Form 0920-1156 Health Center Org Assessment

Form Approved

OMB No. 0920-1156

Exp. Date xx/xx/xxxx

HEALTH CENTER/PRACTIC SETTING ORGANIZATIONAL ASSESSMENT

Public reporting of this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current 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 CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1156)

Definitions

Adolescents: For the purposes of this assessment, adolescents refers to all youth ages 15-19

Family Planning: Any service related to postponing or preventing pregnancy. Family planning services may include a medical examination related to provision of a method, contraceptive counseling, method prescription or supply visits. A patient may receive a family planning service even if the primary purpose of her visit is not for contraception.

Sexual Health Assessment: Assessment of sexual activity, current and future contraceptive options, sexual partners, condom use and protection from STDs and past STD history.

Standard of Care: A standard of care refers to informal or formal guidelines that are generally accepted in the medical community for treatment of a disease or condition.

Health and Human Service (HHS) Teen Pregnancy Prevention (TPP) Evidence Based Program list: List of programs proven to be effective at preventing teen pregnancies, sexually transmitted infections, or sexual risk behaviors. (http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/db/index.html)

Date Assessment was completed: _______________________________________

Please provide the following information for your health center.

Health Center Name:
Mailing Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:

_____________________________________________________________________________________________________________

PART 1: HEALTH CENTER

The following set of questions are to be answered for your overall health center. Please answer each of the following questions as they relate to your health center and the adolescent patients at your health center.

1. PATIENT and HEALTH CENTER CHARACTERISTICS

1. Which of the following describes the setting of your health center? (select all that apply)

	Line	Setting
	1	Federally Qualified Health Center
	2	Community health center (non-FQHC)
	3	Family planning clinic
	4	Health department (state or local)
	5	HMO or Hospital
	6	Indian Health Service
	7	Planned Parenthood affiliate
	8	Private practice
	9	School based health clinic
	10	Sexually transmitted infection clinic
	11	College (Community/University) clinic
	12	Foster Care
	13	Correctional facility
	14	Substance abuse treatment center
	15	Other (please specify)___________________

2. Approximately what percentages of your adolescent patients in your health center have the following characteristics? If unsure, give your best estimate.

Line	Characteristic	0-24%	25-49%	≥50%
1	Pay for their visit using Medicaid or other state or federal assistance
2	Are racial or ethnic minorities
3	Have limited English proficiency

BILLING AND REVENUE

3. Please indicate which non-fee-for service income is received by your health center to support family planning services? (Select ALL that apply)

	Line	Type of Income
	1	Private grant(s)
	2	State appropriations
	3	Section 308 of Public Health Service Act
	4	Title V (MCH Block Grant)
	6	Title X (Family Planning)
	6	Don’t know
	7	Other _______________________________
	8	None (all income is generated through fees)

4. What percentage of revenue by source does your health center receive for adolescent family planning visits?

	Line	Source	% of Revenue
	1	Medicaid Fee for Service
	2	Medicaid Family Planning Waiver
	3	Medicaid Managed Care
	4	Commercial Insurance
	5	Sliding Fee Scale
	6	Full Pay
	7	No Pay (covered by Title X, Title V, grants, etc)
	8	Uninsured (health center absorbs costs)
	9	Other___________________________

5. Does your health center…

Line	Practice	No	Yes
1	Participate in the federal 340B drug discount purchasing program?
2	Have systems in place to facilitate billing third party payers for family planning services?
3	Offer free services or a sliding fee scale for any adolescents?
4	Offer a low, flat fee for any adolescents?
5	Have practices in place to ensure adolescent confidentiality in billing procedures (e.g., not having contraceptive services on EOB)?

6. How frequently does your health center facilitate uninsured patients’ enrollment in available insurance options?

Never

Rarely

Sometimes

Often

Always

ACCESSIBILITY

7. Does your health center have partnerships with other agencies to assist youth in accessing transportation services?

No

Yes

8. Does your health center offer its own transportation services?

No

Yes

9. How often does your health center offer reimbursements to adolescents for transportation to the clinic (i.e., bus tokens or taxi vouchers)?

Never

Rarely

Sometimes

Often

Always

10a. Does your health center provide IUDs and implants to teens regardless of their ability to pay?

No

Yes

10b. If yes, how do you cover costs for these services?

Describe…

11a. Does your health center provide other forms of hormonal contraception to teens regardless of their ability to pay?

No

Yes

11b. If yes, how do you cover costs for these services?

Describe…

2. CONFIDENTIALITY AND CONSENT

12. The following questions relate to your health center’s practices with respect to confidentiality and consent. Please indicate which statement most closely reflects your health center practices across all practice settings (e.g., pediatrics, family planning) where adolescents receive care.

Line		Never	Rarely	Sometimes	Often	Always
1	Minors are informed at every visit about their state’s laws governing the rights of minor patients to consent to sexual and reproductive health care or treatment.
2	Minors are informed verbally of the confidentiality policy at every visit.
3	Minors are informed in writing of the confidentiality policy at every visit.
4	Parents/caregivers are informed of confidentiality policy when accompanying their child to a visit.

13. Does your health center require parental consent for sexual and reproductive health services for minors?

No

Yes

III. HEALTH CENTER RESOURCES AND OUTREACH______________________________________________________________

14. Does your health center use the following technologies?

Line	Technology	No	Yes: Limited Use	Yes: Routinely
1	Electronic health records
2	Electronic systems for billing
3	Email clients for appointment reminders
4	Call clients for appointment reminders
5	Send text messages to clients for appointment reminders
6	Email, phone, or text messages to clients to provide any follow-up on contraceptive method selected
7	Website that allows clients to make appointments online

15. In the past 12 months, did your health center use any of the following methods for community education/outreach to teens? (Not exclusively related to fund-raising)

Line	Method	No	Yes
1	TV
2	Radio
3	Websites
4	Social media (e.g. Facebook, Instagram, Twitter)
5	Billboards
6	Newspapers or magazines
7	Small group education/Face-to-face education
8	Targeted outreach or educational materials to specific youth-serving organizations (e.g., schools, colleges, youth-serving organizations)

16. Does your health center currently…

Line		NO	YES
1	Include youth in clinic advisory boards?
2	Include youth in continuous quality improvement activities?
3	Include youth in decision making processes?
4	Include youth in materials development and review?
5	Offer adolescent support groups or discussion groups to discuss sexuality, birth control, interpersonal relationships or related topics?
6	Provide education materials to parents/guardians on how to talk to their children about sex?
7	Provide evidence-based teen pregnancy/STD/HIV prevention interventions designed for adolescents? (http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/db/index.html)

IV. QUALITY IMPROVEMENT

17. Does your health center have current quality improvement initiatives?

No (If no, skip to #19)

Yes

18. Does your health center have a current quality improvement initiative related to adolescent reproductive health care?

No

Yes

19. List all of the quality improvement initiatives that are currently taking place at your health center (whether they relate to adolescent reproductive health care or not):

List here…

20. As part of participating in the CDC funded teen pregnancy prevention project, in the past 12 months, has your health center modified any clinical practices or other aspects of the provision of health care to adolescents in response to a review of quality improvement data?

No

Yes

If yes, please briefly describe what aspects of service delivery to adolescents were changed.

Describe here…

21. Does your health center have the ability to report on the following information about adolescent clients or about sexual and reproductive health services provided to adolescents?

Line	Item	No	Yes
1	Sexual health assessment conducted
2	Status of sexual activity (sexually active past or present, or not)
3	Pregnancy intention assessed
4	Contraceptive counseling offered
5	Contraceptive counseling provided
6	Primary contraceptive method at start of visit
7	Primary contraceptive method at end of visit

___________________________________________________________________________________________________________

PART 2: PRACTICE SETTING

The following questions should be answered by each practice setting within your health center participating in this initiative (e.g., pediatrics, family planning, mobile unit). Please complete Part 2 separately for each practice setting.

Date Assessment was completed: _______________________________________

Please provide the following information for your practice setting.

Practice Name:
Health Center Location:
Mailing Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:
ID Number:

1. Please indicate your practice setting within the health center? (select one)

	Line	Focus
	1	Adolescent subspecialty
	2	Pediatrics
	3	Obstetrics/gynecology
	4	Family planning
	5	Primary (general health) care/ Family Practice
	6	Urgent care
	7	Mobile Unit
	8	Other (please specify) ___________________

2. How many days/week is your practice setting open? ________

3. Indicate if your practice has any of the following policies.

Line	Policy	NO	YES
1	Offer walk-in appointments for adolescent clients?
2	Offer same day appointments for adolescent clients?
3	Offer appointments after school hours?
4	Offer appointments during the weekend?
5	Gives adolescents priority when scheduling appointments during after school and weekend hours?

4. How frequently does your practice setting provide minors with time alone with a health care provider at every visit?

Never

Rarely

Sometimes

Often

Always

I. PERSONNEL AND TRAINING

5.	a. Please indicate the number of clinical providers of each type in your practice setting and the number who provide the listed family planning services:
Line		Personnel by Major Service Category	Number of Providers	Number who Prescribe contraception	Number Proficient* in IUD insertion and removal	Number Proficient* in implant insertion and removal
1		Family Physicians/General Practitioners/Internists
2		Obstetrician/Gynecologists
3		Pediatrician
4		Other Specialty Physician
5		Nurse Practitioner
6		Physician Assistant
7		Certified Nurse Midwife

* “Proficient” means the clinician has inserted IUDs or Implants without supervision within the last 3 months

b. Please indicate the number of staff of each type in your practice setting and the number of these staff who 1) conduct intakes, 2) assess pregnancy intention and 3) conduct contraceptive counseling?

Line	Personnel by Major Service Category	Number of Providers	Number who Conducts Intake Assessment*	Number who Assess pregnancy intention**	Number who Provide Contraceptive Counseling or Education***
1	Nurses (RN/LPN)
2	Medical Assistant/ Medical Technician
3	Social Worker
4	Health Educator
5	Other: (Please describe: )

*“Conducts Intake Assessment” means asking clients their main reason for visiting the practice, current medications and/or conditions and/or conducting a risk assessment

**“Assess Pregnancy Intention” means asking clients if they are trying to become pregnant or interested in becoming pregnant in the near future (e.g. within the next 12 months)
***“Provides Contraceptive Counseling or Education” means asking clients about their past experiences and preferences with contraception and providing information about all available methods.

6. Please indicate what percentage of each type of your staff have received training in the following areas in the past year:

Line	Training	<25%	25% to <50%	50% to 75%	>75%
All Staff
1	Time-alone
2	Adolescent Development
3	Confidentiality/Minor’s Rights
4	Birth Control Basics
5	Common Birth Control Myths
6	Introduction to CDC and OPA’s Providing Quality Family Planning Services (QFP)
Clinical Staff
7	Client-Centered Birth Control Counseling
8	LARC Insertion/Removal
9	Managing LARC Side Effects
10	STD/HIV Basics
11	The Adolescent Healthcare Visit (Assessment and Services)
Staff Providing Contraceptive Counseling
12	Client-Centered Birth Control Counseling
13	STD/HIV Basics
14	The Adolescent Healthcare Visit (Assessment and Services)
Front Line Staff
15	Key Messages for Ensuring Access to SRH Services

II. PRACTICE CLINICAL ASSESSMENT POLICIES AND PROCEDURES

7. Indicate how frequently your practice collects the following clinical and social information from adolescent patients at each visit.

Line		Never	Rarely	Sometimes	Often	Always
1	Conduct or update medical history
2	Conduct or update sexual health assessment
3	Assess pregnancy intention or risk

8. When initiating the following contraceptive methods*, please indicate if your practice requires the following exams and tests for a healthy adolescent client. (Check all exams and tests that apply.)

Line	Contraceptive Method		Blood pressure	Clinical breast exam	Bimanual exam and cervical inspection	Cervical cytology (Pap smear)	Chlamydia/ gonorrhea screening
1	COCs/patch/ring
2	Progestin-only pills (POPs)
3	DMPA (Depo-Provera®)
4	Implant (Implanon ® or Nexplanon ®)
5	Cu-IUD (ParaGard ®)
6	LNG-IUD (Mirena ®; Liletta ®, Skyla ®))
		*Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

III. CLINICAL SERVICES PROVIDED

9. In the past 3 months, were the following contraceptive methods* provided on-site or via prescription/referral to adolescents clients who requested them?

	Line	Contraceptive Method	Dispensed on site, last 3 months		Via Prescription/Referral, last 3 months
			No	Yes	No	Yes
	1	Combined Oral Contraceptives (COCs)
	2	Patch (Ortho Evra®)
	3	Vaginal ring (NuvaRing®)
	4	Progestin-only oral contraceptives
	5	DMPA (Depo-Provera®)
	6	Emergency contraceptive pills (for females)
	7	Emergency contraceptive pills (for males)
	8	Male condom
	9	Female condom
		*Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

10. How does your practice obtain the following forms of contraception* for adolescents? Also, please note whether your practice ran out of supplies of that method in the last 3 months.

Line		Contraceptive Method	Available to clients in your practice setting		Stocked in advanced in practice setting or pharmacy		Only ordered when requested by patient		Supplies ran out in last 3 months
			No	Yes	No	Yes	No	Yes	No	Yes
1		Implant (Implanon ® or Nexplanon ®)
2		Cu-IUD (ParaGard ®)
3		LNG-IUD (Mirena ®; Liletta ®, Skyla ®))
	*Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

11. How many days per week does your practice setting have someone trained and available to provide IUDs and implants for adolescent patients?

Line	Number of Days	IUD	Implant
1	1
2	2
3	3
4	4
5	5 or more

12. How are IUDs and implants typically offered to adolescents?

Line	Method	Implant (Implanon® or Nexplanon®)	Cu-IUD (ParaGard®)	LNG-IUD (Mirena®; Liletta®; Skyla ®)
1	Provided same day as requested
2	New appointment made for insertion
3	Referred to another practice setting within the health center
4	Referral to another health center

13. Does your practice provide condoms to adolescents in a manner that allows teens to take them privately and without having to ask?

No Yes

14. Indicate how frequently the following clinical recommendations for contraceptive counseling are followed.

Line	Recommendation	Never	Rarely	Sometimes	Often	Always
1	Assess adolescent pregnancy/fatherhood intentions/risk (i.e., ask about intentions regarding timing of pregnancies/reproductive life plan) in the context of their personal values and life goals.
2	Present information on a wide range of contraceptive methods with the most effective methods presented first, while also discussing how well each method meets the client’s needs.
3	Help clients think about potential barriers to using their selected method correctly and develop a plan to deal with these barriers.
4	Inform adolescents that IUDs and implants are safe and effective contraceptive options in all counseling sessions with adolescents.
5	Provide information and education on dual protection (i.e., hormonal method with barrier method) to prevent pregnancy and STDs in all counseling sessions with adolescents.
6	Provide information and education on abstinence as an effective way to prevent pregnancy and STDs in all counseling sessions with adolescents.

15. Indicate how frequently your practice performs the following.

Line	Recommendation or Standard	Never	Rarely	Sometimes	Often	Always
1	Offer sexually active adolescents hormonal contraception, IUD and implant at every sexual health visit that the adolescent makes to the clinical provider.
2	Offer sexually active adolescents hormonal contraception, IUD and implant at every non-sexual health related visit that the adolescent makes to the clinical provider (e.g. primary care visit).
3	Quick Start initiation (starting birth control the day of the visit) of pill, patch, ring and depo shot offered after negative history* and negative urine pregnancy test (UPT).
4	Quick Start insertion of IUD offered after negative history* and negative urine pregnancy test (UPT) (e.g., no need to schedule a separate insertion visit).
5	Quick Start insertion of implant offered after negative history* and negative urine pregnancy test (UPT) (e.g., no need to schedule a separate insertion visit).
6	Provide or prescribe multiple cycles of oral contraceptive pills (up to 12 months), the patch or the ring to minimize the number of times an adolescent has to return to health center.
7	Provide client with another contraceptive method to use until patient can start the chosen method, if not immediately available on-site, the same day, or client not medically eligible.
8	Offer same-day contraceptive services to adolescents who have a negative history* and negative pregnancy test and do not want to become pregnant.
9	Offer all emergency contraception options (copper-IUD, ulipristal acetate pills, and levonorgestrel pills) to adolescents who have had unprotected intercourse in the last five days (after negative history* and negative urine pregnancy test for early pregnancy).
10	Offer advanced supply of emergency contraceptive pills (levonorgestrel, ulipristal acetate) to adolescents using Tier 2 (moderately effective) or Tier 3 (least effective) methods.
11	For sexually active teens, conduct STI screening annually, or provide diagnostic testing based on sexual history of symptoms.
12	For sexually active teens, offer HIV screening annually, or provide diagnostic testing based on sexual history of symptoms.

*A detailed history provides the most accurate assessment of pregnancy risk in a woman who is about to start using a contraceptive method. A health-care provider can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any one of the following criteria:

• is ≤7 days after the start of normal menses

• has not had sexual intercourse since the start of last normal menses

• has been correctly and consistently using a reliable method of contraception

• is ≤7 days after spontaneous or induced abortion

• is within 4 weeks postpartum

• is fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority [≥85%] of feeds are breastfeeds, amenorrheic and <6 months postpartum

IV. PRACTICE SERVICES AND RESOURCES______________________________________________________________________

16. Indicate if your practice provides the following services or resources by checking the appropriate box.

Line	Service or Resource	NO	YES
1	Displays information on issues related to adolescent sexual and reproductive health in waiting room or exam room where it can be viewed easily by all clients.
2	Displays information on issues related to minor’s rights in waiting room or exam room where it can be viewed easily by al clients.
3	Provides language translation services that match the needs of your adolescent clients

17. Indicate if all, some or none of your patient materials and forms are designed with the following characteristics.

Line	Resource	All	Some	None
1	Provides patient educational materials specifically designed for adolescents, including literacy needs
2	Provides patient forms specifically designed for adolescents, including literacy needs
3	Provides patient educational materials in languages that match the needs of your adolescent clients
4	Provides patient forms in languages that match the needs of your adolescent clients
5	Provides educational materials to meet the gender identity and sexual orientation needs of your adolescent clients
6	Provides patient forms to meet the gender identity and sexual orientation needs of your adolescent clients

VIII. Referrals________________________________________________________________________________________________

18. Indicate how frequently your practice provides the following referral services for adolescent clients.

Line	Type of Referral	Never	Rarely	Sometimes	Often	Always
1	Assess youth for other needed health services (i.e., mental health, substance abuse, immunizations, or STDs) not provided at your health center and provide referrals when indicated
2	Assess youth for other service needs (i.e., interpersonal violence, sexual abuse/assault, food pantry, employment services, educational opportunities, or housing services) and provide referrals when indicated.
3	Refer pregnant and parenting adolescents to home visiting or other programs that provide needed support and reduce rates of repeat pregnancy
4	Refer adolescents to evidence-based teen pregnancy prevention or STD risk reduction programs.

19. Please share any additional comments that you may have in the space below.

Optional comments…

Thank you for completing this survey!

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