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pdfAPPENDIX G
RETAIN PROVIDER SURVEY INSTRUMENTS (R1, R2)
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Retaining Employment and Talent After Injury/Illness Network (RETAIN) PROVIDER
SURVEY ROUND 1: Questionnaire and programming specifications
Programming and operational assumptions:
Modes. The provider survey will be administered in three modes – web, paper, and telephone. These
specifications are for the computer-assisted versions of the instrument only.
Population. This survey is self-administered. There will not be responses via proxy.
Target respondent. This questionnaire is to be administered to providers of medical or social,
rehabilitative services delivered to RETAIN enrollees in intervention group.
Length. The questionnaire is designed to take about 15 minutes to complete.
Languages. The questionnaire is available in English and Spanish (upon request).
Administration and design specifications. Each item in the web questionnaire specifications includes:
which respondents receive the item; dynamic fills, designated by text [in brackets]; emphasis text,
designated in bold font; soft checks that help improve data quality (designated in boxes below applicable
items); response options shown with boxes indicate “check all that apply” response format, whereas
those shown in circles denote “check one” response format.
In this draft, the item as presented in self-administration by web first, followed by the same item as it
appears in CATI (telephone interviewer administration). Relevant text modifications have been made for
each version, as needed.
Login. Users can login via personalized link or through the main survey page using a username and
password. Survey staff can also log in with a separate link as a way of completing questions that inform
survey eligibility (which will not be shown to respondents). These paths are reflected in the specifications
document.
Critical items have soft checks added throughout the instrument.
Partial completes are designated by completion of C1 (awareness of RETAIN) completed, as
applicable.
Sections of the provider questionnaire:
A
Introduction and consent
B
Provision of health care services
C
Provider experience in RETAIN
D
Provider contact information
PROGRAMMER: DO NOT DISPLAY ITEM NUMBERS ON PAGE FOR WEB VERSION
1
FILLS:
PROGRAM STATE
CA
CT
KS
State Name for RETAIN
RETAIN-California
RETAIN-Connecticut
RETAIN-Kansas
KY
Retaining Kentucky's
Workforce through
Universal Design (RKWUD)
RETAIN-Minnesota
RETAIN-Ohio
RETAIN-Vermont
RETAIN-Washington
MN
OH
VT
WA
Coordinator title
Return to Work (RTW) Coordinator
Return to Work (RTW) Coordinator
Return to Work (RTW) Coordinator or Medical and
Workforce Systems Coordinator
Return to Work Coordinator (RTWC)
Return to Work (RTW) Coordinator
Health Services Coordinator (HSC)
Return to Work (RTW) Coordinator
Return to Work (RTW) Coordinator
2
RETAIN: PROVIDER QUESTIONNAIRE R1: WEB/CATI INTRO
OMB No.: XXX
Expiration Date: XX/X/XXXX
WEB LOGIN SCREEN:
Welcome to the Retaining Employment and Talent After Injury/Illness Network
(RETAIN) Survey of Providers!
To begin, please enter your survey username and password below:
Username:
Password:
CLICK THE “NEXT” BUTTON BELOW TO CONTINUE …
If you have any questions, or are having difficulty logging in, we are here to help.
Call the study team at XXX-XXX-XXXX.
Public reporting burden for this collection of information is estimated to average 14 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. The OMB number for this information
collection is XXXX and the expiration date is XX/XX/XXXX. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to: XXX. Do not return the completed
form to this address.
3
RETAIN: PROVIDER QUESTIONNAIRE R1: WEB/CATI INTRO
CATI VERSION
Hello. Hello, my name is [INTERVIEWER NAME]. May I please speak to [PROVIDER NAME]?
I am calling from Mathematica on behalf of the Social Security Administration about an important
national study.
CODE ONE ONLY
SPEAKING TO [PROVIDER] ...................................................................................... 1
GO TO A1
[PROVIDER] COMES TO THE PHONE...................................................................... 2
GO TO A1
NEED TO CALLBACK (NO APPT).............................................................................. 3
TERMINATE
NEED TO CALLBACK (SET APPT) ............................................................................ 4
SETAPPT
[PROVIDER] HAS MOVED/HAS NEW NUMBER ....................................................... 5
TERMINATE
NEVER HEARD OF [PROVIDER]/WRONG NUMBER ............................................... 6
TERMINATE
HUNG UP DURING INTRODUCTION (HUDI) ............................................................ 7
TERMINATE
[PROVIDER] IS DECEASED ....................................................................................... 8
INELIG-TERMINATE
[PROVIDER] IS NO LONGER AT THIS PRACTICE ORG ......................................... 9
INELIG-TERMINATE
4
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION A – INTRODUCTION AND CONSENT
SECTION A. INTRODUCTION AND CONSENT
ALL
[PROVIDER NAME] [PRACTICE ORGANIZATION]
A1. Are you, [PROVIDER NAME] currently providing patient care at [PRACTICE ORGANIZATION]? [NEW]
Yes ........................................................................................................................ 1
No .......................................................................................................................... 0
TERMINATE
NO RESPONSE .................................................................................................... M
TERMINATE
SOFT CHECK: IF A1=0;
To confirm – you are no longer providing patient care at [PRACTICE ORGANIZATION]? If you are
providing patient care at this place, please change your answer to this question.
HARD CHECK: IF A1=NO RESPONSE;
Please provide a response to this question. This helps us make sure you receive only the questions
that best apply to you.
CATI VERSION
A1.
Are you currently providing patient care at [PRACTICE ORGANIZATION]?
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
TERMINATE
DON’T KNOW ....................................................................................................... d
TERMINATE
REFUSED ............................................................................................................. r
TERMINATE
A1=0 D OR R
[PROVIDER NAME] [PRACTICE ORGANIZATION]
TERMINATE.
Thank you for this information. We will update our records and reach out by telephone if we have any
additional questions.
CATI VERSION
TERMINATE. Thank you for this information. We will update our records and reach out by telephone if we
have any additional questions.
INTERVIEWER: RECORD NOTE IN CASE RECORD TO DOCUMENT WHAT THE RESPONDENT OR
GATEKEEPER SAID.
CLOSE INTERVIEW ............................................................................................ 1
5
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION A – INTRODUCTION AND CONSENT
ALL ELIGIBLE (A1=1)
A2.
This survey asks about your experiences as a provider at a practice that provides care and
services for the Retaining Employment and Talent After Injury/Illness Network (RETAIN) program.
You’ll receive $45 for completing this voluntary survey. It will take about 15 minutes to complete.
It includes questions about your experience providing patient care and your experience in RETAIN
(if any). Your answers will be kept confidential and grouped with everyone else who responds.
[NEW]
I agree to take part………………………………...................…1
GO TO B1
I do not agree to take part………………………………………0 TERMINATE REFUSAL
PROGRAMMER: DO NOT ALLOW MISSING VALUES ON THIS ITEM
HARD CHECK: IF A2=0 RESPONSE; Please record an answer to the question above.
CATI VERSION
A2.
This survey asks about your experiences as a provider at a practice that provides care and
services for the Retaining Employment and Talent After Injury/Illness Network (RETAIN) program.
You’ll receive $45 for completing this voluntary survey. It will take about 15 minutes to complete.
It includes questions about your experience providing patient care and your experience in RETAIN
(if any). Your answers will be kept confidential and grouped with everyone else who responds.
Do you have any questions before we begin?
INTERVIEWER: ANSWER QUESTIONS, AS NEEDED, THEN PROCEED ONCE QUESTIONS HAVE
BEEN ADDRESSED.
CODE ONE ONLY
I AGREE TO TAKE PART - OK TO BEGIN .............................................. 1 GO TO B1
REFUSED .................................................................................................. r TERMINATE
6
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION B – PROVISION OF HEALTH CARE SERVICES
SECTION B. PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1)
[PRACTICE NAME]
B1.
What is your primary role at [PRACTICE NAME]?
If you have more than one role, please select the role that takes up most of your time. [HCIA Clin
R2, A1a, rev]
Primary Care Physician......................................................................................... 1
Occupational Medicine Physician ......................................................................... 2
Physical Medicine and Rehabilitation Specialist ................................................... 3
Orthopedic Surgeon .............................................................................................. 4
Neurosurgeon ....................................................................................................... 5
Physical Therapist ................................................................................................. 6
Chiropractor .......................................................................................................... 7
Registered Nurse .................................................................................................. 8
Nurse Practitioner ................................................................................................. 9
Physician Assistant ............................................................................................... 10
Mental Health Professional ................................................................................... 11
Other role, not listed above: .................................................................................. 99
Specify
(STRING 100)
NO RESPONSE .................................................................................................... M
7
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION B – PROVISION OF HEALTH CARE SERVICES
CATI VERSION
B1.
What is your primary role at [PRACTICE NAME]?
If you have more than one role, please choose the role that takes up most of your time.
CODE ONE ONLY
PRIMARY CARE PHYSICIAN ..................................................................................... 1
OCCUPATIONAL MEDICINE PHYSICIAN ................................................................. 2
PHYSICAL MEDICINE AND REHABILITATION SPECIALIST ................................... 3
ORTHOPEDIC SURGEON ......................................................................................... 4
NEUROSURGEON...................................................................................................... 5
PHYSICAL THERAPIST ............................................................................................. 6
CHIROPRACTOR........................................................................................................ 7
REGISTERED NURSE ................................................................................................ 8
NURSE PRACTITIONER ............................................................................................ 9
PHYSICIAN ASSISTANT ............................................................................................ 10
MENTAL HEALTH PROFESSIONAL .......................................................................... 11
OTHER (SPECIFY) ..................................................................................................... 99
___________________________________________________ (STRING 100)
DON’T KNOW .............................................................................................................. d
REFUSED .................................................................................................................... r
8
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION B – PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1)
B2.
How many years have you been in practice? (NEW)
0-5 years ............................................................................................................... 1
6-10 years ............................................................................................................. 2
11-15 years ........................................................................................................... 3
16-25 years ........................................................................................................... 4
More than 25 years ............................................................................................... 5
NO RESPONSE .................................................................................................... M
SOFT CHECK: IF B2=NO RESPONSE;
Your answer to this question helps us better understand the practices and opinions of different groups
of providers.
CATI VERSION
B2.
How many years have you been in practice?
CODE ONE ONLY
0-5 years ...................................................................................................................... 1
6-10 years .................................................................................................................... 2
11-15 years .................................................................................................................. 3
16-25 years .................................................................................................................. 4
More than 25 years ...................................................................................................... 5
DON’T KNOW .............................................................................................................. d
REFUSED .................................................................................................................... r
SOFT CHECK: IF B2=D or R;
Your answer to this question helps us better understand the practices and opinions of different groups
of providers.
9
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION B – PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1)
B3.
In a typical week, approximately what percent of your patient visits are covered by Workers’
Compensation? [NEW]
Less than 15% ...................................................................................................... 1
15-25% .................................................................................................................. 2
26-50% .................................................................................................................. 3
More than 50% ...................................................................................................... 4
I don’t work with workers’ compensation patients ................................................ 5
I don’t know .......................................................................................................... 6
NO RESPONSE .................................................................................................... M
SOFT CHECK: IF B3=NO RESPONSE;
Please provide a response to this question. Your best estimate is fine.
If you do not see patients who receive workers’ compensation, or if their receipt of workers’
compensation is not part of their records, please select from the applicable response options for these
instances.
CATI VERSION
B3.
In a typical week, approximately what percent of your patient visits are covered by Workers’
Compensation?
If you do not see patients who receive workers’ compensation, or if this is not part of their
records, just let me know.
CODE ONE ONLY
Less than 15% ............................................................................................................. 1
15-25% ........................................................................................................................ 2
26-50% ........................................................................................................................ 3
More than 50% ............................................................................................................ 4
I DON’T WORK WITH WORKERS’ COMPENSATION PATIENTS ........................... 5
I DON’T KNOW ............................................................................................................ d
REFUSED .................................................................................................................... r
SOFT CHECK: IF B3=D OR R;
If you do not see patients who receive workers’ compensation, or if their receipt of workers’
compensation is not part of their records, just let me know.
10
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION B – PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1)
B4.
When you are treating a patient with a recent injury or illness that may inhibit or prevent continued
employment, how often do you … (NEW)
PROGRAMMER: FORMAT WEB USING BANKED FORMAT BEOW TO OPTIMIZE FOR MOBILE DEVICES.
a. Try to help your patients return to work, when appropriate?
All the time
1
Most of the
time
2
Some of the
time
3
Rarely
4
Never
5
b. Assess barriers to return to work, when appropriate?
All the time
1
Most of the
time
2
Some of the
time
3
Rarely
Never
4
5
c. Develop a plan to overcome barriers to work, when appropriate?
All the time
1
Most of the
time
2
Some of the
time
3
Rarely
Never
4
5
d. Develop an activity plan which communicates the worker’s ability to
participate in work activities, activity restrictions, and the provider’s
treatment plans, when appropriate?
All the time
1
Most of the
time
2
Some of the
time
3
Rarely
Never
4
5
e. Provide information to employers about injured workers, when
appropriate?
All the time
1
Most of the
time
2
Some of the
time
3
Rarely
Never
4
5
f. Discuss possible work accommodations for injured workers with
employers, when appropriate?
All the time
1
Most of the
time
2
Some of the
time
3
Rarely
Never
4
5
11
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION B – PROVISION OF HEALTH CARE SERVICES
CATI VERSION
B4.
When you are treating a patient with a recent injury or illness that may inhibit or prevent continued
employment, how often do you …
Would you say all of the time; some of the time; or rarely?
CODE ONE PER ROW
All the
time
Most of
the
time
Some
of the
time
Rarely
Never
DK
REF
a. Try to help your patients
return to work, when
appropriate?
1
2
3
4
5
D
R
b. Assess barriers to return to
work, when appropriate?
1
2
3
4
5
D
R
c. Develop a plan to overcome
barriers to work, when
appropriate?
1
2
3
4
5
D
R
d. Develop an activity plan which
communicates the worker’s
ability to participate in work
activities, activity restrictions,
and the provider’s treatment
plans, when appropriate?
1
2
3
4
5
D
R
e. Provide information to
employers about injured
workers, when appropriate?
1
2
3
4
5
D
R
1
2
3
4
5
D
R
f.
Discuss possible work
accommodations for injured
workers with employers, when
appropriate?
12
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION B – PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1)
B5.
When treating patients with a recent injury or illness that may inhibit or prevent continued
employment, do you make referrals to any outside public or private programs, when
appropriate? Do not include referrals for medical services or supports.
Yes ........................................................................................................................ 1
GO TO B6
No .......................................................................................................................... 0
GO TO B7
No Response ........................................................................................................ M
GO TO B7
CATI VERSION
B5.
When treating patients with a recent injury or illness that may inhibit or prevent continued
employment, do you make referrals to any outside public or private programs, when appropriate?
Do not include referrals for medical services or supports.
YES ....................................................................................................................... 1
GO TO B6
NO ........................................................................................................................ 0
GO TO B7
DON’T KNOW ....................................................................................................... d
GO TO B7
REFUSED ............................................................................................................. r
GO TO B7
PROVIDER MAKES REFERRALS TO OUTSIDE PUBLIC OR PRIVATE PROGRAMS (B5=1)
B6.
What kinds of outside public or private programs do you typically refer these patients to?
OUTSIDE PUBLIC OR PRIVATE PROGRAMS
(STRING 250)
CATI VERSION
B6.
What kinds of outside public or private programs do you typically refer these patients to?
PROBE:
Any others?
___________________________________________________ (STRING 250)
OUTSIDE PUBLIC OR PRIVATE PROGRAMS
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
13
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION B – PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1)
B7.
When you are treating a patient with a recent injury or illness that may inhibit or prevent continued
employment, how do you typically communicate with their employers, if at all? [NEW]
Select all that apply
Email ..................................................................................................................... 1
Letter ..................................................................................................................... 2
Complete a return-to-work form ............................................................................ 3
Telephone ............................................................................................................. 4
Other way(s) .......................................................................................................... 5
I do not communicate with injured workers’ employers ........................................ 6
NO RESPONSE .................................................................................................... M
CATI VERSION
B7.
When you are treating a patient with a recent injury or illness that may inhibit or prevent continued
employment, how do you typically communicate with their employers most often, if at all?
IF NEEDED: If you do not communicate with injured workers’ employers, just let me know.
CODE ALL THAT APPLY
Email ........................................................................................................................... 1
Letter ........................................................................................................................... 2
Complete a return-to-work form ............................................................................... 3
Telephone ................................................................................................................... 4
Other way(s) ............................................................................................................... 5
I DO NOT COMMUNICATE WITH INJURED WORKERS’ EMPLOYERS ................. 6
DON’T KNOW .............................................................................................................. d
REFUSED .................................................................................................................... r
14
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION B – PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1)
B8.
Are there any issues that limit your ability to provide optimal care for patients with a recent injury
or illness that may inhibit or prevent their continued employment? [CPC+, B15, rev]
Yes ........................................................................................................................ 1
GO TO B9
No .......................................................................................................................... 0
GO TO C1
NO RESPONSE .................................................................................................... M
GO TO C1
CATI VERSION
B8.
Are there any issues that limit your ability to provide optimal care for patients with a recent injury or
illness that may inhibit or prevent their continued employment?
YES ....................................................................................................................... 1
GO TO B9
NO ........................................................................................................................ 0
GO TO C1
DON’T KNOW ....................................................................................................... d
GO TO C1
REFUSED ............................................................................................................. r
GO TO C1
PROVIDER REPORTS ISSUES THAT LIMITED ABILITY TO PROVIDE OPTIMAL CARE FOR THIS
POPULATION (B8=1)
B9.
If yes, what issues limit your ability to provide optimal care for patients with a recent injury or illness
that may inhibit or prevent their continued employment? [CPC+, B15, rev]
(STRING 250)
NO RESPONSE .................................................................................................... M
CATI VERSION
B9.
What issues limit your ability to provide optimal care for patients with a recent injury or illness that may
inhibit or prevent their continued employment?
PROBE: Anything else?
___________________________________________________ (STRING 250)
DON’T KNOW .............................................................................................................. d
REFUSED .................................................................................................................... r
15
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION C – PROVIDER EXPERIENCE IN RETAIN
Section C. Provider Experience in RETAIN
ALL CONSENTING (A2=1)
C1.
RETAIN stands for Retaining Employment and Talent After Injury/Illness Network. Are you aware
that your practice organization is participating in RETAIN? [Million Hearts, Provider R1- Q16 rev]
Yes ........................................................................................................................ 1
No .......................................................................................................................... 0
GO TO D1
NO RESPONSE .................................................................................................... M
GO TO D1
SOFT CHECK: IF C1=NO RESPONSE;
Your answer to this question is important, as it helps us only ask questions that are relevant to you.
CATI VERSION
C1.
RETAIN stands for Retaining Employment and Talent After Injury/Illness Network.
Are you aware that your practice organization is participating in RETAIN?
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO D1
DON’T KNOW ....................................................................................................... d
GO TO D1
REFUSED ............................................................................................................. r
GO TO D1
SOFT CHECK: IF C1=D OR R;
Your answer to this question is important, as it helps us only ask questions that are relevant to you.
Are there any questions I can answer or concerns I can help address?
16
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION C – PROVIDER EXPERIENCE IN RETAIN
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
C2.
In a typical week, approximately what percent of your patients are RETAIN enrollees? [HCIA
Clinician Rd 2, A5a, rev]
Less than 25% ...................................................................................................... 1
25-49% .................................................................................................................. 2
50-74% .................................................................................................................. 3
75-100% ................................................................................................................ 4
I don’t always know when I’m working with RETAIN enrollees............................. 5
I don’t work with RETAIN enrollees ...................................................................... 6
NO RESPONSE .................................................................................................... M
SOFT CHECK: IF C2=NO RESPONSE;
Please provide a response to this question. Your best estimate is fine. If you do not see patients who
are enrolled in RETAIN, or if their participation is not part of their records, please select from the
applicable response options for these instances.
CATI VERSION
C2.
In a typical week, approximately what percent of your patients are RETAIN enrollees?
IF NEEDED:
If you do not see patients who are enrolled in RETAIN, or if their participation is not
part of their records, just let me know.
CODE ONE ONLY
Less than 25% ............................................................................................................. 1
25-49% ........................................................................................................................ 2
50-74% ........................................................................................................................ 3
75-100% ...................................................................................................................... 4
I DON’T ALWAYS KNOW WHEN I’M WORKING WITH RETAIN ENROLEES.......... 5
I DON’T WORK WITH RETAIN ENROLLEES ............................................................ 6
DON’T KNOW .............................................................................................................. d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C2=D OR R;
If you do not see patients who are enrolled in RETAIN, or if their participation is not part of their
records, just let me know.
17
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION C – PROVIDER EXPERIENCE IN RETAIN
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
[COORDINATOR TITLE]
C3.
As part of the RETAIN program, a [COORDINATOR TITLE] is someone who coordinates medical
services, works with employers/supervisors to develop alternative job duties or help people find
temporary employment. They may also provide coaching and individualized supports, like job
retraining, problem solving skills trainings, or peer supports.
Do you work with a [COORDINATOR TITLE] as part of the RETAIN program? (NEW)
Yes ........................................................................................................................ 1
No .......................................................................................................................... 0
GO TO C6
NO RESPONSE .................................................................................................... M
GO TO C6
CATI VERSION
C3.
As part of the RETAIN program, a [COORDINATOR TITLE] is someone who coordinates medical
services, works with employers/supervisors to develop alternative job duties or help people find
temporary employment. They may also provide coaching and individualized supports, like job
retraining, problem solving skills trainings, or peer supports.
Do you work with a [COORDINATOR TITLE] as part of the RETAIN program?
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO C6
DON’T KNOW ....................................................................................................... d
GO TO C6
REFUSED ............................................................................................................. r
GO TO C6
WORK WITH SERVICE COORDINATOR (C3=1)
[COORDINATOR TITLE]
C4.
In general, does working with a RETAIN [COORDINATOR TITLE] make your overall job easier or
more difficult to do, or has it had no effect? [HCIA Clinician R2, C3, rev]
Select one only
Easier .................................................................................................................... 1
More difficult .......................................................................................................... 2
No effect ................................................................................................................ 3
NO RESPONSE .................................................................................................... M
GO TO C6
CATI VERSION
C4.
In general, does working with a RETAIN [COORDINATOR TITLE] make your overall job easier or
more difficult to do, or has it had no effect?
CODE ONE ONLY
EASIER ....................................................................................................................... 1
MORE DIFFICULT....................................................................................................... 2
NO EFFECT ................................................................................................................ 3
DON’T KNOW .............................................................................................................. d
GO TO C6
18
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION C – PROVIDER EXPERIENCE IN RETAIN
REFUSED .................................................................................................................... r
GO TO C6
PROVIDER HAS OPIONION ON IMPACT OF SERVICE COORDINATOR ON HIS/HER JOB (C4=1, 2, 3)
[COORDINATOR TITLE]
C5.
Why does working with a [COORDINATOR TITLE] make your overall job easier or more difficult to
do, or why has it had no effect on your job? [NEW]
(STRING 250)
NO RESPONSE .................................................................................................... M
CATI VERSION
C5.
Why does working with a [COORDINATOR TITLE] make your overall job easier or more difficult to
do, or why has it had no effect on your job?
___________________________________________________ (STRING 250)
DON’T KNOW .............................................................................................................. d
REFUSED .................................................................................................................... r
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
[COORDINATOR TITLE]
C6.
Do the overall administrative requirements for RETAIN take up too much of your time or are they
reasonable?
These requirements could include hardcopy and electronic documentation, working with RETAIN
[COORDINATOR TITLE], and/or attending meetings. [HCIA Clinician Rd. 2, C4, rev]
Take up too much time.......................................................................................... 1
Are reasonable ...................................................................................................... 2
I do not have administrative requirements for RETAIN ........................................ 3
NO RESPONSE .................................................................................................... M
CATI VERSION
C6.
Do the overall administrative requirements for RETAIN take up too much of your time or are they
reasonable?
These requirements could include hardcopy and electronic documentation, working with RETAIN
[COORDINATOR TITLE], and/or attending meetings.
CODE ONE ONLY
TAKE UP TOO MUCH TIME ....................................................................................... 1
ARE REASONABLE .................................................................................................... 2
I DO NOT HAVE ADMINISTRATIVE REQUIREMENTS FOR RETAIN ..................... 3
REFUSED r
19
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION C – PROVIDER EXPERIENCE IN RETAIN
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
C7.
Formal training is defined as workshops, webinars, conferences, seminars, grand rounds, and
presentations provided via phone, web, or in-person.
Have you attended any formal training for RETAIN since April of 2020? [HCIA Clinician Rd. 2, B1]
Yes ........................................................................................................................ 1
No .......................................................................................................................... 0
GO TO C12
NO RESPONSE .................................................................................................... M
GO TO C12
SOFT CHECK: IF C7=NO RESPONSE;
Your answer to this question helps researchers better understand how often providers like you took
part in the trainings offered.
If you are not aware of having taken part in any trainings for RETAIN, please select “no.”
CATI VERSION
C7.
Formal training is defined as workshops, webinars, conferences, seminars, grand rounds, and
presentations provided via phone, web, or in-person.
Have you attended any formal training for RETAIN since April of 2020?
IF NEEDED: If you are not aware of having taken part in any trainings for RETAIN, just let me know.
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO C12
DON’T KNOW ....................................................................................................... d
GO TO C12
REFUSED ............................................................................................................. r
GO TO C12
SOFT CHECK: IF C7=D OR R;
Your answer to this question helps researchers better understand how often providers like you took
part in the trainings offered. If you are not aware of having taken part in any trainings for RETAIN, just
let me know.
20
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION C – PROVIDER EXPERIENCE IN RETAIN
ATTENDED FORMAL TRAINING FOR RETAIN (C7=1)
C8.
Did the formal training you attended for RETAIN include any of the following topics? [HCIA
Clinician Rd. 2, B1c, rev]
Select all that apply
Occupational health best practices ....................................................................... 1
Assessing barriers for returning to work ............................................................... 2
Alternatives to opioids for pain management ........................................................ 3
Other training topic(s)............................................................................................ 99
Specify
(STRING 100)
NO RESPONSE .................................................................................................... M
CATI VERSION
C8.
Did the formal training you attended for RETAIN include any of the following topics?
CODE ALL THAT APPLY
Occupational health best practices ............................................................................ 1
Assessing barriers for returning to work ...................................................................... 2
Alternatives to opioids for pain management ............................................................. 3
Other training topic(s) – SPECIFY .............................................................................. 99
____________________________________ (STRING 100)
DON’T KNOW .............................................................................................................. d
REFUSED .................................................................................................................... r
21
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION C – PROVIDER EXPERIENCE IN RETAIN
ATTENDED FORMAL TRAINING FOR RETAIN (C7=1)
C9.
Please think back to all of the formal training you attended related to RETAIN.
How much do you agree or disagree with the following statement?
“The training helped me return injured or ill workers to productive work as soon as medically
possible.” [HCIA Clinician Rd. 2, B2, rev]
Strongly disagree .................................................................................................. 1
Somewhat disagree .............................................................................................. 2
Neither agree nor disagree ................................................................................... 3
Somewhat agree ................................................................................................... 4
Strongly agree ....................................................................................................... 5
NO RESPONSE .......................................................................................................... M
CATI VERSION
C9.
Please think back to all of the formal training you attended related to RETAIN and tell me how
much do you agree or disagree with the following statement.
“The training helped me return injured or ill workers to productive work as soon as medically
possible.”
Do you:
CODE ONE ONLY
Strongly disagree .................................................................................................. 1
Somewhat disagree .............................................................................................. 2
Neither agree nor disagree ................................................................................... 3
Somewhat agree................................................................................................... 4
Strongly agree? .................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
22
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION C – PROVIDER EXPERIENCE IN RETAIN
ATTENDED FORMAL TRAINING FOR RETAIN (C7=1)
C10.
Please think back to all of the formal training you attended related to RETAIN.
On a scale of 1 to 5, where 1 is “no change at all” and 5 is “the most change possible,” how much
has the training you have received for RETAIN changed the way you interact with all of your
patients with a recent injury or illness that may inhibit or prevent their continued employment?
(NEW)
No change at all
1
2
3
4
5
The most change possible
NO RESPONSE .......................................................................................................... M
CATI VERSION
C10.
Please think back to all of the formal training you attended related to RETAIN.
On a scale of 1 to 5, where 1 is “no change at all” and 5 is “the most change possible,” how much
has the training you have received for RETAIN changed the way you interact with all of your
patients with a recent injury or illness that may inhibit or prevent their continued employment?
CODE ONE ONLY
1 - No change at all .............................................................................................. 1
2 ............................................................................................................................ 2
3 ............................................................................................................................ 3
4 ............................................................................................................................ 4
5 - The most change possible .............................................................................. 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ATTENDED FORMAL TRAINING FOR RETAIN (C7=1)
C11.
What additional topic areas, if any, would you have liked to have seen in the RETAIN training
offerings? [HCIA Clinician Rd. 2, B2a, rev]
OTHER TRAINING TOPICS FOR RETAIN PROVIDERS
(STRING 250)
NO RESPONSE .................................................................................................... M
CATI VERSION
C11.
What additional topic areas, if any, would you have liked to have seen in the RETAIN training
offerings?
___________________________________________________ (STRING 250)
OTHER TRAINING TOPICS FOR RETAIN PROVIDERS
NONE .......................................................................................................................... 1
DON’T KNOW .............................................................................................................. d
23
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION C – PROVIDER EXPERIENCE IN RETAIN
REFUSED .................................................................................................................... r
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
C12.
To what extent are each of the following currently a barrier to RETAIN achieving its goals?
PROGRAMMER: FORMAT FOR WEB USING BANKED FORMAT SHOWN BEOW TO OPTIMIZE FOR MOBILE DEVICES.
a. Insufficient provider time for amount of work
Major barrier
1
Minor barrier
2
Not applicable to
my job
Not a barrier
3
4
b. Ineffective communication with service coordinator
Major barrier
1
Minor barrier
2
Not applicable to
my job
Not a barrier
3
4
c. Employer attitudes
Major barrier
1
Minor barrier
2
Not applicable to
my job
Not a barrier
3
4
d. Patient attitudes
Major barrier
1
Minor barrier
2
Not applicable to
my job
Not a barrier
3
4
CATI VERSION
C12.
To what extent are each of the following currently a barrier to RETAIN achieving its goals?
I will read a list of challenges some programs face. For each, please tell me if you think it is a
major barrier, a minor barrier, or not a barrier to RETAIN achieving its goals.
CODE ONE PER ROW
MAJOR
BARRIER
MINOR
BARRIER
NOT A
BARRIER
NOT
APPLICABLE
TO MY JOB
a. Insufficient provider time for
amount of work
1
2
3
4
b. Ineffective communication with
service coordinator
1
2
3
4
c.
1
2
3
1
2
3
Employer attitudes
d. Patient attitudes
DK
REF
D
R
D
R
4
D
R
4
D
R
24
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION C – PROVIDER EXPERIENCE IN RETAIN
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
C13.
Not all clinical practices that were asked to collaborate with this program agreed to do so.
Based on your experience, would any of the following issues discourage clinical practices from
participating in RETAIN? [HCIA Clinician Rd. 2, E3, rev]
PROGRAMMER: FORMAT WEB USING BANKED FORMAT BEOW TO OPTIMIZE FOR MOBILE DEVICES.
a. Too many requirements. For example, additional meetings with care team,
program documentation, more work at home
Would discourage participation
1
Would not discourage participation
0
b. Current model of care is working, didn’t want to make a change
Would discourage participation
1
Would not discourage participation
0
c. Not a good financial decision for practice or organization
Would discourage participation
1
Would not discourage participation
0
d. Promoting work is not an appropriate focus for clinical practices
Would discourage participation
1
Would not discourage participation
0
e. Other barrier not listed above (SPECIFY): ___________ (150 CHAR)
Would discourage participation
99
Would not discourage participation
0
25
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION C – PROVIDER EXPERIENCE IN RETAIN
CATI VERSION
C13.
Not all clinical practices that were asked to collaborate with this program agreed to do so.
I’m going to read a list of issues. Based on your experience, please tell me whether each would
discourage clinical practices from participating in RETAIN or not.
IF NEEDED: Would this discourage clinical practices from participating in RETAIN?
CODE ONE PER ROW
WOULD
DISCOURAGE
PARTICIPATION
WOULD NOT
DISCOURAGE
PARTICIPATION
DK
REF
a. Too many requirements. For example,
additional meetings with care team,
program documentation, more work at
home
1
0
D
R
b. Current model of care is working,
didn’t want to make a change
1
0
D
R
c. Not a good financial decision for
practice or organization
1
0
D
R
d. Promoting work is not an appropriate
focus for clinical practices
1
0
D
R
e. Other barrier not listed above
(SPECIFY)
99
0
D
R
____________ (STRING 150)
26
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION C – PROVIDER EXPERIENCE IN RETAIN
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
C14.
Based on your experience with RETAIN, should this program model be set up in other clinical
settings or workplaces like yours? [HCIA Clinician Rd. 2, E7]
Yes ........................................................................................................................ 1
No .......................................................................................................................... 0
NO RESPONSE .................................................................................................... M
CATI VERSION
C14.
Based on your experience with RETAIN, should this program model be set up in other clinical
settings or workplaces like yours?
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
STATE = 1 AND PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
INSERT FILL CONDITION OR DELETE ROW
Insert question here
PLACEHOLDER FOR STATE-1 - Specific Items (4)
STATE = 2 AND PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
INSERT FILL CONDITION OR DELETE ROW
Insert question here
PLACEHOLDER FOR STATE-2 - Specific Items (4)
STATE = 3 AND PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
INSERT FILL CONDITION OR DELETE ROW
Insert question here
PLACEHOLDER FOR STATE-3 - Specific Items (4)
STATE = 4 AND PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
INSERT FILL CONDITION OR DELETE ROW
Insert question here
PLACEHOLDER FOR STATE-4 - Specific Items (4)
27
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION D – PROVIDER CONTACT INFORMATION
SECTION D.
PROVIDER CONTACT INFORMATION
ALL CONSENTING (A2=1)
[PRACTICE NAME] [PROVIDERAddress1] [PROVIDERAddress2] [PROVIDERCity], [PROVIDERState]
[PROVIDERPostCode] [
D1.
Thanks for answering these questions. Can you please confirm your contact information? This is
the mailing address where we will send your $45 for completing this survey. [Million Hearts,
Provider R1-Q21, rev]
Our records show:
[PRACTICE NAME]
[PROVIDERAddress1] [PROVIDERAddress2]
[PROVIDERCity], [PROVIDERState] [PROVIDERPostCode]
Is this correct? If not, please select “no” to update this information.
CONFIRMED AS ALL CORRECT ................................................................. 1 GO TO D3
UPDATES ARE NEEDED .............................................................................. 0 GO TO D2
NO RESPONSE ................................................................................................... M GO TO D3
SOFT CHECK: IF D1=NO RESPONSE;
This information helps us keep in touch with you so we can reach out if we have any questions about
the information you provide. This is also where we will mail your $45 check.
PROGRAMMER: If values for fills are missing, then populate fill with “Not on file”.
CATI VERSION
D1.
Thanks for answering these questions. Can you please confirm your contact information?
Our records show: [PRACTICE NAME], [PROVIDERAddress1] [PROVIDERAddress2]
[PROVIDER City], [PROVIDERState] [PROVIDERPostCode]
Is this correct?
YES ....................................................................................................................... 1
GO TO D3
NO – UPDATES ARE NEEDED ........................................................................... 0
GO TO D2
DON’T KNOW ....................................................................................................... d
GO TO D3
REFUSED ............................................................................................................. r
GO TO D3
SOFT CHECK: IF D1=D OR R;
This information helps us keep in touch with you so we can reach out if we have any questions about
the information you provide. This is also where we will mail your $45 check.
28
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION D – PROVIDER CONTACT INFORMATION
MAILING ADDRESS NEEDS UPDATE (D1=0)
D2.
What is your mailing address? [Million Hearts, Provider R1-Q22, rev]
Street address / PO Box:
(STRING 150)
City:
STRING 100)
State:
USE DROP DOWN MENU
Zip code:
(STRING 5)
NO RESPONSE ...................................................................................... M
SOFT CHECK: IF D2=NO RESPONSE ALL CELLS;
This information helps us keep in touch with you so we can reach out if we have any questions about
the information you provide. This is also where we will mail your $45 check.
CATI VERSION:
D2.
What is your mailing address?
___________________________________________________
STREET 1 OR P.O. BOX NUMBER
___________________________________________________
STREET 2
___________________________________________________
CITY
___________________________________________________ USE DROP DOWN MENU
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF D2= D OR R :
This information helps us keep in touch with you so we can reach out if we have any questions about
the information you provide. This is also where we will mail your $45 check.
29
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION D – PROVIDER CONTACT INFORMATION
ALL CONSENTING (A2=1)
[PROVIDER TELEPHONE NUMBER]
D3.
What is the best telephone number to reach you at? Our records show it as:
[PROVIDER TELEPHONE NUMBER]
Is this correct? If not, please select “no” to update this information. [NEW]
This is correct ....................................................................................................... 1 GO TO D5
Not correct – need to update ................................................................................ 0 GO TO D4
NO RESPONSE .......................................................................................................... M
GO TO D5
SOFT CHECK: IF D3=NO RESPONSE;
This information helps us keep in touch with you so we can reach out if we have any questions about
the information you provide.
CATI VERSION:
D3.
What is the best telephone number to reach you at? Our records show it as:
[PROVIDER TELEPHONE NUMBER]
Is this correct?
This is correct .............................................................................................................. 1 GO TO D5
Not correct – need to update ....................................................................................... 0 GO TO D4
DON’T KNOW .............................................................................................................. d GO TO D5
REFUSED .................................................................................................................... r
GO TO D5
SOFT CHECK: IF D3=D OR R;
This information helps us keep in touch with you so we can reach out if we have any questions about
the information you provide.
30
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION D – PROVIDER CONTACT INFORMATION
BEST PHONE NEEDS UPDATE (D3=0)
D4.
What is the best telephone number to reach you at? [NEW]
TELEPHONE
NO RESPONSE .................................................................................................... M
SOFT CHECK: IF D4=NO RESPONSE;
This information helps us keep in touch with you so we can reach out if we have any questions about
the information you provide.
CATI VERSION:
D4. What is the best telephone number to reach you at?
|
|
|
|-|
|
|
|-|
|
|
|
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF D4= D OR R;
This information helps us keep in touch with you so we can reach out if we have any questions about
the information you provide.
31
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION D – PROVIDER CONTACT INFORMATION
ALL CONSENTING (A2=1)
D5.
What’s the email address you check most often? (PROMISE-P18M-VI.D4)
EMAIL (STRING 250)
NO RESPONSE .................................................................................................... M
SOFT CHECK: IF D5= INVALID EMAIL;
Please enter a valid email address. This information helps us keep in touch with you so we can reach
out if we have any questions about the information you provide.
CATI VERSION:
D5. What’s the email address you check most often?
IF NEEDED: This information helps us keep in touch with you so we can reach out if we have any
questions about the information you provide.
INTERVIEWER:
EMAIL ADDRESS SHOULD INCLUDE TEXT, THE @ SYMBOL, TEXT, A PERIOD,
AND A VALID DOMAIN, SUCH AS ABCD@EFGH.COM
SPECIFY____________________________________
DON’T KNOW ....................................................................................................... D
REFUSED ............................................................................................................. R
SOFT CHECK: IF D5= INVALID EMAIL; INTERVIEWER: PLEASE ENTER A VALID EMAIL ADDRESS.
32
RETAIN: PROVIDER QUESTIONNAIRE R1: SECTION D – PROVIDER CONTACT INFORMATION
ALL CONSENTING (A2=1)
D6.
Thank you for completing the RETAIN provider survey! Your efforts help make the evaluation of
RETAIN a success. We look forward to connecting with you for the next survey one year from now.
If you have any questions, or if your contact information changes, please call XXX-XXX-XXXX.
[Million Hearts, Provider R1-Closing, rev]
CATI VERSION
D6.
That is the end of the provider survey - thanks for completing it! Your efforts help make the
evaluation of RETAIN a success.
We look forward to connecting with you for the next survey one year from now. If you have any
questions, or if your contact information changes, please call XXX-XXX-XXXX.
CLOSE INTERVIEW ............................................................................................ 1
33
OMB Control No.: XXXX-XXXX
Expiration date: XX/XX/XXXX
Retaining Employment and Talent
After Injury/Illness Network (RETAIN)
Provider Survey
Your input matters!
This survey should be
completed by:
Please return this survey by:
[Name, Practice, MPRID]
[DATE]
Public reporting burden for this collection of information is estimated to average 14 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: xxxxx. Do
not return the completed form to this address.
ABOUT THIS SURVEY
This survey is part of a national evaluation of the Retaining Employment and Talent After
Injury/Illness Network (RETAIN) program. The study is sponsored by the Social Security
Administration (SSA).
As a provider at a practice organization that is participating in RETAIN, we are asking you
to complete this survey. This study seeks to learn about your experiences providing
patient care and your experience with RETAIN (if any).
You’ll receive $45 for completing this voluntary survey. It takes about 15 minutes to
complete. Your answers will be kept confidential and grouped together with everyone
else who responds.
INSTRUCTIONS
Please record your answers as clearly as possible. Mark each applicable response box
with a check () or a “X.”
Proceed to the next item in the survey unless instructed to route elsewhere.
RETURNING THIS FORM
Thank you for completing this survey!
Please return it to:
RETAIN Survey Team
Mathematica
P.O. Box 2393
Princeton, NJ 08540
If you have any questions about the survey, call 1-XXX-XXX-XXXX or email the survey
team at XXXX@mathematica-mpr.com.
PROVISION OF HEALTH CARE SERVICES
BEGIN HERE
Q1.
Are you currently providing patient care at the practice organization listed on the
cover?
□ Yes
□ No
Q2.
RETURN THIS QUESTIONNNAIRE IN THE ENVELOPE PROVIDED.
What is your primary role at the practice organization listed on the cover?
If you have more than one role, please select the role that takes up most of your time.
MARK ONE ONLY
□ Primary Care Physician
□ Occupational Medicine Physician
□ Physical Medicine and
Rehabilitation Specialist
□ Orthopedic Surgeon
□ Neurosurgeon
□ Physical Therapist
□ Chiropractor
□ Registered Nurse
□ Nurse Practitioner
□ Physician Assistant
□ Mental Health Professional
□ Other role, not listed above
___________________________
Q3.
How many years have you been in practice?
MARK ONE ONLY
□ 0-5 years
□ 6-10 years
□ 11-15 years
□ 16-25 years
□ More than 25 years
1
Q4.
In a typical week, approximately what percent of your patient visits are covered by
Workers’ Compensation?
MARK ONE ONLY
□ Less than 15%
□ 15–25%
□ 26-50%
□ More than 50%
□ I don’t work with workers’ compensation patients
□ I don’t know
Q5.
When you are treating a patient with a recent injury or illness that may inhibit or
prevent continued employment, how often do you …
MARK ONE PER ROW
All the
time
Most of
the time
Some
of the
time
Rarely
Never
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
d. Develop an activity plan which
communicates the worker’s ability to
participate in work activities, activity
restrictions, and the provider’s
treatment plans, when appropriate?
□
□
□
□
□
e. Provide information to employers about
injured workers, when appropriate?
□
□
□
□
□
f.
□
□
□
□
□
a. Try to help your patients return to work,
when appropriate?
b. Assess barriers to return to work, when
appropriate?
c. Develop a plan to overcome barriers to
work, when appropriate?
Discuss possible work accommodations
for injured workers with employers,
when appropriate?
2
Q6.
When treating patients with a recent injury or illness that may inhibit or prevent
continued employment, do you make referrals to any outside public or private
programs, when appropriate? Do not include referral for medical services or supports.
MARK ONE ONLY
□ Yes
□ No
Q7.
GO TO Q8
What kinds of outside public or private programs do you typically refer these patients
to?
________________________________________________________________________
________________________________________________________________________
Q8.
When you are treating a patient with a recent injury or illness that may inhibit or
prevent continued employment, how do you typically communicate with their
employers, if at all?
MARK ALL THAT APPLY
□ Email
□ Letter
□ Complete a return-to-work form
□ Telephone
□ Other way(s)
□ I do not communicate with injured workers’ employers
3
Q9.
Are there any issues that limit your ability to provide optimal care for patients with a
recent injury or illness that may inhibit or prevent their continued employment?
MARK ONE ONLY
□ Yes
□ No
GO TO Q11
Q10. If yes, what issues limit your ability to provide optimal care for patients with a recent
injury or illness that may inhibit or prevent their continued employment?
________________________________________________________________________
________________________________________________________________________
PROVIDER EXPERIENCE IN RETAIN
Q11. RETAIN stands for Retaining Employment and Talent After Injury/Illness Network.
Are you aware that your practice organization is participating in RETAIN?
□ Yes
□ No
GO TO Q25 ON PAGE 9
Q12. In a typical week, approximately what percent of your patients are RETAIN enrollees?
MARK ONE ONLY
□ Less than 25%
□ 25–49%
□ 50–74%
□ 75–100%
□ I don’t always know when I’m working with RETAIN enrollees
□ I don’t work with RETAIN enrollees
4
Q13. As a part of the RETAIN program, a [COORDINATOR TITLE] is someone who
coordinates medical services, works with employers/supervisors to develop
alternative job duties or help people find temporary employment. They may also
provide coaching and individualized supports, like job retraining, problem solving
skills trainings, or peer supports.
Do you work with a [COORDINATOR TITLE] as part of the RETAIN program?
MARK ONE ONLY
□ Yes
□ No
GO TO Q16
Q14. In general, does working with a RETAIN [COORDINATOR TITLE] make your overall job
easier or more difficult to do, or has it had no effect?
MARK ONE ONLY
□ Easier
□ More difficult
□ No effect
Q15. Why does working with a [COORDINATOR TITLE] make your overall job easier or more
difficult to do, or why has it had no effect on your job?
________________________________________________________________________
________________________________________________________________________
Q16. Do the overall administrative requirements for RETAIN take up too much of your time
or are they reasonable?
These requirements could include hardcopy and electronic documentation, working
with RETAIN [COORDINATOR TITLE], and/or attending meetings.
MARK ONE ONLY
□ Take up too much time
□ Are reasonable
□ I do not have administrative requirements for RETAIN
5
Q17. Formal training is defined as workshops, webinars, conferences, seminars, grand
rounds, and presentations provided via phone, web, or in-person. Have you attended
any formal training for RETAIN since April of 2020?
□ Yes
□ No
GO TO Q22
Q18. Did the formal training you attended for RETAIN include any of the following topics?
MARK ALL THAT APPLY
□ Occupational health best practices
□ Assessing barriers for returning to work
□ Alternatives to opioids for pain management
□ Other training topic(s) – Specify: __________________________________________
Q19. Please think back to all of the formal training you attended related to RETAIN.
How much do you agree or disagree with the following statement?
“The training helped me return injured or ill workers to productive work as soon as
medically possible.”
MARK ONE ONLY
□ Strongly disagree
□ Somewhat disagree
□ Neither agree nor disagree
□ Somewhat agree
□ Strongly agree
6
Q20. Please think back to all of the formal training you attended related to RETAIN.
On a scale of 1 to 5, where 1 is “no change at all” and 5 is “the most change possible,”
how much has the training you have received for RETAIN changed the way you
interact with all of your patients with a recent injury or illness that may inhibit or
prevent their continued employment?
MARK ONE ONLY
□ 1 – No change at all
□2
□3
□4
□ 5 – The most change possible
Q21. What additional topic areas, if any, would you have liked to have seen in the RETAIN
training offerings?
________________________________________________________________________
________________________________________________________________________
Q22. To what extent are each of the following currently a barrier to RETAIN achieving its
goals?
MARK ONE PER ROW
a. Insufficient provider time for amount of work
b. Ineffective communication with service
coordinator
c. Employer attitudes
d. Patient attitudes
7
Major
barrier
Minor
barrier
Not a
barrier
Not
applicable
to my job
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Q23. Not all clinical practices that were asked to collaborate with this program agreed to do
so. Based on your experience, would any of the following issues discourage clinical
practices from participating in RETAIN?
MARK ONE PER ROW
Would discourage
participation
Would not
discourage
participation
a. Too many requirements. For example, additional
meetings with care team, program documentation,
more work at home
□
□
b. Current model of care is working, didn’t want to
make a change
□
□
□
□
□
□
□
□
c. Not a good financial decision for practice or
organization
d. Promoting work is not an appropriate focus for
clinical practices
e. Other barrier not listed above (specify)
_______________________________________
Q24. Based on your experience with RETAIN, should this program model be set up in other
clinical settings or workplaces like yours?
□ Yes
□ No
PLACEHOLDER FOR STATE-SPECIFIC ITEMS (4)
8
PROVIDER CHARACTERISTICS AND CONTACT INFORMATION
Q25. What is your mailing address?
This information helps us keep in touch with you so we can reach out if we have any
questions about the information you provide. This is also where will mail your $45
check.
________________________________________________________________________
STREET
________________________________________________________________________
CITY
STATE
ZIP CODE
Q26. What is the best telephone number to reach you at?
|
|
|
|-|
AREA CODE
|
|
|-|
|
|
|
|
PHONE NUMBER
Q27. What’s the email address you check most often?
____________________________________________ @ __________________________
Thank you for completing the RETAIN provider survey! Your efforts help make the
evaluation of RETAIN a success. Please return this survey in the envelope provided.
We look forward to connecting with you for the next survey one year from now. If you
have any questions, or if your contact information changes, please call XXX-XXX-XXXX.
9
OMB No.: XXX
Expiration Date: XX/XX/2023
Retaining Employment and Talent After Injury/Illness Network (RETAIN) Provider Survey
Round 2 (R2): questionnaire and programming specifications
12.17.19 (Deliverable 9.2C – R2)
Programming and operational assumptions:
Modes. The provider survey will be administered in three modes – web, paper, and telephone. These
specifications are for the computer-assisted versions of the instrument only.
Population. This survey is self-administered. There will not be responses via proxy.
Target respondent. This questionnaire is to be administered to providers of medical or social,
rehabilitative services delivered to RETAIN enrollees in intervention group. All eligible sample members
will be included in the R2 survey, regardless of participation in R1. Sample members will be considered
ineligible if they are no longer providing services at the practice organization of record.
Length. The questionnaire is designed to take about 14 minutes to complete.
Languages. The questionnaire is available in English and Spanish (upon request).
Administration and design specifications. Each item in the web questionnaire specifications includes:
which respondents receive the item; dynamic fills, designated by text [in brackets]; emphasis text,
designated in bold font; soft checks that help improve data quality (designated in boxes below applicable
items); response options shown with boxes indicate “check all that apply” response format, whereas
those shown in circles denote “check one” response format. In this draft, the item as presented in selfadministration by web first, followed by the same item as it appears in CATI (telephone interviewer
administration). Relevant text modifications have been made for each version, as needed.
Login. Users can login via personalized link or through the main survey page using a username and
password.
Critical items have soft checks added throughout the instrument.
Partial completes are designated by completion of C1 (awareness of RETAIN) completed, as
applicable.
Sections of the provider questionnaire:
A
Introduction and consent
B
Provision of health care services
C
Provider experience in RETAIN
D
Contact information
PROGRAMMER:
Do not display item numbers on page for web version
CATI load file will include the following variables used in universe logic and fills in this instrument as
follows:
Variable
Description- additional notes
Format
R1 survey status
IF = 13: R1 survey was completed
numeric
IF > 13: R1 survey was non-complete
Practice organization name
alpha
Provider mailing address
Alpha-numeric
Provider phone
numeric
The load file will also include the following information used for state-specific fills:
STATE
CA
CT
KS
State Name for
RETAIN
RETAIN-California
RETAIN-Connecticut
RETAIN-Kansas
Coordinator title
Return to Work (RTW) Coordinator
Return to Work (RTW) Coordinator
Return to Work (RTW) Coordinator or Medical and Workforce
Systems Coordinator
KY
Retaining Kentucky's
Workforce through
Universal Design
(RKW-UD)
Return to Work Coordinator (RTWC)
MN
OH
VT
WA
RETAIN-Minnesota
RETAIN-Ohio
RETAIN-Vermont
RETAIN-Washington
Return to Work (RTW) Coordinator
Health Services Coordinator (HSC)
Return to Work (RTW) Coordinator
Return to Work (RTW) Coordinator
2
RETAIN PROVIDER QUESTIONNAIRE R2: WEB/CATI INTRO
OMB No.: XXX
Expiration Date: xx/xx/xxxxx
LOGIN SCREEN – FOR USERNAME AND PASSWORD LOGIN USERS:
Welcome to the Retaining Employment and Talent After Injury/Illness Network (RETAIN)
Survey of Providers!
To begin, please enter your survey username and password below:
Username:
Password:
PLEASE CLICK THE “NEXT” BUTTON BELOW TO CONTINUE …
If you have any questions, or are having difficulty logging in, we are here to help.
Please call the study team xxx-xxx-xxxx (toll free).
Public reporting burden for this collection of information is estimated to average 17 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. The OMB number for this information collection is XXXX and the expiration date is XX/XX/XXXX.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to: XXX. Do not return the completed form to this address.
3
RETAIN PROVIDER QUESTIONNAIRE R2: WEB/CATI INTRO
CATI VERSION
Hello. Hello, my name is [INTERVIEWER NAME]. May I please speak to [PROVIDER NAME]?
I am calling from Mathematica on behalf of the Social Security Administration about an important
national study.
CODE ONE ONLY
SPEAKING TO [PROVIDER] ...................................................................................... 1
GO TO A1
[PROVIDER] COMES TO THE PHONE...................................................................... 2
GO TO A1
NEED TO CALLBACK (NO APPT).............................................................................. 3
TERMINATE
NEED TO CALLBACK (SET APPT) ............................................................................ 4
SETAPPT
[PROVIDER] HAS MOVED/HAS NEW NUMBER ....................................................... 5
TERMINATE
NEVER HEARD OF [PROVIDER]/WRONG NUMBER ............................................... 6
TERMINATE
HUNG UP DURING INTRODUCTION (HUDI) ............................................................ 7
TERMINATE
[PROVIDER] IS DECEASED....................................................................................... 8
INELIG-TERMINATE
[PROVIDER] IS NO LONGER AT THIS PRACTICE ORG ......................................... 9
INELIG-TERMINATE
4
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION A – INTRODUCTION AND CONSENT
SECTION A. INTRODUCTION AND CONSENT
ALL
[PRACTICE ORGANIZATION]
A1. Are you currently providing patient care at [PRACTICE ORGANIZATION]? [NEW]
Yes ........................................................................................................................ 1
No .......................................................................................................................... 0
TERMINATE
NO RESPONSE .................................................................................................... M
TERMINATE
SOFT CHECK: IF A1=0;
To confirm – you are no longer providing patient care at [PRACTICE ORGANIZATION]? If you are
providing patient care at this place, please change your answer to this question.
HARD CHECK: IF A1=NO RESPONSE;
Please provide a response to this question. This helps us make sure you receive only the questions
that best apply to you.
CATI VERSION
A1.
Are you currently providing patient care at [PRACTICE ORGANIZATION]?
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
TERMINATE
DON’T KNOW ....................................................................................................... d
TERMINATE
REFUSED ............................................................................................................. r
TERMINATE
5
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION A – INTRODUCTION AND CONSENT
ALL ELIGIBLE (A1=1)
A2.
This survey asks about your experiences as a provider at a practice that provides care and
services for the Retaining Employment and Talent After Injury/Illness Network (RETAIN) program.
You’ll receive $45 for completing this voluntary survey. It will take about 14 minutes to complete.
It includes questions about your experience providing patient care and your experience in RETAIN
(if any). Your answers will be kept confidential and grouped with everyone else who responds.
[NEW]
I agree to take part………………………………...................…1
GO TO B1
I do not agree to take part………………………………………0 TERMINATE REFUSAL
PROGRAMMER: DO NOT ALLOW MISSING VALUES ON THIS ITEM
HARD CHECK: IF A2=0 RESPONSE; Please record an answer to the question above.
CATI VERSION
A2.
This survey asks about your experiences as a provider at a practice that provides care and
services for the Retaining Employment and Talent After Injury/Illness Network (RETAIN) program.
You’ll receive $45 for completing this voluntary survey. It will take about 14 minutes to complete.
It includes questions about your experience providing patient care and your experience in RETAIN
(if any). Your answers will be kept confidential and grouped with everyone else who responds.
Do you have any questions before we begin?
INTERVIEWER: ANSWER QUESTIONS, AS NEEDED, THEN PROCEED ONCE QUESTIONS HAVE
BEEN ADDRESSED.
CODE ONE ONLY
I AGREE TO TAKE PART - OK TO BEGIN .............................................. 1 GO TO B1
REFUSED .................................................................................................. r TERMINATE
6
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION B – PROVISION OF HEALTH CARE SERVICES
SECTION B. PROVISION OF HEALTH CARE SERVICES
PROGRAMMER SKIP BOX 1
IF R1 INSTRUMENT WAS COMPLETED BY PROVIDER (STATUS 13) SKIP
TO B4. ELSE IF NONCOMPLETE AT R1 (STATUS >13) GO TO B1.
ALL CONSENTING (A2=1) AND STATUS AT R1 SURVEY WAS NON COMPLETE (R1 STATUS >13)
[PRACTICE NAME]
B1.
What is your primary role at [PRACTICE NAME]?
If you have more than one role, please select the role that takes up most of your time. [HCIA Clin
R2, A1a, rev]
Primary Care Physician......................................................................................... 1
Occupational Medicine Physician ......................................................................... 2
Physical Medicine and Rehabilitation Specialist ................................................... 3
Orthopedic Surgeon .............................................................................................. 4
Neurosurgeon ....................................................................................................... 5
Physical Therapist ................................................................................................. 6
Chiropractor .......................................................................................................... 7
Registered Nurse .................................................................................................. 8
Nurse Practitioner ................................................................................................. 9
Physician Assistant ............................................................................................... 10
Mental Health Professional ................................................................................... 11
Other role, not listed above: .................................................................................. 99
Specify
(STRING 100)
NO RESPONSE .................................................................................................... M
7
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION B – PROVISION OF HEALTH CARE SERVICES
CATI VERSION
B1.
What is your primary role at [PRACTICE NAME]?
If you have more than one role, please choose the role that takes up most of your time.
CODE ONE ONLY
PRIMARY CARE PHYSICIAN ..................................................................................... 1
OCCUPATIONAL MEDICINE PHYSICIAN ................................................................. 2
PHYSICAL MEDICINE AND REHABILITATION SPECIALIST ................................... 3
ORTHOPEDIC SURGEON ......................................................................................... 4
NEUROSURGEON...................................................................................................... 5
PHYSICAL THERAPIST ............................................................................................. 6
CHIROPRACTOR........................................................................................................ 7
REGISTERED NURSE ................................................................................................ 8
NURSE PRACTITIONER ............................................................................................ 9
PHYSICIAN ASSISTANT ............................................................................................ 10
MENTAL HEALTH PROFESSIONAL .......................................................................... 11
OTHER (SPECIFY) ..................................................................................................... 99
___________________________________________________ (STRING 100)
DON’T KNOW .............................................................................................................. d
REFUSED .................................................................................................................... r
8
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION B – PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1) AND STATUS AT R1 SURVEY WAS NON COMPLETE (R1 STATUS >13)
B2.
How many years have you been in practice? [NEW]
0-5 years ............................................................................................................... 1
6-10 years ............................................................................................................. 2
11-15 years ........................................................................................................... 3
16-25 years ........................................................................................................... 4
More than 25 years ............................................................................................... 5
NO RESPONSE .................................................................................................... M
SOFT CHECK: IF B2=NO RESPONSE; Your answer to this question helps us better understand the
practices and opinions of different groups of providers.
CATI VERSION
B2.
How many years have you been in practice?
CODE ONE ONLY
0-5 years ...................................................................................................................... 1
6-10 years .................................................................................................................... 2
11-15 years .................................................................................................................. 3
16-25 years .................................................................................................................. 4
More than 25 years ...................................................................................................... 5
DON’T KNOW .............................................................................................................. d
REFUSED .................................................................................................................... r
SOFT CHECK: IF B2=D or R;
Your answer to this question helps us better understand the practices and opinions of different groups
of providers.
9
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION B – PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1) AND STATUS AT R1 SURVEY WAS NON COMPLETE (R1 STATUS >13)
B3.
In a typical week, approximately what percent of your patient visits are covered by Workers’
Compensation? [NEW]
Less than 15% ...................................................................................................... 1
15-25% .................................................................................................................. 2
26-50% .................................................................................................................. 3
More than 50% ...................................................................................................... 4
I don’t work with workers’ compensation patients ................................................ 5
I don’t know .......................................................................................................... 6
NO RESPONSE .................................................................................................... M
SOFT CHECK: IF B3=NO RESPONSE;
Please provide a response to this question. Your best estimate is fine.
If you do not see patients who receive workers’ compensation, or if their receipt of workers’
compensation is not part of their records, please select from the applicable response options for these
instances.
CATI VERSION
B3.
In a typical week, approximately what percent of your patient visits are covered by Workers’
Compensation?
If you do not see patients who receive workers’ compensation, or if this is not part of their
records, just let me know.
CODE ONE ONLY
Less than 15% ............................................................................................................. 1
15-25% ........................................................................................................................ 2
26-50% ........................................................................................................................ 3
More than 50% ............................................................................................................ 4
I DON’T WORK WITH WORKERS’ COMPENSATION PATIENTS ........................... 5
I DON’T KNOW ............................................................................................................ d
REFUSED .................................................................................................................... r
SOFT CHECK: IF B3=D OR R;
If you do not see patients who receive workers’ compensation, or if their receipt of workers’
compensation is not part of their records, just let me know.
10
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION B – PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1)
B4.
When you are treating a patient with a recent injury or illness that may inhibit or prevent continued
employment, how often do you … [NEW]
PROGRAMMER: FORMAT WEB USING BANKED FORMAT BEOW TO OPTIMIZE FOR MOBILE DEVICES.
a. Try to help your patients return to work, when appropriate?
All the time
1
Most of the
time
2
Some of the
time
3
Rarely
4
Never
5
b. Assess barriers to return to work, when appropriate?
All the time
1
Most of the
time
2
Some of the
time
3
Rarely
Never
4
5
c. Develop a plan to overcome barriers to work, when appropriate?
All the time
1
Most of the
time
2
Some of the
time
3
Rarely
Never
4
5
d. Develop an activity plan which communicates the worker’s ability to
participate in work activities, activity restrictions, and the provider’s
treatment plans, when appropriate?
All the time
1
Most of the
time
2
Some of the
time
3
Rarely
Never
4
5
e. Provide information to employers about injured workers, when
appropriate?
All the time
1
Most of the
time
2
Some of the
time
3
Rarely
Never
4
5
f. Discuss possible work accommodations for injured workers with
employers, when appropriate?
All the time
1
Most of the
time
2
Some of the
time
3
11
Rarely
Never
4
5
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION B – PROVISION OF HEALTH CARE SERVICES
CATI VERSION
B4.
When you are treating a patient with a recent injury or illness that may inhibit or prevent continued
employment, how often do you …
Would you say all of the time; some of the time; or rarely?
CODE ONE PER ROW
All the
time
Most of
the
time
Some
of the
time
Rarely
Never
DK
REF
a. Try to help your patients
return to work, when
appropriate?
1
2
3
4
5
D
R
b. Assess barriers to return to
work, when appropriate?
1
2
3
4
5
D
R
c. Develop a plan to overcome
barriers to work, when
appropriate?
1
2
3
4
5
D
R
d. Develop an activity plan which
communicates the worker’s
ability to participate in work
activities, activity restrictions,
and the provider’s treatment
plans, when appropriate?
1
2
3
4
5
D
R
e. Provide information to
employers about injured
workers, when appropriate?
1
2
3
4
5
D
R
1
2
3
4
5
D
R
f.
Discuss possible work
accommodations for injured
workers with employers, when
appropriate?
12
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION B – PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1)
B5.
When treating patients with a recent injury or illness that may inhibit or prevent continued
employment, do you make referrals to any outside public or private programs, when appropriate?
Do not include referrals for medical services or supports. [NEW]
Yes ........................................................................................................................ 1
GO TO B6
No .......................................................................................................................... 0
GO TO B7
No Response ........................................................................................................ M
GO TO B7
CATI VERSION
B5.
When treating patients with a recent injury or illness that may inhibit or prevent continued
employment, do you make referrals to any outside public or private programs, when appropriate?
Do not include referrals for medical services or supports.
YES ....................................................................................................................... 1
GO TO B6
NO ........................................................................................................................ 0
GO TO B7
DON’T KNOW ....................................................................................................... d
GO TO B7
REFUSED ............................................................................................................. r
GO TO B7
PROVIDER MAKES REFERRALS TO OUTSIDE PUBLIC OR PRIVATE PROGRAMS (B5=1)
B6.
What kinds of outside public or private programs do you typically refer these patients to?
OUTSIDE PUBLIC OR PRIVATE PROGRAMS
(STRING 250)
CATI VERSION
B6.
What kinds of outside public or private programs do you typically refer these patients to?
PROBE:
Any others?
___________________________________________________ (STRING 250)
OUTSIDE PUBLIC OR PRIVATE PROGRAMS
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
13
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION B – PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1)
B7.
When you are treating a patient with a recent injury or illness that may inhibit or prevent continued
employment, how do you typically communicate with their employers, if at all? [NEW]
Select all that apply
Email ..................................................................................................................... 1
Letter ..................................................................................................................... 2
Complete a return-to-work form ............................................................................ 3
Telephone ............................................................................................................. 4
Other way(s) .......................................................................................................... 5
I do not communicate with injured workers’ employers ........................................ 6
NO RESPONSE .................................................................................................... M
CATI VERSION
B7.
When you are treating a patient with a recent injury or illness that may inhibit or prevent continued
employment, how do you typically communicate with their employers most often, if at all?
IF NEEDED: If you do not communicate with injured workers’ employers, just let me know.
CODE ALL THAT APPLY
Email ........................................................................................................................... 1
Letter ........................................................................................................................... 2
Complete a return-to-work form ............................................................................... 3
Telephone ................................................................................................................... 4
Other way(s) ............................................................................................................... 5
I DO NOT COMMUNICATE WITH INJURED WORKERS’ EMPLOYERS ................. 6
DON’T KNOW .............................................................................................................. d
REFUSED .................................................................................................................... r
14
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION B – PROVISION OF HEALTH CARE SERVICES
ALL CONSENTING (A2=1)
B8.
Are there any issues that limit your ability to provide optimal care for patients with a recent injury
or illness that may inhibit or prevent their continued employment? [CPC+, B15, rev]
Yes ........................................................................................................................ 1
GO TO B9
No .......................................................................................................................... 0
GO TO C1
NO RESPONSE .................................................................................................... M
GO TO C1
CATI VERSION
B8.
Are there any issues that limit your ability to provide optimal care for patients with a recent injury or
illness that may inhibit or prevent their continued employment?
YES ....................................................................................................................... 1
GO TO B9
NO ........................................................................................................................ 0
GO TO C1
DON’T KNOW ....................................................................................................... d
GO TO C1
REFUSED ............................................................................................................. r
GO TO C1
PROVIDER REPORTS ISSUES THAT LIMITED ABILITY TO PROVIDE OPTIMAL CARE FOR THIS
POPULATION (B8=1)
B9.
IWhat issues limit your ability to provide optimal care for patients with a recent injury or illness that
may inhibit or prevent their continued employment? [CPC+, B15, rev]
(STRING 250)
NO RESPONSE .................................................................................................... M
CATI VERSION
B9.
What issues limit your ability to provide optimal care for patients with a recent injury or illness that may
inhibit or prevent their continued employment?
PROBE: Anything else?
___________________________________________________ (STRING 250)
DON’T KNOW .............................................................................................................. d
REFUSED .................................................................................................................... r
15
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
Section C. Provider Experience in RETAIN
ALL CONSENTING (A2=1)
C1.
RETAIN stands for Retaining Employment and Talent After Injury/Illness Network. Are you aware
that your practice organization is participating in RETAIN? [Million Hearts, Provider R1- Q16 rev]
Yes ........................................................................................................................ 1
No .......................................................................................................................... 0
GO TO D1
NO RESPONSE .................................................................................................... M
GO TO D1
SOFT CHECK: IF C1=NO RESPONSE;
Your answer to this question is important, as it helps us only ask questions that are relevant to you.
CATI VERSION
C1.
RETAIN stands for Retaining Employment and Talent After Injury/Illness Network.
Are you aware that your practice organization is participating in RETAIN?
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO D1
DON’T KNOW ....................................................................................................... d
GO TO D1
REFUSED ............................................................................................................. r
GO TO D1
SOFT CHECK: IF C1=D OR R;
Your answer to this question is important, as it helps us only ask questions that are relevant to you.
Are there any questions I can answer or concerns I can help address?
16
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
C2.
In a typical week, approximately what percent of your patients are RETAIN enrollees? [HCIA
Clinician Rd 2, A5a, rev]
Less than 25% ...................................................................................................... 1
25-49% .................................................................................................................. 2
50-74% .................................................................................................................. 3
75-100% ................................................................................................................ 4
I don’t always know when I’m working with RETAIN enrollees............................. 5
I don’t work with RETAIN enrollees ...................................................................... 6
NO RESPONSE .................................................................................................... M
SOFT CHECK: IF C2=NO RESPONSE;
Please provide a response to this question. Your best estimate is fine. If you do not see patients who
are enrolled in RETAIN, or if their participation is not part of their records, please select from the
applicable response options for these instances.
CATI VERSION
C2.
In a typical week, approximately what percent of your patients are RETAIN enrollees?
IF NEEDED:
If you do not see patients who are enrolled in RETAIN, or if their participation is not
part of their records, just let me know.
CODE ONE ONLY
Less than 25% ............................................................................................................. 1
25-49% ........................................................................................................................ 2
50-74% ........................................................................................................................ 3
75-100% ...................................................................................................................... 4
I DON’T ALWAYS KNOW WHEN I’M WORKING WITH RETAIN ENROLEES.......... 5
I DON’T WORK WITH RETAIN ENROLLEES ............................................................ 6
DON’T KNOW .............................................................................................................. d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C2=D OR R; If you do not see patients who are enrolled in RETAIN, or if their
participation is not part of their records, just let me know.
17
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
[COORDINATOR TITLE]
C3.
As part of the RETAIN program, a [COORDINATOR TITLE] is someone who coordinates medical
services, works with employers/supervisors to develop alternative job duties or help people find
temporary employment. They may also provide coaching and individualized supports, like job
retraining, problem solving skills trainings, or peer supports.
Do you work with a [COORDINATOR TITLE] as part of the RETAIN program? [NEW]
Yes ........................................................................................................................ 1
No .......................................................................................................................... 0
GO TO C6
NO RESPONSE .................................................................................................... M
GO TO C6
CATI VERSION
C3.
As part of the RETAIN program, a [COORDINATOR TITLE] is someone who coordinates medical
services, works with employers/supervisors to develop alternative job duties or help people find
temporary employment. They may also provide coaching and individualized supports, like job
retraining, problem solving skills trainings, or peer supports.
Do you work with a [COORDINATOR TITLE] as part of the RETAIN program?
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO C6
DON’T KNOW ....................................................................................................... d
GO TO C6
REFUSED ............................................................................................................. r
GO TO C6
18
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
WORK WITH SERVICE COORDINATOR (C3=1)
[COORDINATOR TITLE]
C4.
In general, does working with a RETAIN [COORDINATOR TITLE] make your overall job easier or
more difficult to do, or has it had no effect? [HCIA Clinician R2, C3, rev]
Select one only
Easier .................................................................................................................... 1
More difficult .......................................................................................................... 2
No effect ................................................................................................................ 3
NO RESPONSE .................................................................................................... M
GO TO C6
CATI VERSION
C4.
In general, does working with a RETAIN [COORDINATOR TITLE] make your overall job easier or
more difficult to do, or has it had no effect?
CODE ONE ONLY
EASIER ....................................................................................................................... 1
MORE DIFFICULT....................................................................................................... 2
NO EFFECT ................................................................................................................ 3
DON’T KNOW .............................................................................................................. d
GO TO C6
REFUSED .................................................................................................................... r
GO TO C6
PROVIDER HAS OPIONION ON IMPACT OF SERVICE COORDINATOR ON HIS/HER JOB (C4=1, 2, 3)
[COORDINATOR TITLE]
C5.
Why does working with a [COORDINATOR TITLE] make your overall job easier or more difficult to
do, or why has it had no effect on your job? [NEW]
(STRING 250)
NO RESPONSE .................................................................................................... M
CATI VERSION
C5.
Why does working with a [COORDINATOR TITLE] make your overall job easier or more difficult to
do, or why has it had no effect on your job?
___________________________________________________ (STRING 250)
DON’T KNOW .............................................................................................................. d
REFUSED .................................................................................................................... r
19
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
[COORDINATOR TITLE]
C6.
Do the overall administrative requirements for RETAIN take up too much of your time or are they
reasonable?
These requirements could include hardcopy and electronic documentation, working with RETAIN
[COORDINATOR TITLE], and/or attending meetings. [HCIA Clinician Rd. 2, C4, rev]
Take up too much time.......................................................................................... 1
Are reasonable ...................................................................................................... 2
I do not have administrative requirements for RETAIN ........................................ 3
NO RESPONSE .................................................................................................... M
CATI VERSION
C6.
Do the overall administrative requirements for RETAIN take up too much of your time or are they
reasonable?
These requirements could include hardcopy and electronic documentation, working with RETAIN
[COORDINATOR TITLE], and/or attending meetings.
CODE ONE ONLY
TAKE UP TOO MUCH TIME ....................................................................................... 1
ARE REASONABLE .................................................................................................... 2
I DO NOT HAVE ADMINISTRATIVE REQUIREMENTS FOR RETAIN ..................... 3
REFUSED .................................................................................................................... r
20
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
[STATE PROGRAM LAUNCH DATE]
C7.
Formal training is defined as workshops, webinars, conferences, seminars, grand rounds, and
presentations provided via phone, web, or in-person.
In the past year, have you attended any formal training for RETAIN? [HCIA Clinician Rd. 2, B1]
Yes ........................................................................................................................ 1
No .......................................................................................................................... 0
GO TO C12
NO RESPONSE .................................................................................................... M
GO TO C12
SOFT CHECK: IF C7=NO RESPONSE; Your answer to this question helps researchers better understand
how often providers like you took part in the trainings offered. If you are not aware of having taken part
in any trainings for RETAIN, please select “no.”
CATI VERSION
C7.
Formal training is defined as workshops, webinars, conferences, seminars, grand rounds, and
presentations provided via phone, web, or in-person. In the past year, have you attended any
formal training for RETAIN?
IF NEEDED: If you are not aware of having taken part in any trainings for RETAIN, just let me know.
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO C12
DON’T KNOW ....................................................................................................... d
GO TO C12
REFUSED ............................................................................................................. r
GO TO C12
SOFT CHECK: IF C7=D OR R; Your answer to this question helps researchers better understand how
often providers like you took part in the trainings offered. If you are not aware of having taken part in
any trainings for RETAIN, just let me know.
21
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
ATTENDED FORMAL TRAINING FOR RETAIN (C7=1)
C8.
In the past year, did the formal training you attended for RETAIN include any of the following
topics? [HCIA Clinician Rd. 2, B1c, rev]
Select all that apply
Occupational health best practices ....................................................................... 1
Assessing barriers for returning to work ............................................................... 2
Alternatives to opioids for pain management ........................................................ 3
Other training topic(s)............................................................................................ 99
Specify
(STRING 100)
NO RESPONSE .................................................................................................... M
CATI VERSION
C8.
In the past year, did the formal training you attended for RETAIN include any of the following
topics?
CODE ALL THAT APPLY
Occupational health best practices ............................................................................ 1
Assessing barriers for returning to work ...................................................................... 2
Alternatives to opioids for pain management ............................................................. 3
Other training topic(s) – SPECIFY .............................................................................. 99
____________________________________ (STRING 100)
DON’T KNOW .............................................................................................................. d
REFUSED .................................................................................................................... r
22
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
ATTENDED FORMAL TRAINING FOR RETAIN (C7=1)
C9.
Please think back to all of the formal training you attended related to RETAIN in the past year.
How much do you agree or disagree with the following statement?
“The training helped me return injured or ill workers to productive work as soon as medically
possible.” [HCIA Clinician Rd. 2, B2, rev]
Strongly disagree .................................................................................................. 1
Somewhat disagree .............................................................................................. 2
Neither agree nor disagree ................................................................................... 3
Somewhat agree ................................................................................................... 4
Strongly agree ....................................................................................................... 5
NO RESPONSE .......................................................................................................... M
CATI VERSION
C9.
Please think back to all of the formal training you attended related to RETAIN in the past year.
How much do you agree or disagree with the following statement:
“The training helped me return injured or ill workers to productive work as soon as medically
possible.” Do you:
CODE ONE ONLY
Strongly disagree .................................................................................................. 1
Somewhat disagree .............................................................................................. 2
Neither agree nor disagree ................................................................................... 3
Somewhat agree................................................................................................... 4
Strongly agree? .................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
23
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
ATTENDED FORMAL TRAINING FOR RETAIN (C7=1)
C10.
Please think back to all of the formal training you attended related to RETAIN in the past year.
On a scale of 1 to 5, where 1 is “no change at all” and 5 is “the most change possible,” how much
has the training you have received for RETAIN changed the way you interact with all of your
patients with a recent injury or illness that may inhibit or prevent their continued employment?
[NEW]
No change at all
1
2
3
4
5
The most change possible
NO RESPONSE .......................................................................................................... M
CATI VERSION
C10.
Please think back to all of the formal training you attended related to RETAIN in the past year.
On a scale of 1 to 5, where 1 is “no change at all” and 5 is “the most change possible,” how much
has the training you have received for RETAIN changed the way you interact with all of your
patients with a recent injury or illness that may inhibit or prevent their continued employment?
CODE ONE ONLY
1 - NO CHANGE AT ALL ...................................................................................... 1
2 ............................................................................................................................ 2
3 ............................................................................................................................ 3
4 ............................................................................................................................ 4
5 - THE MOST CHANGE POSSIBLE................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
24
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
C11.
To what extent are each of the following currently a barrier to RETAIN achieving its goals?
PROGRAMMER: FORMAT FOR WEB USING BANKED FORMAT SHOWN BEOW TO OPTIMIZE FOR MOBILE DEVICES.
a. Insufficient provider time for amount of work
Major barrier
1
Minor barrier
2
Not applicable to
my job
Not a barrier
3
4
b. Ineffective communication with [COORDINATOR TITLE]
Major barrier
1
Minor barrier
2
Not applicable to
my job
Not a barrier
3
4
c. Employer attitudes
Major barrier
1
Minor barrier
2
Not applicable to
my job
Not a barrier
3
4
d. Patient attitudes
Major barrier
1
Minor barrier
2
Not applicable to
my job
Not a barrier
3
4
CATI VERSION
C11.
To what extent are each of the following currently a barrier to RETAIN achieving its goals?
I’ll read a list of challenges some programs face. For each, please tell me if you think it is a major
barrier, a minor barrier, or not a barrier to RETAIN achieving its goals.
CODE ONE PER ROW
MAJOR
BARRIER
MINOR
BARRIER
NOT A
BARRIER
NOT
APPLICABLE
TO MY JOB
a. Insufficient provider time for
amount of work
1
2
3
4
b. Ineffective communication with
service coordinator
1
2
3
4
c.
1
2
3
1
2
3
Employer attitudes
d. Patient attitudes
25
DK
REF
D
R
D
R
4
D
R
4
D
R
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
C12.
Not all clinical practices that were asked to collaborate with this program agreed to do so.
Based on your experience, would any of the following issues discourage clinical practices from
participating in RETAIN? [HCIA Clinician Rd. 2, E3, rev]
PROGRAMMER: FORMAT WEB USING BANKED FORMAT BEOW TO OPTIMIZE FOR MOBILE DEVICES.
a. Too many requirements. For example, additional meetings with care team,
program documentation, more work at home
Would discourage participation
1
Would not discourage participation
0
b. Current model of care is working, didn’t want to make a change
Would discourage participation
1
Would not discourage participation
0
c. Not a good financial decision for practice or organization
Would discourage participation
1
Would not discourage participation
0
d. Promoting work is not an appropriate focus for clinical practices
Would discourage participation
1
Would not discourage participation
0
e. Other barrier not listed above (SPECIFY): ___________ (150 CHAR)
Would discourage participation
99
Would not discourage participation
0
26
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
CATI VERSION
C12.
Not all clinical practices that were asked to collaborate with this program agreed to do so.
I’m going to read a list of issues. Based on your experience, please tell me whether each would
discourage clinical practices from participating in RETAIN or not.
IF NEEDED: Would this discourage clinical practices from participating in RETAIN?
CODE ONE PER ROW
WOULD
DISCOURAGE
PARTICIPATION
WOULD NOT
DISCOURAGE
PARTICIPATION
DK
REF
a. Too many requirements. For example,
additional meetings with care team,
program documentation, more work at
home
1
0
D
R
b. Current model of care is working,
didn’t want to make a change
1
0
D
R
c. Not a good financial decision for
practice or organization
1
0
D
R
d. Promoting work is not an appropriate
focus for clinical practices
1
0
D
R
e. Other barrier not listed above
(SPECIFY)
99
0
D
R
____________ (STRING 150)
PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
C13.
Based on your experience with RETAIN, should this program model be set up in other clinical
settings or workplaces like yours? [HCIA Clinician Rd. 2, E7]
Yes ........................................................................................................................ 1
No .......................................................................................................................... 0
NO RESPONSE .................................................................................................... M
CATI VERSION
C13.
Based on your experience with RETAIN, should this program model be set up in other clinical
settings or workplaces like yours?
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
27
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION C. PROVIDER EXPERIENCE IN RETAIN
STATE = 1 AND PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
INSERT FILL CONDITION OR DELETE ROW
Insert question here
PLACEHOLDER FOR STATE-1 - Specific Items (2)
STATE = 2 AND PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
INSERT FILL CONDITION OR DELETE ROW
Insert question here
PLACEHOLDER FOR STATE-2 - Specific Items (2)
STATE = 3 AND PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
INSERT FILL CONDITION OR DELETE ROW
Insert question here
PLACEHOLDER FOR STATE-3 - Specific Items (2)
STATE = 4 AND PROVIDER KNOWS PRACTICE IS PART OF RETAIN (C1=1)
INSERT FILL CONDITION OR DELETE ROW
Insert question here
PLACEHOLDER FOR STATE-4 - Specific Items (2)
28
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION D – PROVIDER CONTACT INFORMATION
SECTION D.
PROVIDER CONTACT INFORMATION
ALL CONSENTING (A2=1)
[PRACTICE NAME] [PROVIDERAddress1] [PROVIDERAddress2] [PROVIDERCity], [PROVIDERState]
[PROVIDERPostCode] [
D1.
Thanks for answering these questions. Can you please confirm your mailing address? This is
where we will send your $45 for completing this survey. [Million Hearts, Provider R1-Q21, rev]
Our records show:
[PRACTICE NAME]
[PROVIDERAddress1] [PROVIDERAddress2]
[PROVIDERCity], [PROVIDERState] [PROVIDERPostCode]
Is this correct? If not, please select “no” to update this information.
CONFIRMED AS ALL CORRECT ................................................................. 1 GO TO D3
UPDATES ARE NEEDED .............................................................................. 0 GO TO D2
NO RESPONSE ................................................................................................... M GO TO D3
SOFT CHECK: IF D1=NO RESPONSE;
This information helps us reach out if we have any questions about the information provided. It is also
where we will mail your $45 check.
PROGRAMMER: If values for fills are missing, then populate fill with “Not on file”.
CATI VERSION
D1.
Thanks for answering these questions. Can you please confirm your mailing address?
This is where we will send your $45 for completing this survey.
Our records show:
[PRACTICE NAME], [PROVIDERAddress1] [PROVIDERAddress2]
[PROVIDER City], [PROVIDERState] [PROVIDERPostCode]
Is this correct?
YES ....................................................................................................................... 1
GO TO D3
NO – UPDATES ARE NEEDED ........................................................................... 0
GO TO D2
DON’T KNOW ....................................................................................................... d
GO TO D3
REFUSED ............................................................................................................. r
GO TO D3
SOFT CHECK: IF D1=D OR R;
This information helps us reach out if we have any questions about the information provided. It is also
where we will mail your $45 check.
29
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION D – PROVIDER CONTACT INFORMATION
MAILING ADDRESS NEEDS UPDATE (D1=0)
D2.
What is your mailing address? [Million Hearts, Provider R1-Q22, rev]
Street address / PO Box:
(STRING 150)
City:
STRING 100)
State:
USE DROP DOWN MENU
Zip code:
(STRING 5)
NO RESPONSE ...................................................................................... M
SOFT CHECK: IF D2=NO RESPONSE ALL CELLS;
This information helps us reach out if we have any questions about the information provided. It is also
where we will mail your $45 check.
CATI VERSION:
D2.
What is your mailing address?
___________________________________________________
STREET 1 OR P.O. BOX NUMBER
___________________________________________________
STREET 2
___________________________________________________
CITY
___________________________________________________ USE DROP DOWN MENU
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF D2= D OR R:
This information helps us reach out if we have any questions about the information provided. It is also
where we will mail your $45 check.
30
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION D – PROVIDER CONTACT INFORMATION
ALL CONSENTING (A2=1)
[PROVIDER TELEPHONE NUMBER]
D3.
What is the best telephone number to reach you at? Our records show it as:
[PROVIDER TELEPHONE NUMBER]
Is this correct? If not, please select “no” to update this information. [NEW]
This is correct ....................................................................................................... 1 GO TO D5
Not correct – need to update ................................................................................ 0 GO TO D4
NO RESPONSE .......................................................................................................... M
GO TO D5
CATI VERSION:
D3.
What is the best telephone number to reach you at? Our records show it as:
[PROVIDER TELEPHONE NUMBER]
Is this correct?
This is correct .............................................................................................................. 1 GO TO D5
Not correct – need to update ....................................................................................... 0 GO TO D4
DON’T KNOW .............................................................................................................. d GO TO D5
REFUSED .................................................................................................................... r
BEST PHONE NEEDS UPDATE (D3=0)
D4.
What is the best telephone number to reach you at? [NEW]
TELEPHONE
NO RESPONSE .................................................................................................... M
CATI VERSION:
D4. What is the best telephone number to reach you at?
|
|
|
|-|
|
|
|-|
|
|
|
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
31
GO TO D5
RETAIN PROVIDER QUESTIONNAIRE R2: SECTION D – PROVIDER CONTACT INFORMATION
ALL CONSENTING (A2=1)
D5.
Thank you for completing the survey! Your efforts help make the evaluation of RETAIN a success. If
you have any questions, please call xxx-xxx-xxxx. [Million Hearts, Provider R1-Closing, rev]
CATI VERSION
D5.
That is the end of the survey - thanks for completing it! Your efforts help make the evaluation of
RETAIN a success. If you have any questions, please call xxx-xxx-xxxx.
CLOSE INTERVIEW ............................................................................................ 1
32
OMB Control No.: XXXX-XXXX
Expiration date: XX/XX/XXXX
Retaining Employment and Talent
After Injury/Illness Network (RETAIN)
Provider Survey
Your input matters!
This survey should be
completed by:
Please return this survey by:
[Name, Practice, MPRID]
[DATE]
Public reporting burden for this collection of information is estimated to average 17 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: xxxxx. Do
not return the completed form to this address.
ABOUT THIS SURVEY
This survey is part of a national evaluation of the Retaining Employment and Talent After
Injury/Illness Network (RETAIN) program. The study is sponsored by the Social Security
Administration (SSA).
As a provider at a practice organization that is participating in RETAIN, we are asking you
to complete this survey. This study seeks to learn about your experiences providing
patient care and your experience with RETAIN (if any).
You’ll receive $45 for completing this voluntary survey. It takes about 14 minutes to
complete. Your answers will be kept confidential and grouped together with everyone
else who responds.
INSTRUCTIONS
Please record your answers as clearly as possible. Mark each applicable response box
with a check () or a “X.”
Proceed to the next item in the survey unless instructed to route elsewhere.
RETURNING THIS FORM
Thank you for completing this survey!
Please return it to:
RETAIN Survey Team
Mathematica
P.O. Box 2393
Princeton, NJ 08540
If you have any questions about the survey, call 1-XXX-XXX-XXXX or email the survey
team at XXXX@mathematica-mpr.com.
PROVISION OF HEALTH CARE SERVICES
BEGIN HERE
Q1.
Are you currently providing patient care at the practice organization listed on the
cover?
□ Yes
□ No
Q2.
RETURN THIS QUESTIONNNAIRE IN THE ENVELOPE PROVIDED.
What is your primary role at the practice organization listed on the cover?
If you have more than one role, please select the role that takes up most of your time.
MARK ONE ONLY
□ Primary Care Physician
□ Occupational Medicine Physician
□ Physical Medicine and
Rehabilitation Specialist
□ Orthopedic Surgeon
□ Neurosurgeon
□ Physical Therapist
Q3.
□ Chiropractor
□ Registered Nurse
□ Nurse Practitioner
□ Physician Assistant
□ Mental Health Professional
□ Other role, not listed above
___________________________
How many years have you been in practice?
MARK ONE ONLY
□ 0-5 years
□ 6-10 years
□ 11-15 years
□ 16-25 years
□ More than 25 years
1
Q4. In a typical week, approximately what percent of your patient visits are covered by
Workers’ Compensation?
MARK ONE ONLY
□ Less than 15%
□ 15–25%
□ 26-50%
□ More than 50%
□ I don’t work with workers’ compensation patients
□ I don’t know
Q5. When you are treating a patient with a recent injury or illness that may inhibit or
prevent continued employment, how often do you …
MARK ONE PER ROW
All the
time
Most of
the time
Some
of the
time
Rarely
Never
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
d. Develop an activity plan which
communicates the worker’s ability to
participate in work activities, activity
restrictions, and the provider’s
treatment plans, when appropriate?
□
□
□
□
□
e. Provide information to employers about
injured workers, when appropriate?
□
□
□
□
□
f.
□
□
□
□
□
a. Try to help your patients return to work,
when appropriate?
b. Assess barriers to return to work, when
appropriate?
c. Develop a plan to overcome barriers to
work, when appropriate?
Discuss possible work accommodations
for injured workers with employers,
when appropriate?
2
Q6.
When treating patients with a recent injury or illness that may inhibit or prevent
continued employment, do you make referrals to any outside public or private
programs, when appropriate? Do not include referral for medical services or supports.
MARK ONE ONLY
□ Yes
□ No
Q7.
GO TO Q8
What kinds of outside public or private programs do you typically refer these patients
to?
________________________________________________________________________
________________________________________________________________________
Q8.
When you are treating a patient with a recent injury or illness that may inhibit or
prevent continued employment, how do you typically communicate with their
employers, if at all?
MARK ALL THAT APPLY
□ Email
□ Letter
□ Complete a return-to-work form
□ Telephone
□ Other way(s)
□ I do not communicate with injured workers’ employers
3
Q9.
Are there any issues that limit your ability to provide optimal care for patients with a
recent injury or illness that may inhibit or prevent their continued employment?
MARK ONE ONLY
□ Yes
□ No
GO TO Q11
Q10. What issues limit your ability to provide optimal care for patients with a recent injury
or illness that may inhibit or prevent their continued employment?
________________________________________________________________________
________________________________________________________________________
PROVIDER EXPERIENCE IN RETAIN
Q11. RETAIN stands for Retaining Employment and Talent After Injury/Illness Network.
Are you aware that your practice organization is participating in RETAIN?
□ Yes
□ No
GO TO Q24 ON PAGE 9
Q12. In a typical week, approximately what percent of your patients are RETAIN enrollees?
MARK ONE ONLY
□ Less than 25%
□ 25–49%
□ 50–74%
□ 75–100%
□ I don’t always know when I’m working with RETAIN enrollees
□ I don’t work with RETAIN enrollees
4
Q13. As a part of the RETAIN program, a [COORDINATOR TITLE] is someone who
coordinates medical services, works with employers/supervisors to develop
alternative job duties or help people find temporary employment. They may also
provide coaching and individualized supports, like job retraining, problem solving
skills trainings, or peer supports.
Do you work with a [COORDINATOR TITLE] as part of the RETAIN program?
MARK ONE ONLY
□ Yes
□ No
GO TO Q16
Q14. In general, does working with a RETAIN [COORDINATOR TITLE] make your overall job
easier or more difficult to do, or has it had no effect?
MARK ONE ONLY
□ Easier
□ More difficult
□ No effect
Q15. Why does working with a [COORDINATOR TITLE] make your overall job easier or more
difficult to do, or why has it had no effect on your job?
________________________________________________________________________
________________________________________________________________________
Q16. Do the overall administrative requirements for RETAIN take up too much of your time or are
they reasonable? These requirements could include hardcopy and electronic
documentation, working with RETAIN [COORDINATOR TITLE], and/or attending
meetings.
MARK ONE ONLY
□ Take up too much time
□ Are reasonable
□ I do not have administrative requirements for RETAIN
5
Q17. Formal training is defined as workshops, webinars, conferences, seminars, grand
rounds, and presentations provided via phone, web, or in-person. In the past year,
have you attended any formal training for RETAIN?
□ Yes
□ No
GO TO Q22
Q18. In the past year, did the formal training you attended for RETAIN include any of the
following topics?
MARK ALL THAT APPLY
□ Occupational health best practices
□ Assessing barriers for returning to work
□ Alternatives to opioids for pain management
□ Other training topic(s) – Specify: __________________________________________
Q19. Please think back to all of the formal training you attended related to RETAIN in the past
year. How much do you agree or disagree with the following statement?
“The training helped me return injured or ill workers to productive work as soon as
medically possible.”
MARK ONE ONLY
□ Strongly disagree
□ Somewhat disagree
□ Neither agree nor disagree
□ Somewhat agree
□ Strongly agree
6
Q20. Please think back to all of the formal training you attended related to RETAIN in the
past year.
On a scale of 1 to 5, where 1 is “no change at all” and 5 is “the most change possible,”
how much has the training you have received for RETAIN changed the way you
interact with all of your patients with a recent injury or illness that may inhibit or
prevent their continued employment?
MARK ONE ONLY
□ 1 – No change at all
□2
□3
□4
□ 5 – The most change possible
Q21. To what extent are each of the following currently a barrier to RETAIN achieving its
goals?
MARK ONE PER ROW
a. Insufficient provider time for amount of work
b. Ineffective communication with
[COORDINATOR TITLE]
c. Employer attitudes
d. Patient attitudes
7
Major
barrier
Minor
barrier
Not a
barrier
Not
applicable
to my job
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Q22. Not all clinical practices that were asked to collaborate with this program agreed to do
so. Based on your experience, would any of the following issues discourage clinical
practices from participating in RETAIN?
MARK ONE PER ROW
Would discourage
participation
Would not
discourage
participation
a. Too many requirements. For example,
additional meetings with care team, program
documentation, more work at home
□
□
b. Current model of care is working, didn’t want to
make a change
□
□
□
□
□
□
□
□
c. Not a good financial decision for practice or
organization
d. Promoting work is not an appropriate focus for
clinical practices
e. Other barrier not listed above (specify):
_____________________________________
Q23. Based on your experience with RETAIN, should this program model be set up in other
clinical settings or workplaces like yours?
□ Yes
□ No
PLACEHOLDER FOR STATE-SPECIFIC ITEMS (2)
8
This page has been left blank for double-sided copying.
CONTACT INFORMATION
Q24. What is your mailing address?
This information helps us keep in touch with you so we can reach out if we have any
questions about the information you provide. This is also where will mail your $45
check.
________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
Q25. What is the best telephone number to reach you at?
|
|
|
|-|
AREA CODE
|
|
|-|
|
|
|
|
PHONE NUMBER
Thank you for completing the RETAIN provider survey! Your efforts help make the
evaluation of RETAIN a success. Please return this survey in the envelope provided.
9
| File Type | application/pdf |
| File Modified | 2020-12-14 |
| File Created | 2020-02-28 |