Form 2 Attachment H: Primary Care Site Patient Characteristics

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

Attachment H: Primary Care Site Patient 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 patient demographics, hospitalizations, and timing of follow-up primary care visits.

PARTICIPANTS: One primary care staff member who has access to review and extract information from the primary care site’s billing, clinical, or other IT systems.

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: Please answer the following questions on this primary care practice’s systems. Please indicate “not available” if the data is not collected or not readily available in your billing, clinical, or other IT systems.

Patient characteristics: Complete the chart below.

	Demographic characteristics	%
Total Sex	Adult Patients Male
Age	18-25 years old
	26-44 years old
	45-64 years old
	65-84 years old
	85+ years old
Ethnicity	Hispanic, Latino/a, or Spanish origin
Race	White
	Black or African American
	American Indian or Alaska Native
	Asian
	Pacific Islander
	Other
	Refused/Unreported

1. What percentage of all patients are active patients (such as had a visit at the practice within 12 months, 18 months, 24 months, etc.)?

Hospitalizations

2. How many of the adult patients in your practice were hospitalized last month?

3. How many hospitalizations occurred among your adult patients in the last month?

4. How many hospitalizations occurred among the adult patients in your practice in 2015?

Readmissions

5. How many 30-day readmissions occurred among the adult patients in your practice in the last month?

6. What is your practice’s adult patient population’s 30-day readmission rate in the past year?

7. What percent of your patient population was hospitalized four or more times in the 2015?

1. How many hospitalizations in total did this subgroup have in the past 12 months?

2. What was the 30-day readmission rate of this subgroup in the past 12 months?

Referrals to the hospital

8. What proportion of patients are referred to the hospital by the following parties? Please estimate if necessary.

Referral source to hospital	%
The practice
Another provider
Self-referred
Total	100

Primary care follow-up

9. What proportion of your hospitalized patients had outpatient follow-up in your practice or with a relevant specialist in the following time frames?

Timing of patients seen in acute care setting	%
7 days or fewer
8 to 14 days
14 to 28 days
28 days or more
No follow-up
Total	100

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 H 3