/weekends)	1	2	3	4	0
All staff are warm and welcoming to each patient	1	2	3	4	0
Clinic materials are available in relevant languages	1	2	3	4	0
Clinic environment is targeted to the patient demographic (e.g. materials, handouts, posters inclusive of LGBTQ youth, minority youths)	1	2	3	4	0
Clinic site feels private and safe (e.g. separate waiting rooms for youth)	1	2	3	4	0
Clinic provides amenities appealing to youth during office hours and/or group meetings (e.g., on-site games, TV, music, food, spaces to lounge)	1	2	3	4	0
Clinic can see youth same-day or next day for appointments	1	2	3	4	0
Clinic has systems for flagging and following up on missed appointments	1	2	3	4	0

18. Which of the following scheduling practices does your clinic use? (select all that apply):

• Walk in – No appointment necessary

• Open access (same-day or next day appointments only)

• Appointments at least 24 hours in advance

19. Clinic provides appointment reminders via: (check all that apply)

• Phone

• Email

• Text

20. Clinic appointments are made via: (check all that apply)

• Clinic staff in-person/phone

• Online systems

• Centralized call-in center

• Other ____________

	Does not describe us	Just getting started	Almost there	Describes us well	Don’t know/NA
Clinic has confidentiality policies in place	1	2	3	4	0
Clinic staff are aware of confidentiality policies/minors’ rights	1	2	3	4	0
Clinic has systems in place to identify patients at risk for dropping out or non-adherence	1	2	3	4	0

24. Clinic has a lab on-site

• Yes

• No

• Don’t Know

25. Clinic has a pharmacy on-site

• Yes

• No

• Don’t know

Community Presence and Linkages

Please describe the degree to which your site has the described community presence and linkages in place. Rank each statement as best as you can.

	Does not describe us	Just getting started	Almost there	Describes us well	Don’t know/NA
Clinic is well-known in community	1	2	3	4	0
Clinic uses social networking strategies to engage youth in care (e.g., websites, Facebook, twitter, etc.)	1	2	3	4	0
Clinic provides targeted outreach to at-risk populations (e.g. young MSMs, young women)	1	2	3	4	0
Clinic participates in advocacy coalitions promoting policy and practice changes for youth	1	2	3	4	0
Clinic has linkages with schools for HIV testing and care	1	2	3	4	0
Clinic has linkages with CBOs for services not provided on-site	1	2	3	4	0
Clinic receives referrals from partner organizations for youth who have tested HIV-positive	1	2	3	4	0
Clinic has linkages to support adherence, such as use of Directly Observed Therapy (DOT), use of Community Health Workers (CHWs), peer navigators/advocates, adherence outreach	1	2	3	4	0
Clinic work with youths’ families, friends and other social influences in care and treatment	1	2	3	4	0

Clinical Standards and Models of Care

Please describe the degree to which your site has the described clinical standards and models of care in place. Rank each statement as best as you can.

	Does not describe us	Just getting started	Almost there	Describes us well	Don’t know/NA
Clinic staff work in a multidisciplinary team care model	1	2	3	4	0
Providers and care team are knowledgeable of and apply most up-to-date clinical guidelines	1	2	3	4	0
Clinic regularly uses technology with HIV-positive youth such as texting/apps for appointment reminders, adherence and general communication	1	2	3	4	0

38. Clinic uses which of the following evidence-based individual-level interventions when working with HIV-positive youth: (check all that apply)

	No	Yes – always & with fidelity	Yes - sometimes	Yes – on occasion	Don’t know/NA
Full spectrum primary care					
Availability during the week and on-call 24/7					
Connections to local ERs or urgent care					
Hormonal care					
Motivational interviewing					
Cognitive Behavioral Therapy					
Mental health screening					
Substance abuse interventions (SBIRT, etc.)
Use of PrEP for prevention with partners					
Use of peer navigators					
Use of Community Health Workers (CHWs)					
Adherence support
Financial incentives					
Directly Observed Therapy					
Technology support, such as text/Short Message Service (SMS) and apps					
Other________
Incorporation of “trauma informed care”
Screening and recognition					
Strength and resilience frameworks					
Programs with paths for recovery					
Mindfulness/meditation/yoga					
Mental health/behavioral referrals					
Psychiatric referrals					
Other_________
Specific EBIs (e.g. CLEAR, WILLOW) _____________________________________
Other _______________

Provider and Care Team

Please describe the degree to which the statements below describe provider and care team knowledge, skills and attitudes at your site. Rank each statement as best as you can.

	Does not describe us	Just getting started	Almost there	Describes us well	Don’t know/NA
Providers prioritize one-on-one relationships and encounters with patients	1	2	3	4	0
Providers are knowledgeable about the socio-economic barriers to care that might affect their patient populations	1	2	3	4	0
Providers have a strong understanding of the unique barriers to care and treatment that impact specific subpopulations of youth with HIV	1	2	3	4	0
Providers are passionate about working with youth	1	2	3	4	0
Providers understand adolescent development	1	2	3	4	0
Providers believe it is important to understand adolescent development to promote retention and adherence	1	2	3	4	0
Providers understand potential barriers to ART adherence among their patients	1	2	3	4	0
Providers have strategies to address these barriers	1	2	3	4	0
Leadership prioritizes working with youth	1	2	3	4	0
Leadership is interested in the clinic modifying practices to address youths’ evolving needs	1	2	3	4	0
Providers collaborate with youths’ families and social networks

Collaboration with Youth and Families

Please describe the degree to which your site collaborates with youth in the ways described below. Rank each statement as best as you can.

	Does not describe us	Just getting started	Almost there	Describes us well	Don’t know/NA
Clinic engages peer navigators as part of programming	1	2	3	4	0
Clinic holds peer support groups	1	2	3	4	0
Clinic schedules activities and events to address youths’ perceived needs and interests (e.g. job skills training, social events)	1	2	3	4	0
Clinic provides incentives for youth participation in activities	1	2	3	4	0
Clinic engages with youth as partners in program development	1	2	3	4	0

55. Clinic has formal mechanisms for feedback from youth (check all that apply):

• Consumer Advisory Board

• Town hall meetings

• Suggestion boxes

• Online forums/reviews

• Other_____________

Additional Documents

Please upload any written documents that you feel provide background on your site. In particular, if you have any of the following, please upload in this survey and/or send via email to [email protected]

• Most recent HRSA HAB grant application for grantee/providers [When not available directly from HAB]

• Any available survey data from the clinic (e.g. customer satisfaction surveys)

• Treatment guidelines and protocols used for HIV primary care (including diagnostic screenings, vaccinations, opportunistic infection prophylaxis, and antiretroviral therapy)

• Organizational charts

• Staffing structure document/staff list

• Written policies or procedures related to peer programs/use of peers

• Papers or manuscripts relevant to site practices (e.g. in Adolescent Trials Network)

1 “Clinician” is defined as a staff member who provides professional diagnostic and therapeutic services directly to a client, such as a physician, physician assistant, clinical nurse specialist, nurse practitioner, or other health care professional certified in his or her jurisdiction to prescribe antiretroviral (ARV) therapy in an outpatient setting.

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