Form 1 Attachment G: Primary Care Site Organizational Character

A

Form Approved
OMB No. XXXX-XXXX
Exp. Date XX/XX/XXXX

ttachment G: Primary Care Site Organizational Characteristics Survey

OVERVIEW:

This self-administered questionnaire will collect primary care site background information to inform the subsequent workflow mapping activities. This questionnaire asks about the primary care site’s organizational characteristics, its staff, patient records, and care coordination with hospitals.

PARTICIPANTS:

One primary care site administrator who is knowledgeable about the clinical and administrative operations of the site, such as a medical director, will fill out this survey. The research participants will receive the survey as an editable Microsoft Word file via email.

MATERIALS:

In order to complete the data collection instrument, each participant will be provided the Project Summary for the Re-engineered Visit for Primary Care (AHRQ REV).

INSTRUMENT AND ADMINISTRATION:

Instructions: The questions about your primary care practice’s organizational characteristics. Please answer to the best of your ability.

Organizational characteristics

1. Is the practice a patient-centered medical home recognized by the National Committee for Quality Assurance (NCQA)? If so, at what level?

2. Does the practice have administrative support beyond this unit (e.g. from the parent organization)? For instance, centralized appointment making, centralized follow up phone calls, etc.

3. What is the payer mix of the practice?

Payer mix	%
Medicare
Medicaid
Commercial
Self-pay/uninsured
Total	100

4. Is the practice in a risk-bearing contract(s)? If yes, for which payer(s) and what kind of risk-bearing contract(s)?

5. Is the practice in an accountable care organization (ACO)? If yes, for which payer(s)?

6. What percentage of practice revenue is currently fee-for-service based?

Primary care site staff

7. How many primary care providers are there in the practice? Please list the number of each type of provider there are in the practice.

Primary care providers	#
Medical Doctor
Doctor of Osteopathic Medicine
Nurse Practitioner
Physician Assistant
Total

8. How many other clinical staff are there? Please list the number of each type of clinical staff there are in the practice.

Other clinical staff	#
Registered nurse (RN)
Licensed practical nurse (LPN)
Pharmacist
Social worker
Medical Assistants
Lab Techs
Other (please describe)
Other (please describe)
Total

9. How many support staff (administrative, secretarial, etc.) are there in your practice?

Support staff	#
Administrator
Secretary
Billing
IT Analyst
Other (please describe)
Other (please describe)
Total

Patient records

10. How does your practice define active patients (such as the patient had a visit at the practice within 12 months, 18 months, 24 months, etc.)?

11. What electronic medical record do you use?

12. Do you use a specific care management electronic record or tool? If so, what?

13. Do you use a specific population health electronic registry or data management system? If so, what?

14. Do you currently manage population health using registries?

    1. If yes, for which patient populations?

Care coordination with hospitals

15. Does the practice use CMS care coordination codes?

16. Complete the following table. For the top two hospitals where your adult patients most frequently receive inpatient care, including whether these hospitals have formal care transitions programs and whether they notify your practice of hospitalizations.

Hospitals your patients go to for inpatient care	Hospital 1	Hospital 2
% of hospitalizations among adult patients in the practice
Does this hospital have a formal care transitions program? (Yes/No)
Does this hospital notify your practice that one of your patients has been hospitalized? (Yes/No)
Are these notifications in real-time? (Yes/No)
If real-time, are these alerts automated or manual? (Automated/Manual/N/A)

Public reporting burden for this collection of information is estimated to average 90 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Rockville, MD 20857.

11/2016 The Re-engineered Visit for Primary Care (AHRQ REV) – Attachment G 3