Patient Navigator Pilot Survey

Care Coordination Pilot – Patient Navigator

Patient Experience Survey

OMB CONTROL NUMBER: 0704-0553

OMB EXPIRATION DATE: 05/31/2025

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, 0704-0553, is estimated to average 5 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. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PATIENT INFO

Patient’s Enrollment Site:

10 MDG-Academy	99 MDG-Nellis
21 MDG-Peterson	Eisenhower AMC
460 MDG-Buckley	ACH Blanchfield-Ft Campbell
ACH Evans-Carson

Patient’s Beneficiary Type:

• Active Duty (Including Guard/Reserve)

• Retired

• Family Member of Active Duty or Guard/Reserve

• Family Member of Retired

• Other: Please Specify (Do not include any personal identifiable information) ______________________

Patient’s Age:

< 18
18-24
25-34
35-44
45-64
65+

QUESTIONNAIRE

1. For what reason(s) did the Patient Navigator assist you with your care? Check all that apply. *

• I received a referral to be seen in the civilian private sector.

• The Patient Navigator helped me book my appointment in the private sector.

• The Patient Navigator helped me book my appointment at a military medical treatment facility.

• I received a referral with an authorization issue that was delaying my care.

• I received a referral with an error that was delaying my care.

• N/A – I opted to not use the Patient Navigator service.

• Other: Please Specify (Do not include any personal identifiable information) _______________________________________

(Question 2 is not shown if patient responded with “N/A – I opted to not use the service.” for Q1.)

2. What is the specialty or sub-specialty for your referral? *

• Behavioral Health

• Gastroenterology

• Hematology Oncology

• Ob-Gyn

• Other: _________________________

(Question 3 is not shown if patient responded with “N/A – I opted to not use the service.” for Q1.)

3. Please rate your response to the following statements: *

	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree
The information provided throughout the referral process helped me gain easier access to care.	¡	¡	¡	¡	¡
The Patient Navigator’s support improved my referral process experience.	¡	¡	¡	¡	¡
The Patient Navigator effectively guided me through the referral process to schedule my specialty care appointment.	¡	¡	¡	¡	¡
The Patient Navigator was helpful in addressing my questions and concerns.	¡	¡	¡	¡	¡
The patient navigator’s service was customized to my personal healthcare needs.	¡	¡	¡	¡	¡

(Question 4 is not shown if patient responded with “N/A – I opted to not use the service.” for Q1.)

4. What were the most important barriers in the referral process that the Patient Navigator helped you overcome? Do not include any personal identifiable information.*

(Question 5 is not shown if patient responded with “N/A – I opted to not use the service.” for Q1.)

4. How did you benefit from the Patient Navigator’s assistance? Do not include any personal identifiable information *

(Question 6 is not shown if patient responded with “N/A – I opted to not use the service.” for Q1.)

4. How likely are you to use the Patient Navigator to schedule future appointments? *

Very Unlikely	Unlikely	Neutral	Likely	Very Likely
¡	¡	¡	¡	¡

(If the patient responded with “Unlikely” or “Very Unlikely” above, the question below is shown.)

If you marked unlikely, why? Do not include any personal identifiable information *

(Question 7 is not shown if patient responded with “N/A – I opted to not use the service.” for Q1.)

4. Please provide additional feedback regarding your experience using the Patient Navigator and/or how we can improve? Do not include any personal identifiable information