Form Approved
OMB No. 0920-New
Expiration Date: XX/XX/XXXX
Using Real-time Prescription and Insurance Claims Data to Support the HIV Care Continuum
Attachment 9
Phase I interview
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)
Phase I interview
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Eligible potential participant information
Name: DOB: ID: Phone: Zip code: County: Health district: Late ART prescriptions:
MCO information
Participant Medicaid Care Organization (MCO): Participant program: MCO phone:
Healthcare provider information
Provider name: Provider credential: Provider phone number:
Pharmacy information
Pharmacy name: Pharmacy phone number: ![]()
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Notes (prior to call)
Record notes (optional) |
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Date and time of call I Now J * must provide value |
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The next questions should be conversational. They are designed to develop rapport with the participant. |
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We talked earlier about this study helping with your prescribed HIV medication and staying healthy. I’d like to ask you a few questions about this.
These questions will help me connect you to services or resources that could help you. I want to remind you, though, that you do not have to answer any questions. You can end this conversation at any time. |
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Using your best guess, when was your last appointment with your main doctor? |
Expand Record notes (optional) |
When your doctor prescribes your HIV medication, how do you usually pick it up? |
Expand Record notes (optional) |
I told you earlier that the study team looked at Medicaid records to understand about prescribed HIV medication. I understand that you have a prescription for:
Sometimes people know these medications as:
Some people have told me it is hard to start new medicines. They have also told me it is hard to keep up with their current medicine.
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Have picked up prescription refill
Could you tell me if you are currently taking [name of late ARV medication(s)]?
Probe . * must provide value |
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Record notes about the reason why the participant is not taking ART. If participant is taking ART, indicate source (optional). If "other" is checked, explain (required). |
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Thank you for this information. We're glad you already have the medications you need.
It seems like we don't need to refer you to any specific services.
We encourage you to contact your doctor or health insurance plan if you have questions about your HIV medications. Thank you!
Thank participant for participating and end the call.
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If the call is interrupted or the participant needs to call back another time, use this field to schedule a future call.
I Today J I Now J
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Call end time I Now J ![]() * must provide value |
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Notes (post call) Record notes on contact information to be updated.
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Does
contact
information
need
to
be
updated?
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Receiving ART from another source
Could you tell me if you are currently taking [name of late ARV medication(s)]?
Probe . * must provide value |
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Record notes about the reason why the participant is not taking ART. If participant is taking ART, indicate source (optional). If "other" is checked, explain (required). |
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Thank you for this information. We're glad you already have the medications you need.
It seems like we don't need to refer you to any specific services.
We encourage you to contact your doctor or health insurance plan if you have questions about your HIV medications. Thank you!
Thank participant for participating and end the call.
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If the call is interrupted or the participant needs to call back another time, use this field to schedule a future call.
I Today J I Now J
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Call end time I Now J ![]() * must provide value |
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Notes (post call) Record notes on contact information to be updated.
Expand |
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Does
contact
information
need
to
be
updated?
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Switched to another medication
Could you tell me if you are currently taking [name of late ARV medication(s)]?
Probe . * must provide value |
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Record notes about the reason why the participant is not taking ART. If participant is taking ART, indicate source (optional). If "other" is checked, explain (required). |
Expand |
Thank you for this information. We're glad you already have the medications you need.
It seems like we don't need to refer you to any specific services.
We encourage you to contact your doctor or health insurance plan if you have questions about your HIV medications. Thank you!
Thank participant for participating and end the call.
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Expand |
If the call is interrupted or the participant needs to call back another time, use this field to schedule a future call.
I Today J I Now J
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Call end time I Now ![]() * must provide value |
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Notes (post call) Record notes on contact information to be updated.
Expand |
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Does
contact
information
need
to
be
updated?
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Have never taken the medication(s)
Could you tell me if you are currently taking [name of late ARV medication(s)]?
Probe . * must provide value |
these
medications
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Record notes about the reason why the participant is not taking ART. If participant is taking ART, indicate source (optional). If "other" is checked, explain (required). |
Expand |
Thank you for this information. We're glad you already have the medications you need.
It seems like we don't need to refer you to any specific services.
We encourage you to contact your doctor or health insurance plan if you have questions about your HIV medications. Thank you!
Thank participant for participating and end the call.
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Expand |
If the call is interrupted or the participant needs to call back another time, use this field to schedule a future call.
I Today J I Now J
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Call end time I Now J ![]() * must provide value |
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Notes (post call) Record notes on contact information to be updated.
Expand |
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Does
contact
information
need
to
be
updated?
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Other reason
Could you tell me if you are currently taking [name of late ARV medication(s)]?
Probe . * must provide value |
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Record notes about the reason why the participant is not taking ART. If participant is taking ART, indicate source (optional). If "other" is checked, explain (required). |
Expand |
Thank you for this information. We're glad you already have the medications you need.
It seems like we don't need to refer you to any specific services.
We encourage you to contact your doctor or health insurance plan if you have questions about your HIV medications. Thank you!
Thank participant for participating and end the call.
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Expand |
If the call is interrupted or the participant needs to call back another time, use this field to schedule a future call.
I Today J I Now J
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Call end time I Now ![]() * must provide value |
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Notes (post call) Record notes on contact information to be updated.
Expand |
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Does
contact
information
need
to
be
updated?
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Have not picked up prescription refill
Could you tell me if you are currently taking [name of late ARV medication(s)]?
Probe . * must provide value |
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Record notes about the reason why the participant is not taking ART. If participant is taking ART, indicate source (optional). If "other" is checked, explain (required). |
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Can you talk about what gets in the way of taking your prescribed medication? Check relevant boxes below. |
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Barriers to filling ART prescriptions (barrier list begin) |
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ART |
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Adherence |
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Structural |
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Social |
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Other
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![]() Expand |
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Some people find it difficult to keep up with their medicine. It can be difficult at times.
I'm glad we have this chance to think together about resources that might help you take your medication.
Before we do that, I want to mention some information that could be helpful. You may already know that HIV medicine is lifesaving. Research tells us that people who start and keep up with their medicine can live just as long as anyone.
Something that we have learned more recently is that HIV medicine also prevents HIV transmission to others, if taken regularly. It's true.
So these pills can not only improve your health, they can also help you protect other people from HIV. |
What questions can I answer about this?
Expand Record any notes (optional) |
I heard you say earlier that...
...get in the way of taking your HIV medicine. Did I get that right?
If yes, move on. If no, clarify barrier(s) with participant and repeat question. |
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Great. Let's think together about ways to help with this.
To start, could you tell me about how you think some of these challenges could be addressed?
Respond according to dialogue with participant.
Great. These ideas will be really useful when we think about resources available to address your challenges.
OR
That's ok. I understand that it can be difficult to know where to begin. Let's think this through together.
Interactively problem-solve to engage participant. |
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It's great to think through this together. Like we talked about, I'd like to link you to some resources that may help you. There are resources available for the challenges we've talked about today.
Could you tell me which of the challenges we've talked about is most important to you?
If participant hos difficulty selecting one barrier, offer some encouragement.
I know it can be difficult to choose just one, but just do your best. We will still provide resource information for the challenges we discussed.
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Select participant-identified primary barrier for direct referral.
Primary barrier:
Which other 1 or 2 other challenges are most important to you?
Select participant-identified secondary and tertiary barrier(s).
Secondary barrier: Tertiary barrier:
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What type of service was the primary referral?
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Go to Referral Script for warm handoff to recommended referral then return here for post-call wrap-up (below).
Primary referral outcome Successful warm handoff
*
must
provide
value Called,
but
did
not
reach
resource
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Secondary referral outcome Successful cold handoff * must provide value Other
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Tertiary
referral
outcome * must provide value Other
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If the call is interrupted or the participant needs to call back another time, use this field to schedule a future call. I Today J I Now J |
Call end time * must provide value |
Notes (post call) Record notes on contact information to be updated.
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Does
contact
information
need
to
be
updated? |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | AIMS Intervention arm, Patient component - Phase 1 |
Author | adkimmel |
File Modified | 0000-00-00 |
File Created | 2021-10-20 |