Connected Care Pilot Program Questionnaire_final version

Promoting Telehealth for Low-Income Consumers; COVID-19 Telehealth Program

Connected Care Pilot Program Questionnaire_final version

OMB: 3060-1271

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OMB Control No. 3060-1271

Approved by OMB [Month] 2022



Connected Care Pilot Program Questionnaire



General Project Summary

Applicant Name:


Project Coordinator Name:

 

Reporting period:

Drop-down menu:

Year 1

Year 2

Year 3



 

Patient Population Questions

Answers:




 

 





1.1a

What is the estimated number of patients indicated on your original application to participate in the Connected Care Pilot Program?

 




 

 

In Total

That are Low Income, if tracked

That are a Veteran, if tracked

That are Both Low Income & Veteran, if tracked

1.1b

How many unique patients do you serve (if you track this):

 

 

 

 

1.1c

How many unique patients were eligible for your Connected Care Pilot project (if you track this):

 

 

 

 

1.1d

How many patients were included in your Connected Care Pilot project AND used connected services during this reporting period:

 

 

 

 



 

Program Goals Questions:

Answers:


1.2a

Are you on track to meet the objectives and goals of your Connected Care Pilot project?

Drop-down menu options: 

Yes

No


1.2b

If you responded no to 1.2a, please choose the primary reason you are not on track to meet the objectives of your Connected Care Pilot project.

Drop-down menu options: 

Lack of provider participation

Lack of patient participation

Administrative Issues

Technical issues

Other


1.2c

Please explain further if you chose "other" in 1.2b:

 


1.2d

Please state your response to the following statement: Lack of health care provider participation interfered with meeting the objectives of your Connected Care Pilot project.

Drop-down menu options: 

Strongly Disagree

Disagree

Somewhat Disagree

Neither Agree nor Disagree Somewhat Agree

Agree

Strongly Agree 

No interference with meeting objectives


1.2e

Please state your response to the following statement: Lack of patient participation interfered with meeting the objectives of your Connected Care Pilot project.

Drop-down menu options: 

Strongly Disagree

Disagree

Somewhat Disagree

Neither Agree nor Disagree Somewhat Agree

Agree

Strongly Agree 

No interference with meeting objectives


1.2f

Please state your response to the following statement: Administrative issues interfered with meeting the objectives of your Connected Care Pilot project.

Drop-down menu options: 

Strongly Disagree

Disagree

Somewhat Disagree

Neither Agree nor Disagree Somewhat Agree

Agree

Strongly Agree 

No interference with meeting objectives


1.2g

Please state your response to the following statement: Technical issues interfered with meeting the objectives of your Connected Care Pilot project.

Drop-down menu options: 

Strongly Disagree

Disagree

Somewhat Disagree

Neither Agree nor Disagree Somewhat Agree

Agree

Strongly Agree 

No interference with meeting objectives




 

Overall Satisfaction Questions:

Answers:


1.3a

How satisfied were you with how your Connected Care Pilot project has been implemented internally?

Drop-down menu options: 

Extremely unsatisfied

Very unsatisfied

Unsatisfied

Not unsatisfied nor satisfied

Satisfied

Very satisfied

Extremely satisfied



1.3b

How satisfied were you with the FCC's administration of the Connected Care Pilot Program?

Extremely unsatisfied

Very unsatisfied

Unsatisfied

Not unsatisfied nor satisfied

Satisfied

Very satisfied

Extremely satisfied



1.3c

How satisfied were you with your experience navigating the Program websites and My Portal?

Extremely unsatisfied

Very unsatisfied

Unsatisfied

Not unsatisfied nor satisfied

Satisfied

Very satisfied

Extremely satisfied



1.3d

How satisfied were you with the ease and clarity of filing required FCC forms?

Extremely unsatisfied

Very unsatisfied

Unsatisfied

Not unsatisfied nor satisfied

Satisfied

Very satisfied

Extremely satisfied



1.3e

How satisfied were you with USAC's ability to help with questions in a timely manner?

Extremely unsatisfied

Very unsatisfied

Unsatisfied

Not unsatisfied nor satisfied

Satisfied

Very satisfied

Extremely satisfied

Not applicable




1.3f

How satisfied were you with the timeframe in which you received a funding commitment?

Extremely unsatisfied

Very unsatisfied

Unsatisfied

Not unsatisfied nor satisfied

Satisfied

Very satisfied

Extremely satisfied




1.3g

How much does the Program funding meet your Connected Care Pilot project’s needs?

Drop-down menu options: 

It covers 75-85% of the amount needed

It covers 50-74.99% of the amount needed

It covers 25-49.99% of the amount needed

It covers 0.01-24.99% of the amount needed



1.3h

(Optional) If you would like to share any other thoughts or feedback on the administration of the Connected Care Pilot Program for this reporting period please do so here:

 [Narrative response]




Provider Focused Questions

 

Telehealth Appointment Questions

Answers:

 

 

2.1a

Did you receive external funding for telehealth services outside of the Connected Care Pilot Program in the last 24 months preceding the end of the current reporting period?

Drop-down menu options:

Yes

No



2.1b

If you answered Yes to 2.1a, what was (were) the other source(s) of the external funding? (Please select all that applied.)

Select all that applied:

Other FCC program(s)

Other federal (non-FCC) program(s)

Other state/local government program(s)

Private funding

Other, please specify



2.1c

How did funding from the Connected Care Pilot Program change the number of patients you served via connected care during the reporting period?

Drop-down menu options:

It decreased the number of patients served.

It did not affect the number of patients served.

It increased the number of patients served by less than 10%.

It increased the number of patients served by 10-20%.

It increased the number of patients served by more than 20%.

Did not track.




2.1d

(Optional) How did providing Connected Care Pilot Program services change the number of patients (including patients served under this program) doctors were capable of seeing see per day?

Drop-down menu options:

It did not affect the number of appointments a provider could have per day.

It decreased the number of appointments a provider could have per day.

It increased the number of appointments a provider could have per day by 1. 

It increased the number of appointments a provider could have per day by 2. 

It increased the number of appointments a provider could have per day by 3.

 It increased the number of appointments a provider could have per day by more than 3. 

Did not track or Project not focused on appointments.

Decline to answer.

 


2.1e

(Optional) How did providing care via Connected Care Pilot Program services change the number of appointments a patient had on average during this reporting period?

Drop-down menu options:

It decreased the average number of appointments.

It did not affect the average number of appointments.

It increased the average number of appointments per patient by less than 5%.

It increased the average number of appointments per patient by 5-10%.  

It increased the average number of appointments per patient by 10-15%.

It increased the average number of appointments per patient more than 15%.  

Did not track or Project not focused on appointments.

Decline to answer.

 


2.1f

(Optional) Did providing care via Connected Care Pilot Program services lead to providers seeing patients outside of standard hours of operation?

Drop-down menu options:

Yes

No

Not Applicable 

Decline to Answer

 


2.1g

(Optional) Please identify the telehealth platforms/services that you used to provide connected care services through your Connected Care Pilot project.

[Narrative response] 



2.1h

(Optional) Please provide an anonymized aggregated number of patients that you were able to provide connected care services to through your Pilot project.

[PDF or native format upload]




 

Two Years Prior, If Tracked
(two years prior to the pilot starting)

Prior Year, If Tracked
(in the year prior to the pilot starting)

Reporting Year, If Tracked
(in the reporting year since the pilot began)

2.1i

Total number of unique patients in the Connected Care Pilot Program.

 

 

 


(Optional) Total number of connected care appointments for patients included in the Connected Care Pilot Program.

 

 

 


(Optional) Total number of Pilot project patients using remote patient monitoring or asynchronous connected care services as part of your Pilot project.





Total number of unique patients served by the hospital/organization.

 

 

 


(Optional) Total number of connected care appointments across entire patient population.

 

 

 


(Optional) Total number of patients using remote patient monitoring or asynchronous connected care services across entire patient population.






 

Patient Participation Questions

Answers:

2.2a

Did you use the Connected Care Pilot Program funding to obtain patient broadband Internet access service?

Drop-down menu options:

Yes

No 

2.2b

If you answered yes to 2.2a, how many patients did the funded patient Internet access service cover during this reporting period?

 

2.2c

What percentage of patients receiving connected care services did so through patient broadband Internet access service funded through the Connected Care Pilot Program?

 



 

Provider Cost Questions

Answers:

 

2.3a

Did providing connected care services through the Connected Care Pilot Program lead to increased savings for the health care provider?

Drop-down menu options:

Yes

No  

I don’t know

Decline to answer

 



 


 

If you answered "yes" to question 2.3a, please answer the following:

 

Estimated Value, if tracked

2.3b

Did providing Connected Care services reduce health practitioner's time per appointment?

Drop-down menu options:

Yes

No  

I don’t know

Decline to answer

 




 




 

2.3c

Did providing Connected Care services reduce equipment purchases or use costs?

Drop-down menu options:

Yes

No  

I don’t know

Decline to answer

 

2.3d

Did providing Connected Care services reduce use of higher level care settings (e.g., ER)?

Drop-down menu options:

Yes

No  

I don’t know

Decline to answer

 





 

Patient Outcome Questions

Answers:

 

 

 

Prior Year, if Tracked
(in the year prior to the pilot starting)

Reporting year , if Tracked
(in the reporting year since the pilot began)

2.4a

(Optional) Total Missed or Cancelled Appointments (All Patients)

 

 

2.4b

(Optional) Total Missed or Cancelled Appointments (Connected Care Pilot Patients)

 

 

2.4c

(Optional) Total Emergency Room Visits (All Patients)

 

 

2.4d

(Optional) Total Emergency Room Visits (Connected Care Pilot Patients)

 

 

2.4e

(Optional) Total Hospital Admissions (All Patients)

 

 

2.4f

(Optional) Total Hospital Admissions (Connected Care Pilot Patients)

 

 

2.4g

(Optional) Average Length (in Days) of Hospital Stays (All Patients)

 

 

2.4h

(Optional) Average Length (in Days) of Hospital Stays (Connected Care Pilot Patients)

 

 





 

Specific Condition Outcome Questions

Answers:

 

2.5a

As a result of the connected care services provided through your Connected Care Pilot project, what percentage of patients do you estimate had improved health outcomes during the reporting period?

Drop-down menu options:


0%

Less than 10%

10-20%

20-30%

30-40%

40-50%

50-60%

60-70%

70-80%

80-90%

90-100%

Unknown





 

Additional Feedback

Answers:


2.6a

Please provide any relevant aggregated, anonymized metrics not already captured above concerning the number of patients served through your Connected Care Pilot project, health care provider cost savings, the impact of funding patient broadband, patient outcomes, or specific health outcomes for the reporting period.:

 [PDF or native format upload.]







Patient Experience Questions

 

Customer Satisfaction Questions:

Answers:


 

3.1a

How do you track overall patient satisfaction?

Please select from the following:

Patient survey

Complaints filed

Anecdotal evidence from providers

We do not track this information

Other, please specify


 

 

3.1b

Please indicate your level of agreement with the following statement: Patients generally report satisfaction with receiving treatment via the Connected Care Pilot program.

Drop-down menu options: 

Strongly Disagree

Disagree

Somewhat Disagree

Neither Agree nor Disagree Somewhat Agree

Somewhat Agree

Agree

Strongly Agree  

 

 

3.1c

If tracked, what percentage of patients report satisfaction with receiving treatment via the Connected Care Pilot program?

 


 

 

Prior Year, if Tracked
(in the year prior to the pilot starting)

Reporting Year, if Tracked
(in the reporting year since the pilot began)


3.1d

Aggregate patient satisfaction for patients in the Connected Care Pilot program

 Drop-down menu options: 

Extremely unsatisfied

Very unsatisfied

Unsatisfied

Not unsatisfied nor satisfied

Satisfied

Very satisfied

Extremely satisfied

Did not track


 Drop-down menu options: 

Extremely unsatisfied

Very unsatisfied

Unsatisfied

Not unsatisfied nor satisfied

Satisfied

Very satisfied

Extremely satisfied

Did not track



 

3.1e

Aggregate patient satisfaction across the entire patient population

Drop-down menu options: 

Extremely unsatisfied

Very unsatisfied

Unsatisfied

Not unsatisfied nor satisfied

Satisfied

Very satisfied

Extremely satisfied

Did not track


Drop-down menu options: 

Extremely unsatisfied

Very unsatisfied

Unsatisfied

Not unsatisfied nor satisfied

Satisfied

Very satisfied

Extremely satisfied

Did not track



 



 

Health Improvement Questions:

Answers:


3.2a

How did you track patient health satisfaction for your Connected Care Pilot project and if so?

Please select from the following:

Patient surveys

Complaints filed

Anecdotal evidence from providers

We do not track this information

Other, please specify_____


 

 

3.2b

What approximate percentage of patients participating in your Connected Care Pilot project reported an improvement in their health (e.g., reduction in acute incidents) during the reporting period?



3.2c

Of the patients that reported an improvement in their health, what approximate percentage attribute that improvement to receiving treatment via the Connected Care Pilot program?

 




 

Cost Savings Questions:

Answers:

 

 

3.3a

If you collected data on cost savings for patients as a result of the Connected Care Pilot program, how did you collect and track these savings?

Drop-down menu options:

Patient survey

Complaints filed

Anecdotal evidence from providers

We do not track this information

Other, please specify _____

 

 

3.3b

Have any patients reported any cost savings by receiving treatment via the Connected Care Pilot program during the reporting period?

Drop down menu options:

Yes

No

 

 

 

 

Answers:

Aggregated Estimated Value, if tracked

 




 

 



 

 


 

Time & Convenience Questions:

Answers:

 


3.4a

If you collected data on cost savings to patients' time as a result of the Connected Care Pilot program, how did you collect and track these savings?

Drop-down menu options:

Patient survey

Complaints filed

Anecdotal evidence from providers

We do not track this information

Other, please specify _____

 


 

 

Answers:

Aggregated Estimate of Time Savings in Hours, If Tracked


3.4b

Receiving treatment via the Connected Care Pilot program enabled your patients to experience a reduction in travel time.

Drop-down menu options: 

Strongly Disagree

Disagree

Somewhat Disagree

Neither Agree nor Disagree

Somewhat Agree

Agree

Strongly Agree 

Did Not Track 

 


3.4c

Receiving treatment via the Connected Care Pilot program enabled your patients to experience a reduction in time taken off work or time away from school/classes

Drop-down menu options: 

Strongly Disagree

Disagree

Somewhat Disagree

Neither Agree nor Disagree

Somewhat Agree

Agree

Strongly Agree  

Did Not Track

 


3.4d

Receiving treatment via the Connected Care Pilot program enabled your patients to experience shorter waiting time.

Drop-down menu options: 

Strongly Disagree

Disagree

Somewhat Disagree

Neither Agree nor Disagree

Somewhat Agree

Agree

Strongly Agree 

Did Not Track 

 




 

Additional Feedback - Optional

Answers:

3.5a

Please provide any relevant anonymized, aggregated metrics on patient cost savings, reductions in patient travel or time.

[PDF or native format upload] 

3.5b

If you would like to share any other thoughts or feedback on the patient experience for this reporting period please do so here:

[Narrative response] 



Final Report

 

Project Goals and Objectives Questions

Answers


FR 1.1a

Did your project advance the goals of the Connected Care Pilot Program? (i.e., Improving health outcomes through connected care; reducing health care costs for patients, facilities, and health systems; and supporting the trend towards connected care everywhere)

Drop-down options:

Yes

No 


FR 1.1b

Select the following statements that were true for your project.

Select all that apply:

My Connected Care Pilot project reduced healthcare costs.

My Connected Care Pilot project improved health outcomes.

My Connected Care Pilot project supported connected care everywhere.


FR1.1c

Please explain how your project met each of the Connected Care Pilot Program goals.

 


FR 1.1d

If your project did not meet each of the Connected Care Pilot Program goals, choose the primary reason why not.

Select all that apply: 

Lack of provider participation

Lack of patient participation

Administrative issues

Technical issues

Other, please specify_________


FR. 1.1e

Did your project meet the goals and objectives that you set for it?

Drop-down options:

Yes

No 


FR 1.1f

If yes, please provide a brief explanation of the goals and objectives that your Connected Care Pilot project met.

 [Narrative response]


FR. 1.1g

If your Connected Care Pilot project did not meet the goals and objectives you set for it, please explain why not.

 




 

Lessons Learned

Answers:


FR 1.2a

As a result of your Connected Care Pilot project, do you have any lessons learned to share in the following areas that would be relevant to the FCC's evaluation of the Pilot Program and its impact on supporting connected care services?

Drop-down options:

Yes

No 


FR 1.2b

Lessons learned concerning the goal of improving health outcomes through connected care.

Drop-down options:

Yes

No 



If the answer to FR 1.2b is Yes, please explain.

Narrative Response


FR 1.2c

Lessons learned concerning the goal of reducing health care costs for patients, facilities, and health care systems.

Drop-down options:

Yes

No 



If the answer to FR 1.2c is Yes, please explain.

Narrative Response


FR 1.2d

Lessons learned concerning the goal of supporting the trend towards connected care everywhere.

Drop-down options:

Yes

No 



If the answer to FR 1.2d is Yes, please explain.

Narrative Response


FR 1.2e

Lessons learned concerning the provision and use of connected care services, particularly for low-income and veteran patients.

Drop-down options:

Yes

No 



If the answer to FR 1.2e is Yes, please explain.

Narrative Response


FR 1.2f

Lessons learned concerning patient retention with respect to connected care services.

Drop-down options:

Yes

No 



If the answer to FR 1.2f is Yes, please explain.

Narrative Response


FR 1.2g

Lessons learned concerning patient training and how best to address digital literacy challenges.

Drop-down options:

Yes

No 



If the answer to FR 1.2g is Yes, please explain.

Narrative Response


FR 1.2h

Do you have any other lessons learned relevant to the FCC's evaluation of the Connected Care Pilot Program and its impact on supporting connected care services?

Drop-down options:

Yes

No 







If the answer to FR 1.2h is Yes, please explain.

Narrative Response




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