Medical Monitoring Project Facility Survey (paper)

Survey ID

Form Approved

OMB No.: 0920-New

Expiration date: XX/XX/XXXX

Medical Monitoring Project Facility Survey

Attachment 4

MMP Facility Survey

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-New)

General instructions

1. Your health care facility was selected to receive the Centers for Disease Control and Prevention (CDC) Medical Monitoring Project (MMP) HIV facility survey because 1 or more patients with HIV have received care at your facility.

2. Who should complete the survey?  The survey should be completed by a senior facility administrator, nurse manager, and/or clinical director. If preferred, that person may call [insert name of CDC contractor] to provide their responses over the phone (xxx-xxx-xxxx).

3. Survey questions refer to characteristics of the facility providing HIV care at the location named in the survey invitation.

   1. Survey questions refer to characteristics of the facility during the past 12 months, unless otherwise specified.

   2. The term provider refers to a health care professional with prescribing privileges authorized by the state.

4. Do not include information that would identify the facility, e.g. name of facility, your name, or names of anyone who works at the facility. Survey data will only be associated with a facility ID number.

I. GENERAL CHARACTERISTICS

Facility ID code:

11-digit FIPS code:

Which terms describe the facility? (Choose all that apply.)

₁ Federally qualified Health Center (FQHC): Search

₂ FQHC look-alike: Definition

₃ Hospital-based (infectious disease clinic)

₄ Hospital-based (primary care clinic)

₅ Private practice

₆ State or local health department

₇ Veterans Administration

₈ STD clinic

₉ Research

₁₀ Other community-based organization

₁₁ Correctional facility

₁₂ Indian Health Service, Tribal Health, or Urban Indian Health Center

₁₃ Other, specify: ______________

Does the facility receive Ryan White HIV/AIDS Program funding?

₁ No

Yes ₂ Yes, choose all that apply below

₁ Part A

₂ Part B

₃ Part C

₄ Part D

₅ Part F (if not checked, skip to next question)

₁ SPNS

₂ AETC

₃ Dental

₄ MAI

Which types of health coverage does the facility accept? (Choose all that apply.)

₁ Medicaid, including Medicaid managed care

₂ Medicare, including Medicare Advantage

₃ Private insurance

₄ ADAP or other Ryan White coverage

₅ Veterans Administration

₆ Tricare

₇ Other, specify: ______________

₈ None of the above

Does the facility use a sliding fee scale for patients without health coverage, i.e., fees adjusted based on ability to pay?

₁ No

Yes ₂ Yes

Number of individual HIV care providers (full-time or part-time)

₁ Physicians (MD or DO)

₂ Nurse practitioners

₃ Other advance practice nurses (e.g., nurse specialist, midwife, anesthetist)

₄ Physician assistants

₅ Registered pharmacists (with prescribing privileges)

₆ Other, specify: ___________

Is there normally a physician at the facility at least 5 days per week who can provide HIV care (not necessarily the same individual each day)?

₁ No

Yes ₂ Yes

Does the facility have:

₁ Only full-time HIV care providers

₂ A mix of full-time and part-time HIV care providers

₃Only part-time HIV care providers

What physician specialties practice at the same geographic location as the facility (onsite)? (Choose all that apply.)

₁ Infectious disease

₂ Internal medicine

₃ Family medicine

₄ Other general practice

₅ Hematology/oncology

₆ Neurology

₇ Dermatology

₈ Pulmonary

₉ Obstetrics and gynecology

₁₀ Cardiology

₁₁ Psychiatry

_{11 12} Ophthalmology

_{12 13} Other, specify: _______________

Number of patients for whom the facility has provided HIV care during the past year, defined as having an HIV viral load or CD4 count ordered or being prescribed antiretroviral therapy for treatment of HIV. Consider running a report of HIV ICD-9/10 codes.

Does the facility provide medical care for people who do not have HIV?

₁ No (Skip next 2 questions)

Yes ₂ Yes

Does the facility provide HIV pre-exposure prophylaxis (PrEP)?

₁ No

Yes ₂ Yes

Does the facility provide HIV post-exposure prophylaxis (PEP)?

₁ No

Yes ₂ Yes

Does the facility provide HIV-specific stigma or discrimination training at least once for all staff who interact with patients.

₁ No

Yes ₂ Yes

Does the acility provide training in other areas of cultural competency at least once for all staff who interact with patients?

₁ No

₂ Yes, specify: _______________ (Examples)

II. CLINCAL AND SUPPORTIVE SERVICES

Which of these clinical and supportive services are currently available at the same geographic location (onsite) or through established outside referral relationships? (Choose all that apply.)

		Onsite	Established outside referral relationship
			
	Clinical case management provided by a nurse	1	2
	Other case management	1	2
	Patient navigation	1	2
	Peer support counseling	1	2
	Peer support groups	1	2
	Access to tools that support ART adherence, such as pill trays or dose reminder apps	1	2
	Social work	1	2
	Language interpretation services	1	2
	Assistance with transportation	1	2
	Assistance with housing	1	2
	Child care	1	2
	Mental health services	1	2
	Substance use disorders treatment	1	2
	Medication-assisted treatment (MAT) for substance use disorders	1	2
	Syringe services	1	2
	Tobacco cessation services	1	2
	Medical nutrition therapy	1	2
	Food bank or meal delivery	1	2
	Pharmacy	1	2
	Dental care	1	2
	High resolution anoscopy	1	2
	Gynecologic care	1	2
	Long-acting contraception (injection or implant)	1	2
	Colposcopy	1	2
	Prenatal care	1	2
	Transgender hormone therapy	1	2
	STI screening and treatment	1	2
	Counseling about reducing risk of HIV and STI transmission	1	2
	HIV testing for partners of HIV patients and others	1	2
	Free home HIV testing for partners of HIV patients and others	1	2

III. ENROLLMENT AND INITIATION OF ANTIRETROVIRAL THERAPY

Which of these documents are required for scheduling the first appointment with an HIV care provider? (Choose all that apply.)

		
	Proof of income	1
	Proof of residence	1
	Government-issued identification	1
	Result of a test for tuberculosis (PPD or IGRA)	1
	Positive HIV antibody or detectable viral load	1
	CD4 lymphocyte count result	1
	None of the above	1

Within how many business days of an initial request are HIV patients who are new to the facility routinely offered an appointment with an HIV care provider?

What are the barriers to offering new patients an appointment with an HIV care provider within 1 business day of an initial request? (Choose all that apply.)

		
	Patient preference	1
	Insufficient provider capacity to see rapid entry patients	1
	Patients lack documents required for facility enrollment	1
	Patients lack documents required for Ryan White HIV/AIDS Program enrollment	1
	Facility administration is not committed to rapid enrollment	1
	Other staff are not committed to rapid enrollment	1
	Other, specify: _________________________	1

Which of the following patients are routinely able to obtain a 30-day supply of antiretroviral medication on the day of their first visit with an HIV care provider? (Choose all that apply.)

		
	Patients with no prescription coverage, e.g., by using a pharmaceutical patient assistance program or funds designated for this purpose	1
	Patients without results of baseline laboratory tests	1
	All patients (If selected, skip next question)	1

Which of these are barriers to patients obtaining a 30-day supply of antiretroviral therapy on the day of the first HIV care provider visit? (Choose all that apply.)

		
	Patient preference	1
	Prescription not given because test results are not available	1
	Delay getting medication paid for	1
	Antiretroviral starter packs are not available to be given to patients	1
	Lack of trained staff to submit patient assistance program applications for free antiretrovirals	1
	Patient cannot afford copayment	1
	Providers are not committed to immediate antiretroviral initiation	1
	Facility administration is not committed to immediate antiretroviral initiation	1
	Lack of a standardized protocol for all clinicians to follow	1
	Other, specify: ___________	1

IV. HIV TELEHEALTH/TELEMEDICINE

Have any providers received HIV clinical consultation or mentoring from outside providers via remote conferencing, e.g., HIV ECHO ?

₁ No

Yes ₂ Yes

Have any providers provided HIV clinical consultation or mentoring for outside providers via remote conferencing, e.g., HIV ECHO ?

₁ No

Yes ₂ Yes

Have any patients received HIV clinical care from outside HIV providers via remote conferencing during a visit (in-person or virtual) at your facility?

₁ No

Yes ₂ Yes

Have any providers provided HIV clinical care for patients via remote conferencing?

₁ No

Yes ₂ Yes

V. SUPPORTING RETENTION IN CARE

Does the facility use data to systematically monitor retention in care of all HIV patients?

₁ No (skip next question)

Yes ₂ Yes

Which types of data does the facility use to monitor retention in care? (Choose all that apply.)

		
	Internal data (e.g., electronic health record or billing data)	1
	Health department surveillance data	1
	CAREWare	1
	Pharmacy refill data	1
	Other, specify:___________________	1

Does the facility collaborate with the state or local health department to identify or contact patients who are out of care, e.g., by providing clinic data or contact information to the health department?

₁ No

Yes ₂ Yes

Does the facility send patient reminders before all provider appointments?

₁ No (skip next question)

Yes ₂ Yes

Which of these patient reminders are routinely used at the facility (?

		
	Text, email, or patient portal message	1
	Automated phone calls	1
	Live phone calls	1
	Letter	1

Does the facility follow-up on all missed appointments?

₁ No (skip next question)

Yes ₂ Yes

With which methods does the facility follow-up on missed appointments? (Choose all that apply.)

		
	Text, email, or patient portal message	1
	Automated phone calls	1
	Live phone calls	1
	Letter	1
	Outreach in the field by a facility employee	1

Is there a pharmacy at the same geographic location as the facility (onsite)?

₁ No (skip to COVID section)

Yes ₂ Yes

Does the facility have direct access to information about prescription fulfillment and pick-up by patients?

₁ No (skip next 2 questions)

Yes ₂ Yes

Does the facility notify patients of all missed prescription pickups?

₁ No (skip next question)

Yes ₂ Yes

With which methods does the facility notify patients of missed prescription pick-ups?

		
	Text, email, or patient portal message	1
	Automated phone calls	1
	Live phone calls	1
	Letter	1

VI. PREVENTION OF PATIENT EXPOSURE TO COVID-19

Which of these measures has your facility taken to protect patients from exposure to COVID-19? (Choose all that apply.)

		
	Screening of all staff and patients for COVID-19 before entering the facility, i.e.,temperature and symptom screening.	1
	Separation of patients in waiting areas by at least 6 feet.	1
	Face masks worn at all times by all persons in the facility.	1
	Telehealth provider visits offered to all patients not requiring face-to-face contact.	1
	Telehealth visits with other facility staff (e.g., case managers/social workers, mental health staff, financial counselors) offered to all patients not requiring face-to-face contact.	1
	Home visits for patients requiring face-to-face contact.	1
	Deferring of routine CD4 and viral load testing.	1
	Arranging delivery of prescriptions rather than pick-up at the pharmacy	1

23