CDC Service Delivery Induction Interview Sample Card

Attachment E2 2019 NAMCS-201 CHC Service Delivery

Site Induction Interview Sample Card

Variable name

Question text and answer categories

START

One button is selected to start the interview:

1. Continue

2. Noninterview (Unable to locate, refusal, etc.)

3. Issue preventing CHC facility interview

4. Quit

CHCTYPE

How would you classify this center?
Enter all that apply - separate with commas

1. Federally-funded Community Health Center (330)

• Community Health Center (CHC)

• Migrant Health Center (MHC)

• Health Care for the Homeless (HCH)

• Public Housing Primary Care (PHPC) grant program

2. Federally Qualified Health Center, but not federally funded (330 look-alike)

3. Urban Indian (437) Health Center

4. None of the above

ADDCHECK

We have your address and telephone number as
(Name and Address) (Phone number)
Is this correct?

1. Yes

2. No, update address and phone

CHC_NAME

What is the correct address?
        Enter 1 to update the CHC name, address, and phone

AVG_WEEKS

On average, in a normal year, how many weeks does the CHC at this location see patients?"

________Number of weeks

WEEK_FOLLUP

You indicated that this CHC LOCATION does not usually see patients in a typical year, is this correct?

1. Yes

2. No

INTRO_SAMP

I would like to discuss a plan for conducting the National Ambulatory Medical Care Survey (NAMCS) to a sample of your providers.  This center has been assigned to a 1-week reporting period that begins on Monday, (Reporting period start date) and ends on Sunday, (Reporting period end date).

I will need to sample 3 providers from your Center.  In order to do this, I will need the name, specialty, and estimated visit volume, corresponding to the sample week, for all physicians and mid-level providers only at the currently sampled in-scope location.

 Please include all providers even if they do not plan on seeing patients during the sample week. In-scope locations include all fixed locations that provide health care, including mobile clinics, and specialty clinics. Please do not include providers that work solely at school-based clinics.

Please exclude anesthesiologists, dentists, hygienists, optometrists, pathologists, psychologists, podiatrists, and radiologists.  Please also exclude any interns, residents, or fellows. Include physicians (both MDs and DOs), nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNMs).

List all providers only from the currently sampled in-scope location, even if they do not expect to see patients during the sampled week.  Enter a zero for the expected visit volume for those providers with no expected visits.   

If the CHC that has been sampled is a health department, please verify that they will not be distributing the 330 grant money to other administratively unconnected community health centers.  If the health department does distribute the money to other CHCs, these need to be sampled, so please contact your supervisor for further instructions. 

PROV_FNAME

What is the provider's first name?
(Include providers from only the sampled CHC location.)

PROV_MNAME

What is the provider's middle name?

PROV_LNAME

What is the provider's last name?

PROV_TYPE

Is (Provider's name) a Medical Doctor (MD) or Doctor of Osteopathy (DO), Nurse Practitioner (NP), Physician Assistant (PA), or Certified Nurse Midwife (CNM)?

1. Medical Doctor (MD)

2. Doctor of Osteopathy (DO)

3. Nurse Practitioner (NP)

4. Physician Assistant (PA)

5. Nurse Midwife (NMW)

Skip Instructions:

1,2: Goto PROV_SPEC
Else goto PROVIDED

PROV_SPEC

What is (Provider's name)'s specialty?
  Enter 'XXX' if the specialty is not listed

PROV_SPEC2

  Is the provider an anesthesiologist, dentist, hygienist, optometrist, pathologist, psychologist, podiatrist, or radiologist?

1. Yes

2. No

PROV_SPEC_SP

  Enter verbatim response for specialty

PROVIDED

?  [F1]
What is the expected visit volume during the sample week for (Provider's name)?
         Enter 0 if provider does not expect to see patients during the reference period.

PREVSAMP

  Compare this provider ((Providers name)) to the listed providers that have been sampled from this community health center in the past.  
        Previously sampled providers
        (Previously sampled providers)

1. Yes, previously sampled

2. No, not previously sampled

VER_PREVSAMP

  Were the previously sampled providers selected correctly?
           Current name                     Previous name
         (Current provider names)     (Previously sampled provider names)

1. Yes

2. No

NOPATIENTS

You have told me that NONE of these providers expect to see patients during the sample week that begins on Monday, (Reporting period start date) and ends on Sunday, (Reporting period end date).  Is this correct?

1. Yes, there are no providers seeing patients during reference week

2. No, incorrect - there are providers seeing patients

Skip Instructions:

1: Exit block and goto BlkBACK.THANK_OOS
2: Go back to TblProv1.PROV_FNAME for the last row.

PROV_STRT

What is (Provider's name)'s address?
           Enter number and street.

PROV_STRT2

What is (Provider's name)'s address?
           Enter line two of address.

PROV_CITY

What is (Provider's name)'s address?
          Enter city.

PROV_STATE

What is (Provider's name)'s address?
          Enter state.

PROV_ZIPCODE

What is (Provider's name)'s address?
         Enter zipcode.

PROV_LOCTYPE

    Enter location/address type

1. Main Office address

2. Alternative/2nd office address

3. Home office

4. Home

5. Unknown

PROV_PHONE

What is (Provider's name)'s telephone number?

PROV_PHTYP

What type of telephone number is this?

0. Main

1. Home

2. Work

3. Mobile

4. Pager, Beeper, Answering Service

5. Public pay phone

6. Toll Free

7. Other

8. Fax

9. Unknown

GREET_NAME

  Enter Greet Name
   (Greet name will be used on the letter that is sent to the provider.)
    Provider Name:  (Provider's name)

MOSTVIS_INTRO

The next section refers to characteristics of the sampled CHC at this location.

NUMPH

(one location listed)

The next questions are about the CHC that is associated with [Pre-fill location].

How many physicians are associated with this CHC? Please include physicians at (address) and physicians at any other locations of this CHC. Do not include interns, residents, or fellows.

1. 1 Physician

2. 2-3 physicians

3. 4-10 physicians

4. 11-50 physicians

5. 51-100 physicians

6. More than 100 physicians

NUMPH

(two or more locations listed)

N/A

PCMH

Is the CHC at this location certified as a patient-centered medical home?

1. Yes

   1. By whom is the CHC at this location certified as a patients-centered medical home? CERT_WHO

      1. Accreditation Association for Ambulatory Health (AAAH)

      2. Joint Commission

      3. National Committee for Quality Assurance (NCQA)

         1. [If yes:]  What level of certification for the National Committee for Quality Assurance (NCQA)? NCQAlevel

            1. Level 1

            2. Level 2

            3. Level 3

      4. Utilization Review Accreditation Commission (URAC)

      5. Other – Specify PCMH_OTH____________

      6. Unknown

2. No

3. Unknown  

QUAL

Does the CHC at this location report any quality measures or quality indicators to either payers or to organizations that monitor health care quality?

1. Yes

2. No

3. Unknown

ACCESS

Is it possible within the CHC at this location to access patient medical records using an electronic health record (EHR) system 24 hours a day?

1. Yes ACCESS_PH

   1. [If yes:] Is this access available to physicians only, or is it also available to other non-physician clinicians? 

1. Physicians (MD/DO) only.

2. All Physicians and non-physician Clinicians.

3. Unknown

2. No

3. Unknown

PMETHOD

What is the primary method by which the CHC at this location receives information about patients in this CHC when they have been seen in the emergency department or hospitalized? (Mark only one box)

1. Electronic transmission (i.e., EHR or EMR)

2. Fax

3. Email

   1. [If yes:] Was this email sent over a secure network? SECNET

1. Yes

2. No

3. Unknown

4. Telephone or in-person communication with provider

5. Paper copy

6. Other PMETHOD_SP

TRANS

Is someone in the CHC at this location responsible for assisting patients to safely transition back to the community within 72 hours of being discharged from a hospital or nursing home?

1. Yes

2. No

3. Unknown

PROTO

Does the CHC at this location have written protocols for providing chronic care services that are used by all members of the care team?

1. Yes

2. No

3. Unknown

DIFTIN

Do all other locations or offices associated with the CHC at this location use the same Federal Tax ID, also known as an Employer Identification Number (EIN), or do any locations or offices associated with the CHC at this location use a different Federal Tax ID or EIN?

1. All use the same Federal Tax ID or EIN

2. Some use a different Federal Tax ID or EIN

3. Unknown 

Staffing Types

(34 variables)

The next set of questions refer to the types of providers who work at [Pre-fill location].

How many of the following full-time and part-time providers are on staff at [Pre-fill location]?

Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.

Please provide the total number of full-time and part-time providers.

Please include the sampled provider in the total count of staff below.

2	Number Full-time (≥30 hours)	Number Part-time (<30 hours)
Physicians (MD and DO)	MD_DO_FT	MD_DO_PT
Non-Physician Clinicians
Physician Assistants (PA)	PA_FT	PA_PT
Nurse Practitioners (NP)	NP_FT	NP_PT
Certified Nurse Midwives (CNM)	CNM_FT	CNM_PT
Clinical Nurse Specialist (CNS)	CNS_FT	CNS_PT
Nurse Anesthetists (NA)	NA_FT	NA_PT
Other Nursing Care
Registered nurses (RN) (not an NP or CNM)	RN_FT	RN_PT
Licensed Practical Nurses (LPN)	LPN_FT	LPN_PT
Certified Nursing Assistants/Aides (CNA)	CNA_FT	CNA_PT
Allied Health
Medical Assistants (MA)	MA_FT	MA_PT
Radiology Technicians (RT)	RT_FT	RT_PT
Laboratory Technicians (LT)	LT_FT	LT_PT
Physical Therapists (PT)	PT_FT	PT_PT
Pharmacists (Ph)	PH_LT	PH_PT
Dieticians/Nutritionists (DN)	DN_FT	DN_PT
Other
Mental Health Providers (MH)	MH_FT	MH_PT
Health Educators/Counselors (HEC)	HEC_FT	HEC_PT
Case Managers (not an RN)/Certified Social Workers (CSW)	CSW_FT	CSW_PT
Community Health Workers (CHW)	CHW_FT	CHW_PT

Autonomy of PAs, NPs, CNMs, CNSs, & NAs (15 variables)

The following questions concern the PAs, NPs, CNMs, CNSs, & NAs practicing at [Pre-fill location].

A.      Physician Assistant	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the PA’s patients logged separately from other providers at this CHC? PA_LOG
Do/does the PA(s) bill for services using their own NPI number? PA_BILL
B.      Nurse Practitioner	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the NP’s patients logged separately from other providers at this CHC? NP_LOG
Do/does the NP(s) bill for services using their own NPI number? NP_BILL
C.      Certified Nurse Midwife	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the CNM’s patients logged separately from other providers at this CHC?CNM_LOG
Do/does the CNM(s) bill for services using their own NPI number? CNM_BILL
D. Clinical Nurse Specialist	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the CNS’s patients logged separately from other providers at this CHC?CNS_LOG
Do/Does the CNS(s) bill for services using their own NPI number? CNS_BILL
E. Certified Nurse Anesthetists	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the CRNA’s patients logged separately from other providers at this CHC? NA_LOG
Do/Does the NA(s) bill for services using their own NPI number? NA_BILL

EMR_INTRO

Answer ALL remaining questions for the current CHC location, which is [Pre-fill].

EBILLREC

Does the CHC reporting location submit any claims electronically (electronic billing)?

1. Yes

2. No

3. Unknown

EMEDREC

Does the CHC reporting location use an electronic health record (EHR) system? Do not include billing record systems.

1. Yes, all electronic

2. Yes, part paper and part electronic

3. No

4. Unknown

EHRINSYR

In which year did the CHC install your current EHR/EMR system?

HHSMU

Does the CHC’s current system meet meaningful use criteria as defined by the Department of Health and Human Services?

1. Yes

2. No

3. Unknown

EHRNAM

What is the name of the CHC’s current EHR system?

1. Allscripts

2. Amazing charts

3. athenahealth

4. Cerner

5. eClinicalWorks

6. e-MDs

7. Epic

8. GE/Centricity

9. Modernizing Medicine

10. NextGen

11. Practice Fusion

12. Sage/Vitera/Greenway

13. Other-Specify EHRNAMOTH

14. Unknown

EMRINS

At the CHC reporting location are there plans for installing a new EHR system within the next 18 months?

1. Yes

2. No

3. Maybe

4. Unknown

EDEMOG EPROLST

EPNOTES

EMEDALG

EMEDID

EREMIND

ECPOE

ESCRIP

EWARN

ECONTRSUB

ECONTRSUBS

ECTOE

ERESULT

ERADI

EIMGRES

EIDPT

EGENLIST

EDATAREP

ESUM

EMSG

EPTREC

Please indicate whether the CHC reporting location has each of the following computerized capabilities and how often these capabilities are used.

These 5 answer choices are for each of the following items a-q.

1. Yes

2. No

3. Unknown

1. Recording patient history and demographic information?

2. Recording patient problem list?

3. Recording clinical notes?

4. Recording patient’s medications and allergies?

5. Reconciling lists of patient medications to identify the most accurate list?

6. Providing reminders for guideline-based interventions or screening tests?

7. Ordering prescriptions?

1. If Yes, ask – Are prescriptions sent electronically to the pharmacy?

2. If Yes, ask – Are warnings of drug interactions or contraindications provided?

8. Do you prescribe controlled substances?

1. If Yes, ask Are prescriptions for controlled substances sent electronically to the pharmacy?

9. Ordering lab tests?

1. If Yes, ask – Are orders sent electronically?

10. Viewing lab results?

1. If yes, ask – Can the EHR/EMR automatically graph a specific patient’s lab results over time?

11. Ordering radiology tests?

12. Viewing imaging results?

13. Identifying patients due for preventive or follow-up care?

14. Providing data to generate lists of patients with particular health conditions?

15. Providing data to create reports on clinical care measures for patients with specific chronic conditions (for example, HbA1c for diabetics)?

16. Providing patients with clinical summaries for each visit?

17. Exchanging secure messages with patients?

REFOUT

Please remind the CHC administrator that when responding to any of the remaining questions with the word “you”/”your” in the text, they should refer to the currently sampled CHC location.

Do you refer any patients to providers outside of the CHC?

1. Yes

2. No

REFOUTHOW

How do you send patient health information to them? Electronically does not include scanned or PDF documents, fax, or eFax.

1. Electronically (EHR, webportal, or online registries)

2. Via paper-based methods (Fax, eFax, or mail)

3. Do not send patient health information to providers outside of this CHC

REFIN

Do you see patients from providers outside of the CHC?

1. Yes

2. No

REFINHOW

How do you receive patient health information from them? Electronically does not include scanned or PDF documents, fax, or eFax. Check all that apply.

1. Electronically (EHR, webportal, or online registries)

2. Via paper-based methods (Fax, eFax, or mail)

3. Do not send patient health information to the provider

ESHARE

The next questions are about sharing (either sending or receiving) patient health information.

Do you share any patient health information electronically?

Electronically does not include scanned or PDFdocuments from fax, eFax, or mail.

1. Yes

2. No

ESHARES

Do you electronically send patient health information to another provider whose EHR system is different from your own?
    

1. Yes

2. No

3. Don’t know

ESHARER

Do you electronically receive patient health information from another provider whose EHR system is different from your own?
    

1. Yes

2. No

3. Don’t know

EDISCHSR

Do you electronically send or receive hospital discharge summaries to or from providers outside of the CHC? Check all that apply.
    

1. Send electronically

2. Receive electronically

3. Do not send or receive

EEDSR

Do you electronically send or receive emergency department notification to or from providers outside the CHC? Check all that apply.    

1. Send electronically

2. Receive electronically

3. Do not send or receive

ESUMCSR

Do you electronically send or receive summary of care records for transitions of care or referrals to or from providers outside of the CHC? Check all that apply.    

1. Send electronically

2. Receive electronically

3. Do not send or receive

PTONLINE

Can patients seen at the CHC do the following online activities? Check all that apply.
    

1. View their medical record online

2. Download and transmit health information in the electronic medical record to their personal files

3. Request corrections to their electronic medical record

4. Enter their health information online (e.g. weight, symptoms)?

5. Upload their data from self-monitoring devices (e.g. blood glucose readings)?

6. None of the above

Revenue & Contracts, Compensation, New Patients

PR330

PRTITLEV

PROTHFED

PRSTLOC

PRPRIVAT

PRCARE

PRCAID

PRFEES

PROTHER

TOTALGRANT

What percent of your CHC's revenue comes from the following sources?

1. 330 Grant

2. Title 5 grant or contract

3. Other Federal Grant

4. State/Local Grant

5. Individual, corporation or foundation grants or donations

6. Medicare

7. Medicaid/CHIP

8. Patient payments

9. Other (including private insurance, Tricare, VA, etc.)?

PRMCARE PRMAID

PRPRVT

PRPATPAY

PROTH

Please remind the CHC administrator that the remaining questions refer to the current CHC location, which is [Pre-fill-in location].

I would like to ask a few questions about the current CHC’s revenue and contracts with managed care plans.

What percent of your patient care revenue comes from the following sources…

1. Medicare?

2. Medicaid?

3. Private insurance?

4. Patient payments

5. Other (including charity, research, Tricare, VA, etc.)?

PCTRVMAN

Roughly, what percent of the patient care revenue received by this CHC comes from managed care contracts?

REVFFS

REVCAP

REVCASE

REVOTHER

Roughly, what percent of your patient care revenue comes from each of the following methods of payment?

1. Fee-for-service?

2. Capitation?

3. Case rates (for example, package pricing/episode of care)?

4. Other?

ACEPTNEW

Are you currently accepting "new" patients into the CHC at [Fill-in location]?

1. Yes

2. No

3. Don’t know

CAPITATE

NOCAP

NMEDICARE

NMEDICAID

NWORKCMP

NSELFPAY

NNOCHARGE

From those new patients, which of the following types of payment do you accept at [Fill-in location]?

1. Capitated private insurance?

2. Non-capitated private insurance?

3. Medicare?

4. Medicaid?

5. Workers’ compensation?

6. Self-pay?

7. No charge?
   
   

The following answer choices are used for each of the above seven payment types:

1. Yes

2. No

3. Don’t know

PHYSCOMP

Which of the following methods best describes your basic compensation for providers at this CHC?

Bold answer choices & add FR instruction to prompt them to read answers aloud.

1. Fixed salary

2. Share of practice billings or workload

3. Mix of salary and share of billings or other measures of performance (e.g., provider’s own billings, practice's financial performance, quality measures, practice profiling)

4. Shift, hourly or other time-based payment

5. Other

COMP

CHCs may take various factors into account in determining the compensation (salary, bonus, pay rate, etc.) paid to the physicians/providers in the CHC.  Please indicate whether the CHC explicitly considers each of the following factors in determining your compensation. 
  Enter all that apply, separate with commas

1. Factors that reflect the providers own productivity

2. Results of satisfaction surveys from the provider’s patients

3. Specific measures of quality, such as rates of preventive services for the provider’s patients

4. Results of practice profiling, that is, comparing the provider’s pattern of using medical resources with that of other providers

5. The overall financial performance of the CHC

SASDAPPT

Does the CHC set time aside for same day appointments?

1. Yes

2. No

3. Don’t know

Skip Instructions:

1. Goto SDAPPT

SKIP to APPTTIME

APPTTIME

On average, about how long does it take to get an appointment for a routine medical exam?

1. Within 1 week

2. 1 - 2 weeks

3. 3 - 4 weeks

4. 1 - 2 months

5. 3 or more months

6. Do not provide routine medical exams

7. Don't know

CALLBACKNOTES

I'd like to schedule a DATE to (conduct/complete) the interview.
What DATE AND TIME would be best to visit again?
           Today is:  ^IntDate                        

Skip Instructions:

RF: Goto CBREF
All others, goto THANKCB

CBREF

   Exit this case now.
    Call the case up again and make it a non-interview before transmitting.

THANKCB

Thank you.
I will call/come back at the time suggested
      Revisit   (Appointment information)

THANKYOU

This concludes the interview.  Thank you for your patience, and for taking the time to answer our questions.

THANK_OOS

Thank you (Respondent name), your center is not within the scope of this study.
We appreciate your time and interest.

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