Philadelphia Barriers to Care Survey (modified February

Cooperative Re-Engagement Controlled Trial (CoRECT)

Attachment #7

Philadelphia Barriers to Care Survey

Form Approved

OMB No. 0920-1133

Expiration Date: 08/31/2019

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 (0920-1133)

Patient Barrier Assessment

Field Record #:________________ Last Name: ____________________ First Name:________________ DOB: __________ Worker #:_________

Directions: Using the common barriers list below, enter the barrier number that corresponds to the patient’s response.

Today’s Date	Barriers Domain	Barrier(s)	Barrier Priority	Barrier identified by:	Barrier Status	Intervention Phase	Notes
/ /			( ) Primary ( ) Secondary	( ) Pt ( ) DIS ( ) Both	( ) Resolved ( ) Not Resolved ( ) Pending	( ) Care Engagement ( ) Transition to Care ( ) Both
/ /			( ) Primary ( ) Secondary	( ) Pt ( ) DIS ( ) Both	( ) Resolved ( ) Not Resolved ( ) Pending	( ) Care Engagement ( ) Transition to Care ( ) Both
/ /			( ) Primary ( ) Secondary	( ) Pt ( ) DIS ( ) Both	( ) Resolved ( ) Not Resolved ( ) Pending	( ) Care Engagement ( ) Transition to Care ( ) Both

Barrier Domain = Letters Barriers = Numbers

Common Barriers

A. Attitude / Perception about HIV and Health G. Health insurance and access to medical care P. Challenge with medical provider

1. Felt good 25. Didn’t know where to go for medical care 49. My doctor is not addressing my needs

50. Other:_________________________

2. Felt sick 26. Didn't have health insurance Q. Patient education

3. Since there is no cure for HIV, why should I go to my doctor 27. Didn’t have enough money to pay my co-pay 51. Lack of understand of HIV disease

4. CD4 count and viral load are good 28. Was afraid that it might cost too much 52. Other:_________________________

29. Other:__________________________ R. Intimate partner violence

5. Didn’t think I am HIV positive H. Time management and Organization 53. Afraid to ask partner to use condoms

6. Didn’t want to think about being HIV positive 30. Forgot about my appt. 54. Other:_________________________

7. Other: __________________ 31. Forgot about my appt. S. Food Insecurity

B. Challenge with medical facility 32. Couldn't get the time off work or school 55. I don’t have enough food

8. Didn’t know when to follow-up with my healthcare provider 33. Had other responsibilities 56. Other:_________________________

34. Other:__________________________ T. Financial challenges

9. Didn’t not like the way I was treated at the clinic in the past I. Child Care 57. Intermittent public assistance

10. Clinic facility hours, locations, or wait-time is inconvenient 35. Had problems getting child care 58. Other:_________________________

36. Other:__________________________ U. Utilities

11. Didn’t trust the doctors J. Transportation 59. Can’t pay my utilities

12. Had a hard time making an appt. with the facility 37. Issues with transportation to my appt. 60. Other:________________________

38. Other:___________________________ V. Communication with service system

13. Couldn't get an appt. with a provider that I like K. Substance Abuse 61. No TTY

14. Took too long to get an appt. 39. Was too drunk or high 62. Language barrier

15. Had problem finding a provider who speaks my language 40. Other:___________________________ W. Other:__________________________

16. Other:___________________ L. Disclosure / Privacy 63._____________________________

C. Mental Health 41. Didn't want to go to the doctor until I told my family/friends

17. Felt depressed 42. Other:___________________________

18. Other:___________________ M. Religious Objection

D. Medication Adherence 43. Don't need to go to the doctor because GOD will cure me

19. Medication side effects 44. Other:___________________________

20. Other:___________________ N. Housing

E. Stigma 45. I had trouble finding a place to live

21. Didn’t want to be seen at an HIV clinic 46 Other

22. Other:___________________ O. Incarceration

F. Unemployment 47. I just got out of jail

23. I do not have a job 48. Other:____________________________

24. Other:___________________

Note: If the patient’s barrier is not listed above, please note the barrier in this section and provide the following information; Barrier domain, barrier, barrier priority, who identified the barrier, barrier status, intervention phase and any notes.

______________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________