2019 CHC Provider Induction Interview

Form Approved

OMB No. 0920-0234

Exp. Date xx/xx/20xx

Attachment E1: 2019 NAMCS-201 CHC Service Delivery Site Induction Interview, List of All Proposed Questions

This table lists all proposed 2018 survey questions in the order that they would appear in the survey. Deleted questions appear in red.

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

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

DIAL

• Dial number: (Last respondent: XXX)

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

2. All phone numbers bad/Need new number

3. No answer/problem

Hello

Hello. This is…from the U.S. Census Bureau.

May I speak to Ms. Citizen?

• If call is transferred, repeat this screen when 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

2. Unknown/no longer there

3. Reached on a different number

4. Not available now, not at desk, etc.

5. On vacation or otherwise temporarily away from work

6. Other outcome or problem interviewing respondent

INTRO_APPT

Hello Ms. Citizen

I am (your 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 xxx?

• Enter 999 to start the 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.

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?
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

ADDCHECK

• Verify the following information is correct.

[CHC address & phone number}

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

1. Yes, information is correct

2. No, updates needed

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 advance 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 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?
◊ 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)

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

DoneTbProv1

• Have you entered in all providers for this location?

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

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.

NUMPH

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.

◊ Include all out-of-scope physicians other than interns, residents, and fellows in the count.

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

   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

Staffing Types

(34 variables)

The next set of questions refers 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(s) in the total count of staff below.

Include all out-of-scope physicians other than interns, residents, and fellows in the count.

		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_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 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 PAs, NPs, CNMs, CNSs, & CRNAs 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 CRNA(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 its current EHR 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

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?

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

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.)?

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?

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/CHIP?

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?

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 physicians’/providers’ 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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