Form 3-1 PMHCA Program Implementation Survey_2-3-2020

Attachment B5:

Pediatric Mental Health Care Access Program Program Implementation Survey

HRSA Evaluation of the Maternal and Child Health Bureau Pediatric Mental Health Care Access and Screening and Treatment for Maternal Depression and Related Behavioral Disorders Programs Project

December 2019

HRSA Evaluation of the Maternal and Child Health Bureau Pediatric Mental Health Care Access and Screening and Treatment for Maternal Depression and Related Behavioral Disorders Programs Project

Pediatric Mental Health Care Access Program

Program Implementation Survey

Funding for data collection supported by the

Maternal and Child Health Bureau (MCHB)

Health Resources and Services Administration (HRSA)

U.S. Department of Health and Human Services

Public Burden Statement: This data collection will provide the Health Resources and Services Administration with information to guide future program and policy decisions regarding increasing health care providers’ (i.e., physicians, nurse practitioners, physician assistants, nurse midwives, and other health care professionals) capacity to address patients’ behavioral health and access to behavioral health services. 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 0906-XXXX and it is valid until XX/XX/202X. This information collection is voluntary. The current project will fully comply with the Privacy Act of 1974 (5 U.S.C. Section 552a, 1998; https://www.justice.gov/opcl/privacy-act-1974). The Privacy Act may apply to some data collection activities (e.g., the study will collect email addresses from some respondents). Public reporting burden for this collection of information is estimated to average xx hours 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. 

HRSA funded [insert name of state] to implement a Pediatric Mental Health Care Access (PMHCA) program. HRSA also funded JBS International, Inc. (JBS) to conduct an outcome and impact evaluation of the MCHB PMHCA program (hereafter referred to as the HRSA MCHB evaluation). JBS is an independent evaluator of the program and is not part of HRSA or any other federal agency.

Survey Purpose: As part of the HRSA MCHB evaluation, we are conducting a survey to learn more about the implementation of [insert name of state]’s HRSA PMHCA program. The survey is designed to collect information on your experiences with the PMHCA program (e.g., program implementation activities, health care provider enrollment, health care provider training, behavioral health service delivery, care coordination support, community linkages, sustainability) and assist HRSA in future program implementation.

Survey Instructions: This online survey should take twenty (20) minutes or less for you to complete. Please answer based on your current practice and understanding, unless otherwise indicated. There are no right or wrong answers to the survey questions. Please feel free to consult with your colleagues to gather information, as necessary, to complete this survey. Please note that your responses will remain private. Survey results will be reported to HRSA in the aggregate, and no identifying information will appear in the evaluation reports without your prior approval. No identifiable data will be provided to HRSA.

Program Involvement

1. What is your current employment position?

   • [OPEN-ENDED RESPONSE]

2. How long have you been in this position?

   • [OPEN-ENDED RESPONSE]

3. What is your project role in your PMHCA program?

   • Project Director

   • Principal Investigator

   • Program Manager

   • Other (specify)

Clinical Behavioral Health Consultation Service Development

4. How many provider FTEs, by provider type, are funded by this HRSA-funded cooperative agreement for your clinical behavioral health consultation service? For example, if two psychiatrists are funded, the first at 1 FTE and the second at .5 FTE, indicate 2 in the Number column and 1.5 in the FTE column.

	Number	FTE
Psychiatrists
Psychologists
Advanced practice nurses
Social workers
Licensed mental health counselors
Substance use disorder counselors
Case coordinators
Other (specify)

Health Care Provider/Practice Recruitment and Enrollment

5. Are you enrolling health care practices or individual health care providers into your PMHCA program? Select one.

• Only health care practices (If selected, move on to Question 6)

• Only individual health care providers (If selected, move on to Question 8)

• Both health care practices and individual health care providers (If selected, move on to Question 6)

6. How many health care practices have been enrolled in your PMHCA program to date?

• [OPEN-ENDED RESPONSE]

7. What type(s) of health care practices have been enrolled in your PMHCA program to date? Select all that apply.

• University-based practice(s)

• Non-academic, hospital-based practice(s)

• Emergency department(s)

• Managed care organization(s)

• Private practice(s)

• Community health center(s)/Federally Qualified Health Center(s)

• School-based health center(s)

• Other (specify)

8. How many individual health care providers have been enrolled in your PMHCA program to date?

• [OPEN-ENDED RESPONSE]

9. What types of health professionals have enrolled in your PMHCA program to date? Select all that apply.

• Pediatricians

• Family physicians

• Advanced practice nurses/nurse practitioners

• Physician assistants

• Medical assistants

• Nurses

• Social Workers

• Other (specify)

Health Care Provider Training

10. How many health professionals have been trained by your PMHCA program to date (e.g., via Webinar, in-person trainings)?

• [OPEN-ENDED RESPONSE]

11. What factor(s) facilitated your implementation of health professional training? Select all that apply.

• Provider acceptance

• Ability to offer Continuing Medical Education (CME)/Continuing Education (CE) credits

• Champion support

• Participant engagement

• Scheduling

• Length of training/training sessions

• Training format

• Training promotion

• Other (specify)

12. What challenges did you encounter while implementing health professional training? Select all that apply.

• Lack of provider acceptance

• Inability to offer CME/CE credits

• Infrastructure challenges (e.g., facilities, technology, staffing)

• Lack of champion support

• Lack of participant engagement

• Scheduling

• Length of training/training sessions

• Training format

• Training promotion

• Other (specify)

Clinical Behavioral Health Consultation, Including Use of Telehealth

13. [Note: This question will only be asked in Option Year 1.] When did you/will you begin implementing clinical behavioral health consultation in your PMHCA program?

• [RESPONSE TO BE PROVIDED IN MONTH/YEAR FORMAT]

14. What telehealth mechanism(s) do you use in your PMHCA program for clinical behavioral health consultation? Select all that apply.

• Email

• Screensharing

• Telephone (terrestrial and/or wireless communications)

• Text messaging

• Video conferencing

• Other (specify)

Care Coordination Support, Including Use of Telehealth

15. [Note: This question will only be asked in Option Year 1.] When did you/will you begin implementing care coordination support (i.e., communication/collaboration, accessing resources, referral services) in your PMHCA program?

• [RESPONSE TO BE PROVIDED IN MONTH/YEAR FORMAT]

16. What telehealth mechanism(s) do you use in your PMHCA program for care coordination support? Select all that apply.

• Email

• Screensharing

• Telephone (terrestrial and/or wireless communications)

• Text messaging

• Video conferencing

• Other (specify)

Community Linkages

17. What types of community linkages has your PMCHA program established to support behavioral health care? Select all that apply.

• Counseling

• Childcare

• Employment/job-seeking training

• Food programs

• Housing support

• Parenting support

• Support groups

• Transportation support

• Education support

• Other (specify)

18. To what extent is your PMHCA program using the established community linkages?

• Not at all

• To a small extent

• To a moderate extent

• To a great extent

• To a very great extent

19. How was the process of establishing the following community linkages?

	Very difficult	Difficult	Neutral	Easy	Very easy	N/A
Counseling	o	o	o	o	o	o
Childcare	o	o	o	o	o	o
Employment/job-seeking training	o	o	o	o	o	o
Food programs	o	o	o	o	o	o
Housing support	o	o	o	o	o	o
Parenting support	o	o	o	o	o	o
Support groups	o	o	o	o	o	o
Transportation support	o	o	o	o	o	o
Education support	o	o	o	o	o	o
Other (specify)	o	o	o	o	o	o

Program Outreach and Dissemination

20. To whom does your PMHCA program disseminate information about program services? Select all that apply.

• Health care providers

• Behavioral health care providers

• Patients

• Partners

• Public

• Other (specify)

21. How are you promoting your PMHCA program? Select all that apply.

• Brochures/Briefs

• Conferences/Workgroup presentations

• Email/E-blasts

• Newsletters

• Posters/Infographics

• Social media

• Videos

• Websites

• Other (specify)

Sustainability

22. Did your state have funding in place to support activities similar to your PMHCA program prior to receiving HRSA cooperative agreement funding?

• Yes

• No

• Do not know

23. Since receiving HRSA cooperative agreement funding, has your state received other funding to support PMHCA program activities?

• Yes (If yes, move on to Question 24).

• No (If no, move on to Question 25).

24. What additional funding have you received for your PMHCA program? Select all that apply.

• Medicaid

• Third-party payer reimbursement

• Other federal funding

• State budget allocation

• State/tribal/jurisdiction grants

• Foundation/nonprofit organization grants

• Other (specify)

25. Do you have a sustainability plan for funding for your PMHCA program once HRSA cooperative agreement funding ends?

• Yes

• No

26. How do you anticipate supporting your PMHCA program once HRSA cooperative agreement funding ends? Select all that apply.

• Medicaid

• Third-party payer reimbursement

• Other federal funding

• State budget allocation

• State/tribal/jurisdiction grants

• Foundation/nonprofit organization grants

• Other (specify)

Program Implementation Facilitators and Barriers

27. What factors have facilitated your program implementation? Select all that apply.

    • Health care provider recruitment

    • Health care provider engagement

• Stakeholder communication and coordination

• Champion support

• Telehealth technology

• Workflow

• Data collection/reporting

• Advisory Committee involvement

• Other (specify)

28. What factors have challenged your program implementation? Select all that apply.

• Health care provider recruitment

• Health care provider engagement

• Stakeholder communication and coordination

• Champion support

• Telehealth technology

• Workflow

• Data collection/reporting

• Advisory Committee involvement

• Other (specify)

Evaluation Capacity-Building Support

29. Will your PMHCA program require any of the following evaluation capacity-building support or technical assistance in the upcoming year? Select all that apply.

• Program evaluation design refinement

• Development of data collection tools/instruments

• Collection and reporting of HRSA-required measures

• Provider training evaluation

• Data analysis

• Dissemination of evaluation results

• Other (specify)

Additional Feedback

30. What else would you like to share with HRSA about the PMHCA program?

0. [OPEN-ENDED RESPONSE]