Form 1 CHCs: Social Needs Platforms Readiness Assessment

National Hypertension Control Initiative

Appendix F_CHC Readiness Assessment

CBOs: Social Needs Platforms Readiness Assessment

OMB: 0990-0482

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FQHC Readiness

This Readiness Assessment for FQHCs is designed to serve the following purposes:

Determine if an FQHC is ready to begin implementation in Wave 1.
Begin to assess the scope of their implementation and determine how much support and
resources will be needed to onboard them to Unite Us.
Gather information to inform the wave deployment schedule and approach for Phase 2 of
the implementation (FQHC engagement and onboarding).

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FQHC Readiness Assessment in SurveyMonkey

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FQHC Readiness Assessment
* Questions marked with an asterisk are required.

Section 1: Basic Information
Description: This assessment should be completed by a key decision maker at your organization in partnership with a representative from
the teams or departments that will be using the Unite Us software.
FQHC Name:* (text box)
Grant ID:* (text box)
Please enter your information:*
● Name (text box)
● Title/role (text box)
● Email (text box)

Where is your FQHC located?*
● State (text box)
● County (text box)
● City (text box)
● Address(s) (text box)

Do you provide programs that address hypertension?* (one answer)
● Yes
● No

Do any of your health center sites routinely perform assessments or screenings with patients to help identify social factors that may
influence their health? (Examples include PRAPARE, WE CARE)* (one answer)
● Yes
● No

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Are any departments/programs from your FQHC already using Unite Us?* (one answer)
● Yes
● No
If “Yes,” please identify which departments/programs. (text box)

Are you prepared to complete necessary legal agreements, such as a Business Associate Agreement (BAA) for a Covered Entity?* (one
● Yes
● No

Section 2: Readiness
Description: This section is designed to help your organization determine if you are ready to begin implementation with Unite Us.

Have you already identified a lead for the Unite Us project/implementation?* (one answer)
● Yes
● No
If “Yes,” please provide their contact information: (multiple text boxes)
● Name
● Email
● Phone Number

Do you have buy-in from leadership and future users of the Unite Us software?* (one answer)
● Yes
● No

Have you attended a Unite Us information session?* (one answer)

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Do you have goals or priorities for the utilization of the Unite Us software?* (one answer)
● Yes
● No
If “Yes,” please describe. (text box)

Section 3: Scope
Description: This section will help Unite Us determine the scope of the implementation for your organization and ensure the appropriate
amount of support and resources are available.

What is your desired time-frame to begin project work?* (multiple choice)
● Immediately
● In the next 1-3 months
● In the next 3-5 months
● After 5 months

Are you prepared to onboard within a 4 week timeline?* (one answer)
● Yes
● No
If “No,” please explain. (text box)

In addition to hypertension programs, are there other programs or teams that you would like to use Unite Us (at no cost)?* (one answer)
● Yes
● No
If “Yes,” please list the additional programs. (text box)

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Section 4: Users
Description: This section will ask questions about the staff members at your organization who will be using Unite Us (e.g. “users”).

Have you identified those staff who will be points of contact for each team or program that will be using Unite Us? This may be a team
supervisor or “super-user” (e.g. participate in workflow conversations, deliver communications to staff about roles/expectations, etc.).
Examples may include Behavioral Health Case Managers, Social Workers, or Community Health Workers.* (one answer)
● Yes
● No

Do you have an estimated number of anticipated users?* (one answer)
● Yes
● No
If “Yes,” please insert the estimated number of users. (text box)

Section 5: Additional Questions
Please identify any community partners you frequently send referrals to. (text box)
If you do have community partners you frequently send referrals to, would you be willing to make a warm handoff/introduction? (one answer)
● Yes
● No

What EHR do you use? (multiple checkboxes)
● Epic (conditional)
● OCHIN (Epic) (conditional)
● Cerner (conditional)
● eCW (conditional)
● Other
(conditional for “Epic,” “OCHIN,” “Cerner,” “eCW”)

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Would you be interested in learning more about our integration capabilities? Please note that pursuing an integration may result in an
associated fee. (one answer)
● Yes (conditional)
● No
(conditional for “Yes”)
What version of this EHR are you on? (text box)
If you use eCW, please provide your eClinicalWorks AUD ID (if you do not know, your office admin or IT administrator should have this). (text
How many instances of this EHR do you use? (text box)
Is your EHR provided by a third party reseller or another organization (i.e. large health system)? If so, which one? (text box)

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File Typeapplication/pdf
File TitleAHA_FQHC Readiness Assessment
File Modified2022-03-24
File Created2022-03-24

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