A
Form
Approved
OMB No. XXXX-XXXX
Exp. Date XX/XX/XXXX
OVERVIEW:
This self-administered questionnaire will collect primary care site background information to inform the subsequent workflow mapping activities. This questionnaire asks about the primary care site’s organizational characteristics, its staff, patient records, and care coordination with hospitals.
PARTICIPANTS:
One primary care site administrator who is knowledgeable about the clinical and administrative operations of the site, such as a medical director, will fill out this survey. The research participants will receive the survey as an editable Microsoft Word file via email.
MATERIALS:
In order to complete the data collection instrument, each participant will be provided the Project Summary for the Re-engineered Visit for Primary Care (AHRQ REV).
INSTRUMENT AND ADMINISTRATION:
Instructions: The questions about your primary care practice’s organizational characteristics. Please answer to the best of your ability.
Organizational characteristics
Is the practice a patient-centered medical home recognized by the National Committee for Quality Assurance (NCQA)? If so, at what level?
Does the practice have administrative support beyond this unit (e.g. from the parent organization)? For instance, centralized appointment making, centralized follow up phone calls, etc.
What is the payer mix of the practice?
Payer mix |
% |
Medicare |
|
Medicaid |
|
Commercial |
|
Self-pay/uninsured |
|
Total |
100 |
Is the practice in a risk-bearing contract(s)? If yes, for which payer(s) and what kind of risk-bearing contract(s)?
Is the practice in an accountable care organization (ACO)? If yes, for which payer(s)?
What percentage of practice revenue is currently fee-for-service based?
Primary
care site staff
How many primary care providers are there in the practice? Please list the number of each type of provider there are in the practice.
Primary care providers |
# |
Medical Doctor |
|
Doctor of Osteopathic Medicine |
|
Nurse Practitioner |
|
Physician Assistant |
|
Total |
|
How many other clinical staff are there? Please list the number of each type of clinical staff there are in the practice.
Other clinical staff |
# |
Registered nurse (RN) |
|
Licensed practical nurse (LPN) |
|
Pharmacist |
|
Social worker |
|
Medical Assistants |
|
Lab Techs |
|
Other (please describe) |
|
Other (please describe) |
|
Total |
|
How many support staff (administrative, secretarial, etc.) are there in your practice?
Support staff |
# |
Administrator |
|
Secretary |
|
Billing |
|
IT Analyst |
|
Other (please describe) |
|
Other (please describe) |
|
Total |
|
Patient records
How does your practice define active patients (such as the patient had a visit at the practice within 12 months, 18 months, 24 months, etc.)?
What electronic medical record do you use?
Do you use a specific care management electronic record or tool? If so, what?
Do you use a specific population health electronic registry or data management system? If so, what?
Do you currently manage population health using registries?
If yes, for which patient populations?
Care coordination with hospitals
Does the practice use CMS care coordination codes?
Complete the following table. For the top two hospitals where your adult patients most frequently receive inpatient care, including whether these hospitals have formal care transitions programs and whether they notify your practice of hospitalizations.
Hospitals your patients go to for inpatient care |
Hospital 1 |
Hospital 2 |
% of hospitalizations among adult patients in the practice |
|
|
Does this hospital have a formal care transitions program? (Yes/No) |
|
|
Does this hospital notify your practice that one of your patients has been hospitalized? (Yes/No) |
|
|
Are these notifications in real-time? (Yes/No) |
|
|
If real-time, are these alerts automated or manual? (Automated/Manual/N/A) |
|
|
Public
reporting burden for this collection of information is estimated to
average 90 minutes per response, the estimated time required to
complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA,
Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane,
Rockville, MD 20857.
11/2016
The Re-engineered Visit for Primary Care (AHRQ REV)
– Attachment G
File Type | application/msword |
Author | JSI |
Last Modified By | Windows User |
File Modified | 2016-11-30 |
File Created | 2016-11-30 |