B5 Attachment B5 - Grantee Site Survey_FINAL 04.08.20

Grantee Site Survey OMB Number (0915-XXXX)

Expiration date (XX/XX/202X)

Note: The survey will start with a login page, followed by the Public Burden Statement, Introduction/ Consent, and Instructions. Then the survey will begin.

Public Burden Statement: This survey is intended to gather information from [GRANT PROGRAM NAME] partner sites. The information gathered will contribute to the Bureau of Health Workforce (BHW) Substance Use Disorder (SUD) Evaluation. 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 information collection is 0915-XXXX and it is valid until XX/XX/202X. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

Introduction/Consent:

Thank you for participating in our Bureau of Health Workforce Survey of training sites! We value your input.

Your responses will be kept confidential. For all of the data we collect for analysis, we will use unique survey identifiers, not respondents’ names. Any published reports will summarize the results in the aggregate and will not include individual responses. At the end of the evaluation, all of the data that are collected will be provided to the Health Resources and Services Administration (HRSA).

Instructions:

Please use the “Continue” and “Previous” buttons to navigate through the questions in the survey. You must use the "Continue" button on the screen after you have responded to a question in order for your answer to be saved. Please do not use your browser buttons.

To exit the survey at any time, use the “Quit” button at the top of each screen. Using the “Quit” button saves your data and allows you to return to the same location later to complete the survey.

You may have had more than one [GRANTEE NAME AND GRANT PROGRAM] trainee at your site. If this is the case, please think about your experiences in providing training to all trainees in the program.

We have provided definitions on certain terms throughout the survey. When available, you will see a question mark icon appear above a term where a definition is available. (OMB Reviewers: These definitions only appear at their first mention in this document to conserve space, but these definitions will be made available in the programmed web survey at every mention of the relevant term.)

Again, we greatly appreciate your time and participation. Let’s get started!

Preload variables required for survey administration:

Email Address

Grant Program (i.e., GPE, BHWET, OWEP)

Grantee Name

Grantee Program Name

Site Name

1. Respondent Characteristics: We would like to begin with a few questions about yourself.

1. What is your role at [SITE NAME]?
   Please select ALL that apply.

[ ] Clinical provider

[ ] Medical/clinical director

[ ] Mental health administrator/office manager

[ ] Mental health department director
[ ] Human resources administrator
[ ] Chief Executive Officer, Chief Financial Officer, or some other chief administrator

[ ] Other: please specify ___________________

2. How long have you been in this role?

[ ] Less than 1 year
[ ] At least 1 year but less than 3 years
[ ] At least 3 years but less than 5 years
[ ] 5 years or more
[ ] Don’t know

2. Site Characteristics: Next, we would like to learn more about how care is delivered at your site.

3. How would you describe the level of behavioral and physical health integration at your site?

Please select ALL that apply.

[ ] Minimal collaboration at a distance: behavioral health and physical health providers communicate sporadically. They have separate facilities and systems (e.g., electronic health records).

[ ] Basic collaboration at a distance: behavioral health and physical health providers communicate about shared patients. They have separate facilities and systems.

[ ] Basic collaboration onsite: behavioral health and physical health providers are located at the same facility. They communicate about shared patients, but still have separate systems.

[ ] Close collaboration in a partially integrated system: behavioral health and physical health providers are in the same facility and communicate regularly about patient care. They share some systems.

[ ] Close collaboration in a fully integrated system: behavioral and physical health providers are co-located in the same practice space and function as part of the same team, communicating regularly and using the same systems.

[ ] Does not apply; there are only behavioral health services at my site. [DISALLOW IF ANOTHER OPTION SELECTED]

[ ] Does not apply; there are only physical health services at my site. [DISALLOW IF ANOTHER OPTION SELECTED]

[ ] I don’t know the level of behavioral and physical health integration. [DISALLOW IF ANOTHER OPTION SELECTED]

4. Does your site offer medication-assisted treatment (i.e., MAT using buprenorphine, methadone, or naltrexone) for opioid use disorders?

Note: Other terms for medication-assisted treatment (MAT) include medication for opioid use disorder (MOUD) and opioid agonist therapy (OAT). This survey uses MAT to cover all three terms.

[ ] Yes

[ ] No

[ ] Don’t know

5. Which payment models are used at your site?

Please select ALL that apply.

[ ] Traditional fee-for-service payments that are not tied to performance on cost or quality measures

[ ] Traditional fee-for-service payments that are tied to performance on cost or quality measures

[ ] Payments that build on a fee-for-service infrastructure, but include payment for performance against a target

[ ] Prospective, population-based payment arrangements, such as capitated payments

[ ] Other: please specify___________________

[ ] I don’t know which payment models are used [DISALLOW IF ANOTHER OPTION SELECTED]

3. Training Opportunities: Now we would like to learn more about the training opportunities that you offer at your site to [GRANTEE PROGRAM NAME] trainees.
   
   
   

6. Do you currently have [GRANTEE PROGRAM NAME] trainees at your site?

[ ] Yes

[ ] No

[ ] Don’t know

[IF Q6=NO, DON’T KNOW, DISPLAY: “When answering the following questions about training opportunities, please think about the most recent cohort or set of trainees at your site.”]

7. Which components, if any, are part of the training that your site provides through [GRANTEE PROGRAM NAME]?

Please provide a response for ALL rows.

Training Components	Yes, our site provides training on this topic	No, our site does not provide training on this topic	Not applicable, our site does not offer this service	Don’t know
Providing mental health dual diagnosis management (WEB SURVEY HOVER OVER FEATURE: Also known as "co-occurring disorder management")
Applying knowledge of psychopharmacology
Providing substance use screening, assessment, and treatment services, excluding opioid use disorder services
Providing opioid use disorder screening and treatment services, excluding medication-assisted treatment
Developing care coordination plans that integrate substance use disorder treatment with other care
Providing medication-assisted treatment either individually or as part of a team
Using the Prescription Drug Monitoring Program (WEB SURVEY HOVER OVER FEATURE: The Prescription Drug Monitoring Program (PDMP) is an electronic database that tracks controlled substance prescriptions.)
Providing care under different payment models
Applying cultural or linguistic competency skills (WEB SURVEY HOVER OVER FEATURE: Cultural competency refers to knowledge, behaviors, attitudes, and policies that allow health professionals to understand/respect cultural differences and similarities such as by providing information in the language or cultural context most appropriate for the person being served.)
Applying strategies to reduce stigma around behavioral health issues
Ensuring patient confidentiality and privacy during care delivery
Delivering substance use disorder services through telehealth technology (WEB SURVEY HOVER OVER FEATURE: Telehealth refers to the use of electronic information and telecommunications such as videoconferencing or streaming media to support long-distance clinical health care and patient and professional health-related education.)
Pandemic emergency preparedness

8. [ASK IF Q7=“PROVIDING OPIOID USE DISORDER SCREENING AND TREATMENT SERVICES, EXCLUDING MEDICATION-ASSISTED TREATMENT” OR “PROVIDING MEDICATION-ASSISTED TREATMENT EITHER INDIVIDUALLY OR AS PART OF A TEAM”]

Which opioid use disorder treatments are part of the training that your site provides through the [GRANTEE PROGRAM NAME]?

Please select ALL that apply.

[ ] Buprenorphine (e.g., administration, education)

[ ] Methadone

[ ] Naltrexone

[ ] Provider educational interventions

[ ] Community educational interventions

[ ] Social services and referrals

[ ] Screening, Brief Intervention, and Referral to Treatment (SBIRT)

[ ] Training on harm reduction or the prevention of escalation

(WEB SURVEY HOVER OVER FEATURE: Harm reduction refers to preventing harmful opioid use, including among individuals who misuse but do not yet meet the clinical criteria for use disorders.)

[ ] Other: please specify ___________________

[ ] Our site does not provide training on opioid use disorder treatments [DISALLOW IF ANOTHER OPTION SELECTED]

[ ] Don’t know

9. Does your site provide interprofessional training to [GRANTEE PROGRAM NAME] trainees?

(WEB SURVEY HOVER OVER FEATURE: Interprofessional training refers to two or more types of professionals learning about, from, and with each other to enable effective collaboration and improve health outcomes.)

[ ] Yes

[ ] No

[ ] Don’t know

10. With which types of professionals, if any, do your trainees work?

Please check ALL that apply.

[ ] Physician, excluding Psychiatrists (MD/Doctor of Medicine, DO/Doctor of Osteopathic Medicine)

[ ] Psychiatrist

[ ] Physician Assistant

[ ] Nurse Practitioner

[ ] Registered Nurse

[ ] Psychiatric Nurse Specialist

[ ] Certified Nurse-Midwife

[ ] Dentist (DDS/Doctor of Dental Surgery, DMD/Doctor of Medicine in Dentistry)

[ ] Dental Hygienist

[ ] Pharmacist

[ ] Clinical Psychologist

[ ] Substance Use Disorder Counselor

[ ] Marriage and Family Therapist

[ ] Licensed Clinical Social Worker

[ ] Other Licensed Professional Counselor

[ ] Behavioral Health Professional (not licensed)

[ ] Peer Provider

[ ] Administrative Staff

[ ] Other: please specify ___________________

[ ] I don’t know which professionals our trainees work with [DISALLOW IF ANOTHER OPTION SELECTED]

11. Which support services are available to trainees at your site?

Please check ALL that apply.

[ ] Mentors/preceptors

[ ] Direct supervision

[ ] Peer support

[ ] Regular meetings with site leadership (e.g., weekly, monthly, quarterly)

[ ] Other: please specify ___________________

[ ] No support services are available to trainees at my site [DISALLOW IF ANOTHER OPTION SELECTED]

[ ] I don’t know which support services are available [DISALLOW IF ANOTHER OPTION SELECTED]

12. Does your site provide training on team-based care to [GRANTEE PROGRAM NAME] trainees?

(WEB SURVEY HOVER OVER FEATURE: Team-based care delivery consists of intentionally created groups of at least three types of health providers with shared responsibility for a patient, group of patients, their families, and/or communities.)

[ ] Yes

[ ] No

[ ] Don’t know

13. Which elements of team-based care, if any, do your [GRANTEE PROGRAM NAME] trainees participate in at your site?

Please check ALL that apply.

[ ] Screening and assessment for behavioral health disorders

[ ] Development of treatment plans

[ ] Care coordination

[ ] Referral to other services

[ ] Harm reduction

[ ] Other: please specify ___________________

[ ] I don’t know which elements trainees participate in [DISALLOW IF ANOTHER OPTION SELECTED]

14. [ASK IF Q12=YES] Which challenges has your site experienced with providing team-based training?

Please check ALL that apply.

[ ] An insufficient number of staff

[ ] Disagreements about provider roles

[ ] Restrictions on sharing patient information, specifically for patients receiving treatment for substance use

[ ] State and federal policies that hinder reimbursement for care

[ ] Workflow and logistical obstacles

[ ] Other: please specify ___________________

[ ] No challenges [DISALLOW IF ANOTHER OPTION SELECTED]

[ ] I don’t know which challenges my site has experienced [DISALLOW IF ANOTHER OPTION SELECTED]

15. What kind of training in administrative processes do [GRANTEE PROGRAM NAME] trainees receive?

[ ] Hands-on training in record-keeping and payment processes

[ ] Learning about record-keeping and payment processes (but not hands-on training on implementation)

[ ] Other: please specify ___________________

[ ] No training in administrative processes

[ ] I don’t know which training in administrative processes trainees receive

16. Which challenges have you experienced with implementing the [GRANTEE PROGRAM NAME]?

Please check ALL that apply.

[ ] Clarifying trainee roles and responsibilities

[ ] Providing the specific expertise sought by trainees

[ ] Providing clinical supervision for training in opioid use disorder treatment

[ ] Providing clinical supervision for training in substance use disorder treatment

[ ] Lack of available preceptors or mentors

[ ] Patient volume is too great to address trainee questions

[ ] Limited opportunities to provide training in interprofessional care

[ ] Limited opportunities to provide training in team-based care

[ ] Difficulties scheduling trainees at our site

[ ] Other: please specify ___________________

[ ] No challenges [DISALLOW IF ANOTHER OPTION SELECTED]

[ ] I don’t know which challenges my site has experienced [DISALLOW IF ANOTHER OPTION SELECTED]

4. Services and Outcomes: In this section, we would like to know more about the services that your site provides, including the number of patients that you serve. You may provide estimates based on actual data or your best guess.

17. Please provide the approximate percentage of your patient population who have received the following services over the past month. Percentages may total to more or less than 100 percent given that some patients may have received more than one service. Click here for an example:

(WEB SURVEY HOVER OVER FEATURE: “If you saw about 1,000 patients per month, and 200 patients sought pediatric care, you would report 20%. If you saw about 500 patients a month for acute primary care, some of whom were the same person, you would still report 50% for acute primary care.)

Please provide a percentage for ALL rows.

	Patient Services	% of Patients [RANGE CHECK 0-100/ITEM]	Don’t know
Patients of any age with behavioral health needs	Substance use disorder treatment, excluding opioid use disorder treatment
	Opioid use disorder treatment, excluding medication-assisted treatment
	Medication-assisted treatment for opioid use disorder
	Treatment for depression or anxiety disorders
	Treatment for schizophrenia, severe depression, or psychosis
Patients of any age without behavioral health needs	Perinatal care
	Pediatric care
	Acute primary care
	Care for chronic conditions

18. [ASK IF PERCENTAGE PROVIDED FOR ANY ROW IN Q17] What was the source for your response(s) to the previous question?

[ ] From a report or data analytics dashboard

[ ] Best guess

[ ] Other: please specify ___________________

19. Over the last six months, what percentage of your clients have used each of the following as their primary source of coverage?

Please provide a percentage for ALL rows.

Patient Coverage Source	% of Patients [RANGE CHECK 0-100/ITEM]	Don’t know
Uninsured (including charity care, out-of-pocket, sliding scale, self-pay)
Medicaid/Children’s Health Insurance Program (CHIP)/State-sponsored insurance plan
Medicare
Private insurance (including TRICARE, Veterans, and military)
Other: please specify____________________
[QC CHECK: SUM MUST = 100%]	=100%	N/A

20. [ASK IF PERCENTAGE PROVIDED FOR ANY ROW IN Q19] What was the source for your response(s) to the previous question?

[ ] From a report or data analytics dashboard

[ ] Best guess

[ ] Other: please specify ___________________

21. [FILL IN XX BASED ON MOST RECENT FISCAL YEAR OF SURVEY] From October 20XX to September 20XX, how many patients have received care at your site as a result of your participation in [GRANTEE PROGRAM NAME]? Please provide your best estimate.

Total number of patients: __________ [RANGE 0-50,000]

[ ] Don’t know

22. Of these patients, what percentage have received care in the following?

A. An interprofessional environment: ________________ (Enter %) [RANGE 0-100]

[ ] Don’t know

B. An integrated setting: _________________ (Enter %) [RANGE 0-100]

[ ] Don’t know

5. COVID-19 Pandemic: The final set of questions asks about your site’s experiences during the COVID-19 pandemic.

23. Which of the following did your site experience during the COVID-19 pandemic?

Please select ALL that apply.

[ ] Staff missed work due to self-isolation or quarantine

[ ] Site closed

[ ] Site reduced number of staff or staff hours

[ ] Administered COVID-19 testing

[ ] Provided more acute/urgent care visits, as opposed to well visits

[ ] Provided fewer patient visits overall (including all visit types)

[ ] Temporarily eliminated clinical service hours and permitted only administrative work

[ ] Provided more care via telehealth for primary care visits

[ ] Changed delivery of behavioral health services

[ ] Lack of capacity (e.g., hospital beds or staff resources) to meet patient demand

[ ] Limited availability of personal protective equipment (PPE)

[ ] Lack of emergency policies/protocols in place

[ ] Additional time spent on reporting requirements for COVID-19

[ ] Trainees were not able to attend experiential training as planned

(HOVER OVER WEB FEATURE: Experiential training includes not only a designated faculty member’s instruction delivered to an individual or group of individuals, but also a component of direct work experience such as clinical practice-based experiences or supervised experiences in health care settings.)

[ ] Other: please specify___________________

[ ] Did not experience any changes with [GRANTEE PROGRAM] during the COVID-19 pandemic [DISALLOW IF ANOTHER OPTION SELECTED]

24. [ASK IF Q23=CHANGED DELIVERY OF BEHAVIORAL HEALTH SERVICES ] How did the delivery of behavioral health services change during the COVID-19 pandemic?

Please select ALL that apply.

[ ] Provided more substance use disorder services through telehealth

[ ] Delayed scheduling visits with new patients for substance use disorder services

[ ] Delayed scheduling routine follow-up visits with patients for substance use disorder services

[ ] Delayed toxicology testing for patients who are prescribed buprenorphine

[ ] Limited ability to provide mental health visits, excluding substance use disorder treatment (e.g., took time away from conducting these visits, or limited ability to schedule these visits)

[ ] Limited ability to provide substance use disorder services

[ ] Limited ability to provide opioid use disorder services, excluding medication-assisted treatment (i.e., buprenorphine, methadone, or naltrexone)

[ ] Limited ability to provide medication-assisted treatment

[ ] Other: please specify ___________________

25. Did you receive additional funding from HRSA or other federal agencies (e.g., Centers for Medicare & Medicaid Services) in spring 2020 to help your site respond to the COVID-19 pandemic?

[ ] Yes

[ ] No

[ ] Don’t know

26. [ASK IF Q25=YES] How did you use the additional funding?

Please select ALL that apply.

[ ] Increased testing for COVID-19

[ ] Acquired personal protective equipment (PPE)

[ ] Acquired other medical supplies other than PPE

[ ] Improved telehealth capabilities

[ ] Provided safety education for staff

[ ] Provided overtime pay for staff

[ ] Other: please specify ___________________

[ ] Don’t know

Please click on the “Submit” button to submit your responses. Once submitted, your answers cannot be changed.

[END] That was the last question. Thank you again for participating in our survey!

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