Form 0920-0234 Att F1- 2020 NAMCS-201 CHC Service Delivery Site

Attachment F1: 2020 NAMCS-201 CHC Service Delivery Site

Induction Interview

Form Approved

OMB No. 0920-0234

Exp. Date 05/31/2022

Notice-CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0234).

Assurance of confidentiality-We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

Variable Name

Question Text and Answer Categories

START

1. Continue [goto DIAL]

2. Noninterview (Unable to locate, refusal, etc.) [goto NONINT_TYPE]

3. Issue Preventing CHC Facility Interview [goto CALL_RO]

4. Quit [goto DONE]

DIAL

Dial number (Last respondent: (director’s name/respondent’s name))

Director’s Phone 1:

Director’s Phone 2:

CHC Phone 1:

CHC Phone 2:

Other Contact Phone 1:

Other Contact Phone 2:

1. Someone answers [goto HELLO]

2. All phone numbers bad/Need new number [goto NOGOOD_PHN]

3. No answer/problem [goto NOGOOD_PHN]

NONINT_TYPE

Enter type of noninterview

1. Unable to locate-await guidance from RO

[goto NONINT_NAME]

2. Potential Refusal-follow-up required

[goto NONINT_NAME to NONINT_PTYPE—EXIT_THANK]

3. Refusal

[goto NONINT_NAME to NONINT_PTYPE—EXIT_THANK]

4. Out-of-Scope-Specify

[goto OOS_SPECIFY]

5. Moved-further work needed to obtain address

[got NONINT_NAME to NONINT_PTYPE—EXIT_THANK]

OOS_SPECIFY

Specify Out of Scope [goto NONINT_NAME to NONINT_PTYPE--EXIT_THANK]

CALL_RO

Call your RO and inform them of the situation (if you have not already done so).

Await resolution from the RO before continuing with this case.

1. Enter 1 to Exit [goto DONE]

NONINT_NAME

NONINT_TITLE

NONINT_PHONE

NONINT_PTYPE

Enter the name of the person who provided the information. If necessary, ask “What is your name?”

Enter title of the person who provided the information. If necessary, ask “What is your title?”

Enter phone number of the person who provided the information. If necessary, ask “What is your phone number?” Enter “0” if none

Enter the phone number type. If necessary, ask “What type of phone is this?”

0. Main

1. Home

2. Work

3. Mobile

4. Pager, Beeper, Answering Service

5. Toll Free

6. Other

7. Fax

8. Unknown

[goto EXIT_THANK]

EXIT_THANK

Thank you for your time.

HANG UP.

NOGOOD_PHN

All phone numbers for this case are bad.

Press Alt-F9 to remove delete/update phone numbers.

After exiting the case, try to find a new number for this Community Health Center. [if DIAL=2]

1. Enter 1 to Exit [goto DONE]

[OR]

All numbers have been tried. [if DIAL=3]

Try this case another time.

1. Enter 1 to Exit [goto DONE]

[exit instrument]

HELLO

Hello. This is (FR’s name) from the U.S. Census Bureau.

May I speak to (director’s name/respondent’s name)?

If call is transferred, repreat this screen whan phone is answered

Case Status: New Case

If respondent indicates non-interview status or there is an issue preventing the interview, go back to START screen and report the case accordingly.

1. Correct person, correct person called to the phone, or call is transferred to correct person [goto INTRO_APPT]

2. Uknown/no longer there [toto CORRECT_CHC]

3. Respondent can best be reached on a different number [goto REACHED_ON]

4. Not abailable now, not at desk, etc. [goto BACK_LATER]

5. On vacation or otherwise temporarily away from work [goto BACK_LATER]

6. Other outcome or problem interviewing respondent [goto DONE]

CORRECT_CHC

Is this (fill CHC name)?

1. Yes [goto NEW_DIRECTOR]

2. No [goto EXIT_THANK]

NEW_DIRECTOR

What is director’s name?

Enter 1 to record a new director

1. Enter 1 to update information [update director’s info-continue-goto HELLO]

2. Continue [goto HELLO]

REACHED_ON

What phone number should I use to reach (director’s name)

Press Alt-F9 To update Phone number(s)

(When done updating phone(s), enter 1 to continue)

[goto TRANSFER]

TRANSFER

Can you transfer me?

1. Yes [goto HELLO]

2. No [goto EXIT_THANK]

BACK_LATER

Do you want to call back later to try and speak to (director’s greet name/respondent’s name) or do you want to continue with a new/different respondent?

REPORTING PERIOD: (reporting period start date)-(reporting period end date)

1. Yes, callback later [togo DONE]

2. Continue with new/different respondent [goto KNOWL_RESP]

KNOWL_RESP

Perhaps you can help me. I am calling on behalf of the National Center for Health Statistics. May I speak to someone who can answer questions about ambulatory care?

Previous Respondent(s)

(list names)

1. Person you are speaking with can help [goto OTH_NAME]

2. Someone else can help [goto OTH_NAME]

OTH_NAME

What is your/their name and title?

Enter 1 to update contact information

1. Enter 1 to update information [update-goto HELLO]

2. Continue [goto DONE]

INTRO_APPT

Hello (director’s name/respondent’s name).

I am (FR’s name). I’m calling for the CDC’s National Center for Health Statistics regarding their study of ambulatory care. You should have received a letter from the Director of the National Center for Health Statistics, explaining the study. You probably also received a letter from the U.S. Census Bureau. We are acting as the data collection agency for this study.

I would like to arrange an appointment with you within the next week or so to discuss the study.

It will take about 30 minutes.

What would be a good time for you before (reporting period begin date)?

[wording before sample week]

What would be a good time for you?

[wording after sample week]

Enter 999 to start induction now

If respondent indicates non-interview status or there is an issue preventing the interview, go back to START screen and report the case accordingly.

[goto CHCTYPE]

CHCTYPE

You must make sure that every respondent answering the following induction interview questions has provided informed consent. To ensure informed consent, please ask each different respondent if they have seen the advance letter sent from NCHS. If they have not seen the letter, please provide a copy and offer to summarize the contents before continuing the induction interview.

How would you classify this center? Would you say that it is a…

Enter all that apply - separate with commas

If you have called the RO and confirmed the location is 4. None of the above, go to START screen and report the case accordingly.

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 [reminder then exit the case and call Census RO]

[1-3 goto ADDHCECK]

[4-verify-gotto DONE]

ADDCHECK

Verify the following information is correct.

[fill sampled CHC address]

[fill sampled CHC phone number]

[fill CHC director’s name]

If information is available, update the Director’s name.

This pre-filled address represents the sampled CHC. In vary rare cases, this might need to be changed; if so, please contact your RO before updating and explain the circumstances. However, simple modification such as an updated suite number are acceptable.

1. Yes, information is correct [got AVG_WEEKS]

2. No, updates needed [goto CHC_NAME]

CHC_NAME

Enter 1 to update the CHC name, address, and phone

Update Director information, if available.

AVG_WEEKS

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

[if 0 goto WK_FOLLUP]

WK_FOLLUP

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

1. Yes [goto INTRO_SAMP]

2. No [goto AVG_WEEKS]

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 advanced practice providers only at the currently sampled in-scope location.

The term “advanced practice provider” is to be used by field representatives during the interview to refer to nurse practitioners, physician assistants, or certified nurse midwives. However, please note that some respondents may also use the terms “mid-level provider” or “non-physician clinician” to refer to this same group of providers.

Please include all providers even if they do not see expect to see patients during the sample week.

[wording before sample week]

Please include all providers even if they did not see patients during the sample week.

[wording after sample week]

In-scope locations include all fixed locations that provide health care, including module 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 from the currently sampled in-scope location, even if they did not expect see patients during the sampled week.  

[wording before sample week]

List all providers from the currently sampled in-scope location, even if did not see patients during the sampled week.

[wording after sample week]

Enter a zero for the actual visit volume for those providers with no actual 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. 

Enter all applicable providers working at sampled CHC during sample week

PROV_FNAME

Let’s start with the first provider. What is the provider's first name?
Interns, residents, and fellows are not included. Enter 999 for no more providers.

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) [goto PROV_SPEC]

2. Doctor of Osteopathy (DO) [goto PROV_SPEC]

3. Nurse Practitioner (NP) [goto PROVIDED]

4. Physician Assistant (PA) [goto PROVIDED]

5. Certified Nurse Midwife (NMW) [goto PROVIDED]

PROV_SPEC

What is (provider's name)'s specialty?
Enter 'XXX' if the specialty is not listed. Job A contains a list of physician specialties. Where applicable, please encourage respondent to use this list.

[if ‘XXX’ goto PROV_SPEC2]

PROV_SPEC2

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

1. Yes [goto PROV_SPEC_SP]

2. No [goto PROV_SPEC_SP]

PROV_SPEC_SP

Enter verbatim response for specialty

PROVIDED

What was the visit volume during the sample week for (provider's name)?

• Enter 0 if providers did not see patients during the reference period.

[if >1 provider at CHC, goto PROV_FNAME and enter provider information]

[if entered all providers in table, enter ‘999’ and goto DoneTblProv1]

DoneTblProv1

(asked after all information for all CHC providers has been entered)

Have you entered in all providers for this location?

If yes, you will not be able to go back and enter any additional provider for this location.

1. Yes [goto PROV_STRT]

2. No [goto provider table]

Enter address informaiton for practicing providers listed in earlier table

PROV_STRT

(check/edit address info for each provider working at CHC (listed in table))

What is (provider’s name) address?

Enter number and street.

The address of each provider MUST match the sampled CHC address. If the address of any of the listed providers in this table is different compared to the sampled CHC address, please call your RO immeadiately and explain the circumstances. You shuld NOT be following CHC providers to non-smapled CHC settings.

PROV_STRT2

What is (provider’s name) address?

Enter line two of address.

The address of each provider MUST match the sampled CHC address. If the address of any of the listed providers in this table is different compared to the sampled CHC address, please call your RO immeadiately and explain the circumstances. You shuld NOT be following CHC providers to non-smapled CHC settings.

PROV_CITY

What is (provider’s name) address?

Enter city.

The address of each provider MUST match the sampled CHC address. If the address of any of the listed providers in this table is different compared to the sampled CHC address, please call your RO immeadiately and explain the circumstances. You shuld NOT be following CHC providers to non-smapled CHC settings.

PROV_STATE

What is (provider’s name) address?

Enter state.

The address of each provider MUST match the sampled CHC address. If the address of any of the listed providers in this table is different compared to the sampled CHC address, please call your RO immeadiately and explain the circumstances. You shuld NOT be following CHC providers to non-smapled CHC settings.

PROV_ZIPCODE

What is (provider’s name) address?

Enter zipcode.

The address of each provider MUST match the sampled CHC address. If the address of any of the listed providers in this table is different compared to the sampled CHC address, please call your RO immeadiately and explain the circumstances. You shuld NOT be following CHC providers to non-smapled CHC settings.

PROV_LOCTYPE

Enter location/address type

The address of each provider MUST match the sampled CHC address. If the address of any of the listed providers in this table is different compared to the sampled CHC address, please call your RO immeadiately and explain the circumstances. You shuld NOT be following CHC providers to non-smapled CHC settings.

1. Main Office adddress

2. Alternative/2^nd office address

3. Home office

4. Home

5. Unknown

PROV_PHONE

What is (provider’s name) telehone number?

PROV_PHTYP

What type of telephone numberis this?

0. Main

1. Home

2. Work

3. Mobile

4. Pager, Beeper, Answering Service

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: (fill provider’s name)

[goto COVID_INTRO]

NOPATIENTS

(asked if 0 providers saw/expect to see patients at CHC)

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. [goto MOSTVIS_INTRO]

3. No, incorrect - there are providers seeing patients

[goto provider table & edit/add-PROV_FNAME]

COVID_INTRO

(section updated 6/5/20)

Now I would like to ask you a few questions about the coronavirus disease (COVID-19) and the impact it had on operations in your CHC and on your staff.

Enter 1 to Continue

COVID_N95_RESP

COVID_EYE

During the past THREE months, how often did your center experience shortages of any of the following personal protective equipment due to the onset of the coronavirus disease (COVID-19) pandemic?

(Note: This heading should remain if different instrument panes are needed.)

Check only one box per piece of equipment.

N95 respirators or other approved facemasks

1. Never

2. Some of the time

3. Most of the time

4. All of the time

5. Don’t know

Eye protection, isolation gowns, or gloves

1. Never

2. Some of the time

3. Most of the time

4. All of the time

1. Don’t know

COVID_TEST

COVID_SHORT

COVID_REFER

During the past THREE months, did your center have the ability to test patients for coronavirus disease (COVID-19) infection?

Check only one box.

1. Yes [goto COVID_SHORT]

During the past THREE months, how often did your center experience shortages of coronavirus disease (COVID-19) tests for any patients who needed testing?

1. Never

2. Some of the time

3. Most of the time

4. All of the time

5. Don’t know

1. No [goto COVID_REFER]

2. Not applicable – did not need to do any COVID-19 testing [goto COVID_AWAY]

3. Don’t know [goto COVID_REFER]

During the past THREE months, how often did your center have a location where patients could be referred to for coronavirus disease (COVID-19) testing?

1. Never

2. Some of the time

3. Most of the time

4. All of the time

5. Don’t know

COVID_AWAY

COVID_PROV1

COVID_PROV2

COVID_PROV3

COVID_PROV4

COVID_PROV5

COVID_PROV6

COVID_PROV_OTH

TELEMED

TELEMED_INC

TELEMED_INC_PER

TELEMED_START

TELEMED_START_PER

During the past THREE months, how often did your center need to turn away or refer elsewhere any patients with confirmed or presumptive positive coronavirus disease (COVID-19) infection?

Check only one box.

1. No COVID-19 patients were not turned away or referred elsewhere

2. Yes, some COVID-19 patients were turned away or referred elseward

3. Yes, most COVID-19 patients were turned away or referred elsewhere

4. Yes, all COVID-19 patients were turned away or referred elsewhere

5. Not applicable – the center did not have any COVID-19 patients

6. Don’t know

During the past THREE months, did any of the following clinical care providers in your center test positive for coronavirus disease (COVID-19) infection?

(Note: This heading should remain if different instrument panes are needed.)

Check only one box per provider.

Physicians

1. Yes

2. No

3. Not applicable-did not have such provider type onsite

4. Don’t know

Physician assistants

1. Yes

2. No

3. Not applicable-did not have such provider type onsite

4. Don’t know

Nurse practitioners

1. Yes

2. No

3. Not applicable-did not have such provider type onsite

4. Don’t know

Certified nurse-midwives

1. Yes

2. No

3. Not applicable-did not have such provider type onsite

4. Don’t know

Registered nurses/licensed practical nurses

1. Yes

2. No,

3. Not applicable-did not have such provider type onsite

4. Don’t know

Other clinical care providers

1. Yes (please specify:_____________________)

2. No

3. Not applicable – did not have such provider type onsite

4. Don’t know

During January and February 2020, was your center using telemedicine or telehealth technologies (for example, audio with video, web videoconference) to assess, diagnose, monitor, or treat patients?

1. Yes [goto TELEMED_INC]

After February 2020, did your center’s use of telemedicine or telehealth technologies to conduct patient visits increase?

1. Yes [goto TELEMED_INC_PER]

After February 2020, how much has your center’s use of telemedicine or telehealth to conduct patient visits increased?

1. Less than 25%

2. 25% to 49%

3. 50% to 74%

4. 75% or more

5. Don’t know

2. No

3. Don’t know

2. No [goto TELEMED_START]

After February 2020, has your center started using telemedicine or telehealth technologies?

1. Yes [goto TELEMED_START_PER]

Since your center started using these technologies, how many of your patient visits have been using telemedicine or telehealth?

1. Less than 25%

2. 25% to 49%

3. 50% to 74%

4. 75% or more

5. Don’t know

2. No

3. Don’t know

3. Don’t know

[goto MOSTVIS_INTRO]

Workforce Questions

MOSTVIS_INTRO

The next section refers to characteristics of the sampled CHC.

NUMPH

The next questions are about the CHC that is associated with

(fill CHC location).

How many physicians are associated with this CHC?

Please include physicians at (fill CHC location), and physicians at any other locations of this CHC.

Do not include interns, residents, or fellows.

Include all in-scope and out-of-scope physicians other than interns, residents, and fellows in the count. DO NOT include advance practice provider on this screen.

1. 1 Physician

2. 2-3 physicians

3. 4-10 physicians

4. 11-50 physicians

5. 51-100 physicians

6. More than 100 physicians

PCMH

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

1. Yes [goto CERT_WHO]

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

Enter all that apply, separate with commas

1. Accreditation Association for Ambulatory Health Care (AAAHC) [goto QUAL]

2. Joint Commission [goto QUAL]

3. National Committee for Quality Assurance (NCQA) [goto NCQAlevel]

What is the level of certification for the National Committee for Quality Assurance (NCQA)? (NCQAlevel)

1. Level 1 [goto QUAL]

2. Level 2 [goto QUAL]

3. Level 3 [goto QUAL]

4. Utilization Review Accreditation Commission (URAC) [goto QUAL]

5. Other [goto PCMH_OTH]

Please specify the name of the other organization that certifies your CHC as a patient-centered medical home. (PCMH_OTH)

6. Unknown [goto QUAL]

2. No [goto QUAL]

3. Unknown [goto QUAL]  

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. Don’t know

[all goto MD_DO_FT]

Type of Staff

(38 different staff variables)

The next set of questions refers to the types of providers who work at (fill CHC location).

How many of the following full-time and part-time providers are on staff at (fill CHC 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(s) in the total count of staff below.

Type of Provider	Number Full-time (≥30 hours)	Number Part-time (<30 hours)
Physicians
Physicians (MD and DO)	MD_DO_FT Full-time physicians (include MDs and DOs)? Do not include interns, residents, or fellows.	MD_DO_PT Part-time physicians (include MDs and DOs)? Do not include interns, residents, or fellows.
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 Specialists (CNS)	CNS_FT	CNS_PT
Certified Registered Nurse Anesthetists (CRNA)	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_FT	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 RNs)/Certified Social Workers (CSW)	CSW_FT	CSW_PT
Community Health Workers (CHW)	CHW_FT	CHW_PT

Autonomy of PAs, NPs, CNMs, CNSs, CRNAs

(10 variables)

The following questions concern PAs, NPs, CNMs, CNSs and CRNAs practicing at (fill CHC location).

Physician Assistant	1. Yes, always	2. Yes, sometimes	3. No	4. Unknown/Not Applicable
[PA_LOG] Are the PA’s patients logged separately from that of other providers at this CHC?
[PA_BILL] Do/Does the PA(s) bill for services using their own NPI number?
Nurse Practitioner	1. Yes, always	2. Yes, sometimes	3. No	4. Unknown/Not Applicable
[NP_LOG] Are the NP’s patients logged separately from that of other providers at this CHC?
[NP_BILL] Do/Does the NP(s) bill for services using their own NPI number?
Certified Nurse Midwife	1. Yes, always	2. Yes, sometimes	3. No	4. Unknown/Not Applicable
[CNM_LOG] Are the CNM’s patients logged separately from that of other providers at this CHC? CNM_LOG
[CNM_BILL] Do/Does the CNM(s) bill for services using their own NPI number?
Clinical Nurse Specialist	1. Yes, always	2. Yes, sometimes	3. No	4. Unknown/Not Applicable
[CNS_LOG] Are the CNS's patients logged separately from that of other providers at this CHC?
[CNS_BILL] Do/Does the CNS(s) bill for services using their own NPI number?
Certified Registered Nurse Anesthetist	1. Yes, always	2. Yes, sometimes	3. No	4. Unknown/Not Applicable
[NA_LOG] Are the CRNA’s patients logged separately from that of other providers at this CHC?
[NA_BILL] Do/Does the CRNA(s) bill for services using their own NPI number?

Electronic Health Record (EHR) Questions

EMR_INTRO

Answer ALL remaining questions for the current CHC location, which is (fill CHC location).

EMEDREC

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

Read answer choices

1. Yes, all electronic [goto EHRINSYR]

2. Yes, part paper and part electronic [goto EHRINSYR]

3. No [goto EMRINS]

4. Unknown [goto EMRINS]

EHRINSYR

In which year did the CHC install its current EHR system?

HHSMU

Does your EHR system meet meaningful use criteria, also called promoting interoperability (certified EHR), 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?

Check only one box. If 13. Other is checked, please specify the name.

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 [goto EHRNAMOTH]

Specify the name of the EHR system (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. Don’t know

[all goto PR330]

Revenue & Contracts, Compensation, New Patients

PR330

PRTITLEV

PROTHFED

PRSTLOC

PRPRIVAT

PRCARE

PRCAID

PRFEES

PROTHER

Please remind administrator that the remaining questions refer to the current CHC location, which is (fill CHC location).

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

330 Grant?

Title 5 Grant or contract?

Other federal grant?

State/local grant?

Individual, corporation or foundation grants or donations?

Medicare?

Medicaid/CHIP?

Patient payments?

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

PCTRVMAN

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

REVFFS

REVCAP

REVCASE

REVOTHER

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

Fee-for-service?

Capitation?

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

Other?

ACEPTNEW

Are you currently accepting new patients into the CHC at (fill CHC address)?

1. Yes [goto CAPITATE]

2. No [goto PHYSCOMP]

3. Don’t know [goto PHYSCOMP]

CAPITATE

NOCAP

NMEDICARE

NMEDICAID

NWORKCMP

NSELFPAY

NNOCHARGE

From those new patients, which of the following types of payment do you accept at (fill CHC address)?

Capitated private insurance?

Non-capitated private insurance?

Medicare?

Medicaid/CHIP?

Workers’ compensation?

Self-pay?

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 the basic compensation for providers at this CHC?

Read answer categories

Fixed salary

1. Share of practice billings or workload

2. Mix of salary and share of billings or other measures of performance (for example: provider’s own billings, practice's financial performance, quality measures, practice profiling)

3. Shift, hourly or other time-based payment

4. 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 physician’s/provider’s compensation. 

  Enter all that apply, separate with commas

Read answer categories.

1. Factors that reflect the providers own productivity

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

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

DONE

(also reach this screen if refusing respondent in middle of interview-F10 entry)

Press 1 to Exit.

[goto CALLBACKNOTES]

NewRinfo

Can you confirm that (director’s name/respondent’s name) is the correct individual to contact for re-interview?

Enter 1 to update the conact and phone

1. Enter 1 to update information [update info-goto THANKYOU]

2. Continue

THANKYOU

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

Early Exit from Instrument

(Instrument entry-F10)

CALLBACKNOTES

(reached after DONE)

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

THANKCB

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

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