MA Standard of Care Survey

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Cooperative Re-Engagement Controlled Trial (CoRECT)

Attachment #8

Massachusetts Standard of Care Survey

Public reporting burden of this collection of information is estimated to average 1 hour 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)

Massachusetts Standards of Care Survey

Clinic: __________________________ Date Completed: _____/_____/_____

Name of Person Completing Survey: _____________________________

Contact Information: ________________________________________________________

Telephone Email

1. Do you currently have a formal, written protocol in your clinic to contact patients who have missed appointments? 1Yes 0No

1. If Yes, has this protocol been updated since [INSERT DATE OF LAST SURVEY] mm/yy?

2. Do you collection information regarding patient preferences for contact? 1Yes 0No

2a.If Yes, where is this information kept

1 Electronic health record

2 Case management record

3 Other: ___________________

3. If you have a protocol please indicate how patients are contacted, when outreach is initiated, how many attempts are made and over what time period patient contacts are attempted. If you do not conduct a specific type of outreach, write “N/A[9]”

Modality	3i. Initiation of Outreach (e.g. after every missed appointment, if no appointment in 6 months)	3ii. Frequency and Time Period (e.g. three attempts)	3iii. Time Period (ex. over 30 days)
3a.Telephone calls	1Yes 0No	_______(# of times)	_____________ (days)
3b.Letters mailed to patient	1Yes 0No	_______(# of times)	_____________ (days)
3c.Emails sent to patient	1Yes 0No	_______(# of times)	_____________ (days)
3d.Text message sent to patient	1Yes 0No	_______(# of times)	_____________ (days)
3e.Notification through electronic patient portal	1Yes 0No	_______(# of times)	_____________ (days) _____________ (days)
3f.Referral to case manager	1Yes 0No	_______(# of times)	_____________ (days)
3g.Other	1Yes 0No	_______(# of times)	_____________ (days)

4. Who has primary responsibility for contacting patients who have missed appointments?

1 Receptionist 6 Practice manager

2 Medical assistant 7 Medical director

3 Nurse 8 other case manager

4 Mid-level practitioners (APRN or PA) 9 Peer

5 Nurse case manager 10 Other: ________

5. Since [INSERT DATE OF LAST SURVEY mm/yy] have any of the following changes occurred to medical, social or support services provided by your clinic onsite or through referral?

5a. Change in the health plans accepted by the clinic (e.g. one or more health plans has been added or dropped by the clinic) 1Yes 0No

5b. Change in network by one or more health plans (i.e. the clinic is no longer “in network” for one or more health plans) accepted by the clinic 1Yes 0No

5c. Changes to clinic operations (e.g. change in hours, location) 1Yes 0No

5d. Changes to clinic capacity (e.g. increase or decrease in number of clinicians; increase or decrease in number of patients) 1Yes 0No

5e. Change in care coordination or support services provided by the clinic (e.g. the number of medical case managers has increased or decreased) 1Yes 0No

5f. Change in care coordination or support services provided through referral (e.g. eligibility for services has changed) 1Yes 0No

5g. Other: _______________________________________ 1Yes 0No

6. Please describe the changes to the medical, social, or support services provided by your clinic on-site or through referral:______________________________________________ ______________________________________________________________________________________________________________________________________________