Assessment of Cancer Prevention Services at Community Me

ASSESSMENT OF CANCER PREVENTION SERVICES AT COMMUNITY MENTAL HEALTH CENTERS

CMHC_OMB_SSA_APPENDIX 4_Survey Instruments_080317

Clinician Interview

OMB: 0920-1229

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OMB No. XXXX-XXXX

Expiration Date: XX/XX/20XX

National Survey on Community Mental Health Center Cancer Prevention Activities: Administrator Survey

Public Burden Statement: 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. The OMB control number for this project is XXXX-XXXX. Public reporting burden for this collection of information is estimated to average 20 minutes per respondent, per year, 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30329; ATTN: PRA (XXXX-XXXX)

OMB No. XXXX-XXXX

Expiration Date: XX/XX/20XX

About the Survey

Your community mental health center (CMHC) has been randomly selected for participation in a study funded by the Division of Cancer Prevention and Control (DCPC) at the Centers for Disease Control and Prevention (CDC) and conducted by Abt Associates. Through this study, we aim to better understand the capabilities of CMHCs to provide cancer prevention and screening services to persons with mental illness, to identify barriers to providing such services, and to propose strategies to addressing these barriers and facilitating such services.

As a part of this study, we are conducting a survey of CMHC administrators. Your participation in this survey will help the CDC better understand the capacity of CMHCs to provide cancer prevention services and the needs of CMHCs for training and resources related to cancer prevention.

Your participation in the survey is voluntary. Your completion of the survey indicates your consent to participate in the study. You may withdraw from the study by deleting responses before submission. Your name or your CMHC’s name will not be included in any papers or reports related to this study. Your name, email address and IP address will be used to track survey completion. However, we will not disclose any information that could identify you, such as your name, telephone number, or email. The research team has procedures in place to protect your confidentiality and minimize risk. All de-identified data from the survey will be provided to the CDC at the end of the study.

The survey should take about 20 minutes to complete.

If you have any questions about the study, please contact Project Director, Sue Pfefferle at Sue_Pfefferle@abtassoc.com, or at (617) 281-2594, or Brooke Steele at Bsteele1@cdc.gov, or at (770) 488-4261.

Instructions

This survey is intended to be completed by a senior administrator (e.g., CEO or COO) who is knowledgeable about services at your CMHC. A leader of psychiatric services at your CMHC will receive a separate survey.
Please respond to the survey thinking about your entire CMHC. The CMHC that you oversee may include more than one location/practice site that provides mental health services. If you oversee services at multiple practice locations/sites, please answer on behalf of all of those sites wherever possible.
If necessary, you may save the survey and complete it at another time by clicking the link in your email invitation.
Once you complete the survey you should press the submit button. Once you submit the survey, you will not be able to edit your responses.
As you fill out the survey, please consider the following definition of cancer prevention services:

Cancer prevention services are activities implemented to assist individuals/populations to decrease their risk factors and increase their protective factors with the goal of minimizing an individual’s odds of developing cancer and maximizing opportunities for early treatment should cancer occur or reoccur.

Cancer prevention services include:

one-on-one or group education,
routine screening,
screening reminders,
navigation services (peer or other) to increase screening uptake,
smoking cessation interventions,
use of social media to promote smoking cessation, and
early cancer detection.

Examples of Evidence on Cancer Risk Factors	Examples of Evidence on Cancer Protective Factors
Smoking	Not smoking
Exposure to second-hand smoke	No exposure to second-hand smoke
Overweight/Obesity	Maintaining a healthy weight
High intake of processed foods with low consumption of fresh produce	Eating a healthy diet with fresh fruits and vegetables
Lack of exercise	Regular exercise
Exposure to toxins and other environmental hazards	Living in a healthy environment
No HPV vaccine (for women)	HPV vaccine (for women)
Family history of cancer	No family history of cancer
No receipt of routine recommended cancer screenings	Getting routine recommended cancer screenings
Lack of physician recommendation for cancer screenings	Physician recommendation for cancer screenings
Excessive alcohol consumption	Abstaining from alcohol

Public Burden Statement: 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. The OMB control number for this project is XXXX-XXXX. Public reporting burden for this collection of information is estimated to average 20 minutes per respondent, per year, 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30329; ATTN: PRA (XXXX-XXXX)

OMB No. XXXX-XXXX

Expiration Date: XX/XX/20XX

General Health and Wellness Services

We are first interested in understanding general health and wellness services. The next four questions ask about any services either provided at your CMHC or for which providers at your CMHC refer out to an outside provider or agency, for adults, adolescents, and children. Please click on the button next to each service that applies.

For adults: do providers at your CMHC…..	Provide the following services?
General health screenings
General health education
Primary care
Yoga and other mind/body techniques
Healthy lifestyle education
Mindfulness meditation education and skills building
Trauma services
Physical activity education and support

For adults: do providers at your CMHC…..	Refer out for the following services?
General health screenings
Primary care
Medical case management
Healthy lifestyle education

Public Burden Statement: 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. The OMB control number for this project is XXXX-XXXX. Public reporting burden for this collection of information is estimated to average 20 minutes per respondent, per year, 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30329; ATTN: PRA (XXXX-XXXX)

For children and adolescents: do providers at your CMHC…..	Provide the following services?
General health screenings
General health education
Primary care
Medical case management
Yoga and other mind/body techniques
Healthy lifestyle education
Mindfulness meditation education and skills building
Trauma services
Physical activity education and support

For children and adolescents: do providers at your CMHC…..	Refer outside your CMHC for the following services
General health screenings
General health education
Primary care
Medical case management
Trauma services
Physical activity education and support

Cancer Prevention Services

For the individuals served by your CMHC, what priority are the following prevention health services, in terms of need?	High priority	Somewhat of a priority	Low priority	Not on our radar
Cancer screening
Ensuring that women under 26 have an HPV vaccine
Hepatitis B and C vaccinations
HIV counseling and testing
Metabolic screening
Tracking referrals for cancer screening
Primary care
Substance use disorder screening or SBIRT
Mental health promotion and prevention

We would also like to know about cancer prevention services at your CMHC.

To what extent are the following cancer risk factors, a priority to address in your CMHC?	High priority	Somewhat of a priority	Low priority	Not on our radar
Smoking
Exposure to second-hand smoke
Overweight and obesity
Lack of exercise
Exposure to toxins and other environmental hazards
Risky sexual behaviors
Family history of cancer
High intake of processed foods with low consumption of fresh produce
Lack of regular health care
Lack of education on cancer prevention
Excessive alcohol use

Please provide one response for each service for Question 7.

Does your CMHC…	Provide the following services?
Tobacco cessation counseling
Clinical breast exams
Cervical cancer screening (Pap test and high-risk HPV test)
Colorectal cancer screening (fecal occult blood test/fecal immunochemical test kit)
Assessment of family history of cancer
One-on-one counseling to encourage screening
Assessment of health behavior risks
Health coaching to decrease risk factors
Screening reminders
Education on cancer prevention

If no items “Provided” in Q7, GO TO Q10.

Please provide one response for each service for Question 8. By refer out, we mean refer to an outside provider or agency.

Does your CMHC…	Refer out for the following services?
Tobacco cessation counseling
Clinical breast exams
Mammogram
Cervical cancer screening (Pap test and high-risk HPV test)
Colorectal cancer screening (fecal occult blood test/fecal immunochemical test kit)
Colorectal cancer screening (colonoscopy)

Who in your CMHC provides cancer prevention services? (Please check all that apply)

	Psychiatrist
	Psychiatric nurse practitioner
	Family nurse practitioner
	Non-psychiatrist physician (MD/DO)
	Psychologist
	Social worker
	Professional counselor
	Nurse
	Health educator
	Health navigator
	Peer support specialist/peer recovery coach
	Other (please specify )

Go to Q11.

(If they are not providing services) Do you anticipate that your CMHC will begin providing cancer prevention services in-house within the next year? (GO to Q12b)

	Yes
	No

(If they are providing any services) Do you anticipate that your CMHC will increase the cancer prevention services it provides in-house within the next year?

	Yes
	No

For what percent of individuals served by your CMHC do you…

	a. Provide cancer screening directly at your CMHC? By cancer screening we mean services such as clinical breast exams; Pap tests, high-risk HPV testing; or fecal occult blood testing/fecal immunochemical test kit, etc.		%
	b. Make referrals to primary care providers for cancer screening?		%
	c. Provide other physical health services directly at your CMHC?		%
	d. Make referrals to primary care providers for other physical health services?		%
What percent of…		Percent		Don’t Know
Adults (aged 18 and over) served by your CMHC have a primary care physician?		%
Children under the age of 18 served by your CMHC have a primary care physician?		%

My CMHC has the following resources necessary to provide cancer prevention services:

	Strongly disagree	Disagree	Not sure	Agree	Strongly agree
Space
Financial resources
Staffing
Training and education on cancer prevention
Other (please describe): ______________________________

What are the needs for workforce development to increase CMHC staff knowledge of evidence-supported cancer prevention strategies?	Please rank your top three priorities
Training on cancer risks
Training on smoking cessation counseling
Training in specific evidence-based cancer interventions
Training on use of your EHR, if any, to track cancer screenings

Characteristics of your CMHC

Now we would like to know some background about your CMHC. If your CMHC has more than one site, please answer on behalf of all of those sites.

How many mental health providers, in full-time equivalents (FTEs) based on a 40 hour week, currently work at your CMHC?

Your best estimate is fine.	FTEs
Therapists, including: licensed certified social workers (LCSW), licensed independent clinical social workers (LICSW), licensed marriage and family therapists (LMFTs), and licensed mental health counselors (LMHCs)
Peer support specialists
Registered nurses
Psychiatric nurse practitioners (APRNs)
Psychiatrists
Psychologists
Primary care providers (MDs, DOs)
Primary care providers (FNPs, PAs)
Other (please specify):___________________________________________________

Is your CMHC involved in any of the following primary care/behavioral health integration efforts? (Please check all that apply)

	Medicaid Health Home under Section 2703 of the Affordable Care Act or planning to become a Health Home
	Both a CMHC and FQHC
	CMHC is also an FQHC look-alike
	CMHC is part of a Patient-Centered Medical Home
	SAMHSA Primary Care Behavioral Health Integration grantee CMHC is working toward primary care/behavioral health integration
	Other (please specify):
	None (If none, GO TO Q19)

How would you characterize your CMHC’s primary model of mental health care delivery in the context of behavioral health integration?

	Co-located mental health and primary care services. Mental health and physical health providers are located at a single location but operate as independent organizations (e.g., staffing, billing, and medical records).
	Close collaboration onsite with some system integration. Mental health and physical health provider relationships have been built and are leveraged to increase shared patient care.
	Full collaboration in a transformed/integrated practice. Mental health and physical health services are fully integrated (e.g., resources are allocated evenly across the entire practice, only one treatment plan exists for all patients to which all providers have access).
	Fully integrated teams. Behavioral health and physical health care professionals working in fully integrated treatment teams.
	Other (please specify) : ______________________

The next two questions ask about services either provided at your CMHC or for which providers at your CMHC refer out to an outside provider or agency. Please click on the button next to each service that applies.

Does your CMHC….	Provide the following services?
Substance use disorder services
Treatment for PTSD
Housing services
Vocational/employment services
Case management
Recovery supports

Does your CMHC….	Refer out for the following services?
Substance use disorder services
Treatment for PTSD
Housing services
Vocational/employment services
Case management
Recovery supports

Do the majority of mental health providers at your CMHC use an electronic health record (EHR) system to document cancer prevention services? Do not include billing record systems. Please select only one answer.

	Yes, all records in EHR
	All electronic, but we use a separate EHR for health services
	EHR for health but not mental health services
	Part paper and part electronic
	No

Who receives services at your CMHC?

For the following questions about the individuals who receive services at your CMHC, we understand that these are approximate percents and your best estimate is fine.

Approximately how many unduplicated individuals does your CMHC serve per year?

What is the approximate age distribution of the individuals who receive services at your CMHC?

5 years old or younger	6 to 12 years old	13 to 17 years old	18 to 25 years old	26 to 64 years old	65 years old or older
%	%	%	%	%	%	= 100%

Approximately what percent of the individuals who receive services at your CMHC identify as Hispanic/Latino?

What is the approximate racial distribution of the individuals who receive services at your CMHC?

African American/ Black	Asian American/ Asian	White/ Caucasian	Native American/ Alaska Native	Some other race/ multiple	No information available
%	%	%	%	%	%	= 100%

Approximately what percent of the individuals who receive mental health services at your CMHC have limited English proficiency?

What environmental risk factors do individuals served by your CMHC face?

	Please rank your top three priorities
No accessible chain grocery stores
Lack of available social services
Stress due to frequent community violence
Lack of public transportation
Low SES environment
No accessible primary care
Lack of quality housing
Unemployment
Other (please specify):

About You

Finally, please tell us a little about yourself.

What is your role?

	CEO or President
	CFO or Business Director
	Chief Medical Officer
	Other, please specify:

How long have you worked at your CMHC, in your present role or another role?

	0 to 2 years
	3 to 5 years
	6 to 10 years
	More than 10 years

Thank you for taking the time to complete this survey!

May we contact you in the future to discuss cancer prevention in more detail?

	Yes
	No

If yes, what is the best email address at which to contact you?

OMB No. XXXX-XXXX

Expiration Date: XX/XX/20XX

National Survey on Community Mental Health Center Cancer Prevention Services: Psychiatric Clinician Survey

Shape47

Public Burden Statement: 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. The OMB control number for this project is XXXX-XXXX. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per year, 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30329; ATTN: PRA (XXXX-XXXX)

OMB No. XXXX-XXXX

Expiration Date: XX/XX/20XX

About the Survey

As a part of this study, we are conducting a survey of CMHC psychiatric clinicians, primarily psychiatrists and psychiatric nurse practitioners. Your participation in this survey will help the CDC better understand the capacity of CMHCs to provide cancer prevention services and the needs of CMHCs for training and resources related to cancer prevention.

Your participation in the survey is voluntary. You are not required to complete the survey. Your completion of the survey indicates your consent to participate in the study. You may withdraw from the study by deleting responses before submission. Your name or your CMHC’s name will not be included in any papers or reports related to this study. Your name, email address and IP address will be used to track survey completion. However, we will not disclose any information that could identify you, such as your name, telephone number, or email. The research team has procedures in place to protect your confidentiality and minimize risk. All de-identified data from the survey will be provided to the CDC at the end of the study.

The survey should take about 15 minutes to complete.

Instructions

This survey is intended to be completed by a psychiatrist or psychiatric nurse practitioner who is knowledgeable about clinical services at your CMHC. A senior administrator at your CMHC will receive a separate survey.
Please respond to the survey thinking about all mental health care provided at your CMHC. The CMHC where you work may include more than one location/practice site. If you provide services at more than one CMHC site, please answer on behalf of all of those sites.
If necessary, you may save the survey and complete it at another time by clicking the link provided in your email invitation.
Once you complete the survey you should press the submit button. Once you submit the survey, you will not be able to edit your responses.
As you fill out the survey, please consider the following definition of cancer prevention services:

Cancer prevention services include:

one-on-one or group education,
routine screening,
screening reminders,
navigation services (peer or other) to increase screening uptake,
smoking cessation interventions,
use of social media to promote smoking cessation, and
early cancer detection.

Examples of Evidence on Cancer Risk Factors	Examples of Evidence on Cancer Protective Factors
Smoking	Not smoking
Exposure to second-hand smoke	No exposure to second-hand smoke
Overweight/Obesity	Maintaining a healthy weight
High intake of processed foods with low consumption of fresh produce	Eating a healthy diet with fresh fruits and vegetables
Lack of exercise	Regular exercise
Exposure to toxins and other environmental hazards	Living in a healthy environment
No HPV vaccine (for women)	HPV vaccine (for women)
Family history of cancer	No family history of cancer
No receipt of routine recommended cancer screenings	Getting routine recommended cancer screenings
Lack of physician recommendation for cancer screenings	Physician recommendation for cancer screenings
Excessive alcohol consumption	Abstaining from alcohol

Public Burden Statement: 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. The OMB control number for this project is XXXX-XXXX. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per year, 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30329; ATTN: PRA (XXXX-XXXX)

General Health and Wellness Services

For adults: do providers at your CMHC…..	Provide the following services?
General health screenings
General health education
Primary care
Medical case management
Yoga and other mind/body techniques
Healthy lifestyle education
Mindfulness meditation education and skills building
Trauma services
Physical activity education and support

For adults: do providers at your CMHC…..	Refer out for the following services?
General health screenings
Primary care
Medical case management
Healthy lifestyle education

For children and adolescents: do providers at your CMHC…..	Provide the following services?
General health screenings
General health education
Primary care
Medical case management
Yoga and other mind/body techniques
Healthy lifestyle education
Mindfulness meditation education and skills building
Trauma services
Physical activity education and support

For children and adolescents: do providers at your CMHC…..	Refer outside your CMHC for the following services
General health screenings
General health education
Primary care
Medical case management
Trauma services
Physical activity education and support

We would also like to know about specific cancer prevention services offered at your CMHC.

Do providers at your CMHC…	Provide the following services?
Tobacco cessation counseling
Clinical breast exams
Mammograms
Cervical cancer screening (Pap test and high-risk HPV test)
Colorectal cancer screening (fecal occult blood test/fecal immunochemical test kit)
Colorectal cancer screening (colonoscopy)
Assessment of family history of cancer
One-on-one counseling to encourage screening
Assessment of health behavior risks
Health coaching to decrease risk factors
Screening reminders

If no “Provide” items for Q5, GO TO Q7b.

Do providers at your CMHC…	Refer out for the following services?
Tobacco cessation counseling
Clinical breast exams
Mammograms
Cervical cancer screening (Pap test and high-risk HPV test)
Colorectal cancer screening (fecal occult blood test/fecal immunochemical test kit)
Colorectal cancer screening (colonoscopy)
Assessment of family history of cancer
One-on-one counseling to encourage screening
Assessment of health behavior risks
Health coaching to decrease risk factors

For what percent of individuals served by your CMHC do clinical staff…(your best estimate is fine)
a. Provide cancer screening directly at your CMHC? By cancer screening we mean services such as clinical breast exams; Pap tests, and high-risk HPV testing; or fecal occult blood testing/fecal immunochemical test kit, etc.	%
b. Make referrals to primary care providers for cancer screening?	%
c. Provide other physical health services directly at your CMHC?	%
d. Make referrals to primary care providers for other physical health services?	%

Does your CMHC employ peer wellness coaches?

Yes

No (GO TO Q 10)
We are interested to learn about what peer wellness coaches do at your CMHC. Do clinical staff refer individuals served at your CMHC to peer wellness coaches on a regular basis for…

Health navigation services?
One-on-one coaching to increase uptake of cancer screening?
Support during cancer testing?
Planning wellness goals?
Accompanying individuals to physical health care appointments?

What percent of individuals served by your CMHC have been diagnosed with cancer in the past six months? Your best estimate is fine.	%	Don’t Know

What services, if any, does your CMHC provide to individuals with a diagnosis of cancer?

Health navigation services
Escort to health care visits
Support to help individuals continue routine screening
Assistance in accessing cancer support groups
Other (please describe)_________________________________________

To what extent do you feel the following providers at your CMHC are equipped to implement cancer prevention services for individuals served by your CMHC?

	Highly equipped	Somewhat equipped	Not very equipped	Not at all equipped
Nurses at your CMHC
Therapists (PhDs, LICSWs or LCSWs, LPCs, LMFTs, or LMHCs) at your CMHC
Peer support specialists at your CMHC
Psychiatric clinicians at your CMHC

What training on evidence-supported cancer prevention strategies would you find useful?	Please rank your top three priorities
Training on cancer risk factors
Training on smoking cessation counseling
Training in specific evidence-based cancer interventions
Training on use of your EHR, if any, to track cancer screenings
Training on brief motivational interventions
Other (please describe)

Providers at my CMHC have the following resources necessary to provide cancer prevention services:

	Strongly disagree	Disagree	Not sure	Agree	Strongly agree
Space
Time
Support staff
Other (please describe):
External Resources

Are you aware of the National Breast and Cervical Cancer Early Detection Program in your state?

	Yes
	No (GO TO Q 17)

Do you have a partnership with the National Breast and Cervical Cancer Early Detection Program in your state? By partnership we mean a memorandum of agreement or understanding, or an informal agreement to refer women for screening through the program.

	Yes
	No

Are you aware of the Comprehensive Cancer Control Coalition in your state?

	Yes
	No (Go to Q 19)

Do you have a partnership with the Comprehensive Cancer Control Coalition in your state? By partnership we mean membership in the coalition, participation in coalition meetings, or a memorandum of understanding or informal agreement with your state’s coalition.

	Yes
	No

Do psychiatric providers at your CMHC have access to your local health information exchange?

	Yes
	No

To what extent do the following areas represent service gaps for individuals served by your CMHC?	Of great concern	Somewhat of a concern	Low concern	Not a concern
Housing services
Employment services
Substance use disorder services
Detox
Medication-assisted treatment
Primary care
Psychiatry

Characteristics of your CMHC

Now we would like to know some background about your CMHC. If your CMHC has more than one site, please answer on behalf of all of those sites.

In what languages does your CMHC provide services? (Please check all that apply)

	English
	Spanish
	Korean
	Mandarin
	Szechuan
	Arabic
	Vietnamese
	Farsi
	Tagalog
	Haitian Creole
	Other (please specify):

About the People Served at the CMHC

For the following questions about the individuals who receive services at your CMHC, we understand that these are approximate percentages and your best estimate is fine.

Approximately what percent of individuals your CMHC serves have co-occurring substance use disorders?

Approximately what percent of individuals your CMHC serves have chronic health conditions?

About You

Finally, please tell us a little about yourself.

Are you…

	A psychiatrist
	A psychiatric nurse practitioner
	Other

How long have you worked at your CMHC?

	0 to 2 years
	3 to 5 years
	6 to 10 years
	More than 10 years

Thank you for taking the time to complete this survey!

May we contact you in the future to discuss cancer prevention in more detail?

	Yes
	No

If yes, what is the best email address at which to contact you?

Abt Associates CDC Contract 200-2014-61267-0002 December 29, 2016 ▌1-8

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