Post-Consultation Questionnaire

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 14a

Post-consultation questionnaire

Public reporting burden of this collection of information is estimated to average 10 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)

AIMS peer mentors should complete this brief survey immediately after providing the consultation with the assigned provider.

The linkage coordinator will use this information to send a follow-up email to the provider. The email will include resources and information based on the barriers and recommended resources endorsed below. The email will not include any other information you might provide in the comments below.

Once you submit this survey, you will not be able to make changes.

If you have questions or other comments, please contact the linkage coordinator(s) (Linkage Coordinator’s name) or Principal Investigator April Kimmel, PhD, at [email protected].

Provider information (auto filled)

Name:

Specialty:

Phone number:

Clinic name: 

Clinic phone:

County:

Health district:

1. Please record your name* ____________________
   
   

2. Please record the name of the provider participant* ____________________

3. About how long did the call last?* _____ minutes

4. What barriers to prescribing ART did the provider face? Check all that apply.*

• Refusal or unwillingness to accept or begin ART

• Denial, fear, or lack of knowledge about HIV

• Substance use disorder (SUD) (such as unmet need for treatment)

• Mental health issues

• History of non-adherence (including appointments)

• Other anticipated non-adherence

• Side effects

• Lifestyle and/or social situation

• Cannot pay for ART [Medicaid doesn't cover ART meds]

• Homelessness or unstable housing

• Provider did prescribe, but patient did not pick up

• Difficulty or unable to assess patient barriers

• Difficulty constructing a regimen with acceptable side effect(s) profile

• Uncomfortable providing treatment and care for patient(s) living with HIV

• Disagrees with current guidelines

• Did not know patient status or does not believe responsible for patient's HIV care

• Someone else manages HIV care/referred out (e.g., if low-volume provider)

• Other (explain: ________________________________)
  
  

5. What resources do you recommend be provided in a follow-up email? Check all that apply*

• Referral to Motivational Interviewing (MI) training

• Link to HealthHIV Primary Care Training/Certification Program

• Link to MedScape TasP module

• Link to National HIV Curriculum

• Mentoring: Follow-up by peer mentor

• Mentoring: Referral to National Clinician Consultation Center

• Mentoring: Referral to AAHIVM Clinical Consultation Program

• Handout/link: Technical Assistance and educational resources

• Handout: Acuity scale for adherence

• Handout: ART guidelines

• Handout: MCO phone numbers (for patient behavioral health support)

• Handout: Local community resources (for patient social support)
  
  

6. Were there any issues (e.g., technical difficulties, interrupted call, difficulty communicating with provider)? If yes, please describe.
   
   

7. Do you have any other comments or feedback for us?

Thank you! *Denotes required items

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Rose S Bono
File Modified	0000-00-00
File Created	2021-10-20