Form Approved
OMB No. 0920-New
Expiration Date: XX/XX/XXXX
Using Real-time Prescription and Insurance Claims Data to Support the HIV Care Continuum
Attachment 14a
Post-consultation questionnaire
Public reporting burden of this collection of information is estimated to average 10 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. 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)
AIMS peer mentors should complete this brief survey immediately after providing the consultation with the assigned provider.
The linkage coordinator will use this information to send a follow-up email to the provider. The email will include resources and information based on the barriers and recommended resources endorsed below. The email will not include any other information you might provide in the comments below.
Once you submit this survey, you will not be able to make changes.
If you have questions or other comments, please contact the linkage coordinator(s) (Linkage Coordinator’s name) or Principal Investigator April Kimmel, PhD, at april.kimmel@vcuhealth.org.
Provider information (auto filled)
Name:
Specialty:
Phone number:
Clinic name:
Clinic phone:
County:
Health district:
Please record
your name* ____________________
Please record the name of the provider participant* ____________________
About how long did the call last?* _____ minutes
What barriers to prescribing ART did the provider face? Check all that apply.*
Refusal or unwillingness to accept or begin ART
Denial, fear, or lack of knowledge about HIV
Substance use disorder (SUD) (such as unmet need for treatment)
Mental health issues
History of non-adherence (including appointments)
Other anticipated non-adherence
Side effects
Lifestyle and/or social situation
Cannot pay for ART [Medicaid doesn't cover ART meds]
Homelessness or unstable housing
Provider did prescribe, but patient did not pick up
Difficulty or unable to assess patient barriers
Difficulty constructing a regimen with acceptable side effect(s) profile
Uncomfortable providing treatment and care for patient(s) living with HIV
Disagrees with current guidelines
Did not know patient status or does not believe responsible for patient's HIV care
Someone else manages HIV care/referred out (e.g., if low-volume provider)
Other
(explain: ________________________________)
What resources do you recommend be provided in a follow-up email? Check all that apply*
Referral to Motivational Interviewing (MI) training
Link to HealthHIV Primary Care Training/Certification Program
Link to MedScape TasP module
Link to National HIV Curriculum
Mentoring: Follow-up by peer mentor
Mentoring: Referral to National Clinician Consultation Center
Mentoring: Referral to AAHIVM Clinical Consultation Program
Handout/link: Technical Assistance and educational resources
Handout: Acuity scale for adherence
Handout: ART guidelines
Handout: MCO phone numbers (for patient behavioral health support)
Handout: Local
community resources (for patient social support)
Were there any
issues (e.g., technical difficulties, interrupted call, difficulty
communicating with provider)? If yes, please describe.
Do you have any other comments or feedback for us?
Thank you! *Denotes required items
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Rose S Bono |
File Modified | 0000-00-00 |
File Created | 2021-10-20 |