Form CMS-10728 Participant Survey

Participant Survey

(CMS-10728, OMB 0938-New)

Survey Introduction

The Value in Opioid Use Disorder Treatment demonstration (Value in Treatment) participant survey provides CMS/CMMI with valuable insights on participant’s implementation experience within the past [six months or performance year]. Specifically, it informs CMS of the interventions implemented, strategies used to implement them, and successes and challenges encountered during implementation. This survey takes approximately 20 minutes to complete.

Your participation in this survey is required as part of your Value in Treatment participation agreement. Please complete this survey within 15 days of receipt.

The survey may be completed in one session. Please save your responses offline in the event that your online responses were not saved as intended. All questions with an asterisk are required and must be answered in order to proceed to the next page.

To protect the privacy of your patients, please do not disclose any of their personal identification or health information when completing this survey. In the event that patients’ identifiable information is inadvertently included on the survey, CMS/CMMI will remove that information from the survey and any subsequent reports. Additionally, any comments made by the individual completing this survey will not be attributed to them, nor will their responses be linked to them in CMS/CMMI’s reports.

If you experience technical difficulties while using this survey platform, please email ValueinTreatment@cms.hhs.gov for assistance.

Survey Questions

Section 1: Participant Information

1. Enter your contact information (individual filling out the survey):

Name: _____________________________________

Email Address: _____________________________________

Phone Number: _____________________________________

Title/Position: _____________________________________

2. Enter the single Tax-payer Identification Number (TIN) and single National Provider Identification (TIN) used by the participant for Value in Treatment billing purposes:

Demo ID: _____________________________________

TIN: _____________________________________

NPI: _____________________________________

3. In the past [six months or performance year], did the participant undergo any business changes (e.g., organization improvements, restructuring, operational change, business name change, etc.)?

• Yes

If yes, did it result in any Value in Treatment service disruptions? Please explain.

____________________________________________________________________

• No

If no, does the applicant have any business changes planned within the next [6 months or performance year]?

• Yes

• No

Section 2: Opioid Use Disorder Care Team

4. In the past [six months or performance year], did any of the following changes occur to the participant’s opioid use disorder care team? Select all that apply.

• Removed and replaced existing care team member(s)

• Removed existing care team member(s); no replacement needed

• Added new care team member(s)

• No changes

5. How would you rate your OUD care team’s level of engagement in Value in Treatment (i.e., interest and participation in providing services to beneficiaries)? Please indicate your rating on a scale of 1 to 5 (1=low, 5=high)

(Low)				(High)
1	2	3	4	5

For ratings 3 or lower, please explain.

____________________________________________________________________

6. How would you rate your OUD care team’s effectiveness with communicating and coordinating Value in Treatment care? Please indicate your rating on a scale of 1 to 5 (1=low, 5=high)

(Low)				(High)
1	2	3	4	5

For ratings 3 or lower, please explain.

____________________________________________________________________

7. What were some of your lessons learned from efforts to engage your OUD care team in Value in Treatment (e.g., what did or didn’t?) If none, enter "N/A."

____________________________________________________________________

Section 3: Beneficiary Screening and Engagement

8. Was it challenging to obtain Beneficiary Agreement Form signatures to obtain their agreement to participate in Value in Treatment and share their health data?

• Yes

• No

If yes, please describe.

____________________________________________________________________

9. What strategies did you use to obtain beneficiary agreement to participate in Value in Treatment and share their health data?

______________________________________________________________________

10. Did beneficiaries eligible for Value in Treatment find the Beneficiary Notification package readable and easy to understand?

• Yes

• No

If no, what improvements do you recommend?

____________________________________________________________________

11. Increased access to Value in Treatment for applicable beneficiaries may occur by establishing voluntary community partnerships that can increase awareness of the services offered by the participant. What types of voluntary partnerships did you have in the last [six months or performance year]? Select all that apply.

• Engagement with EDs and/or inpatient facilities

Briefly describe: _______________________________

• Engagement with physical, behavioral, or substance use providers

Briefly describe: _______________________________

• Engagement with community-based partners

Briefly describe: _______________________________

• Other partnerships

Briefly describe: _______________________________

• None of the above

12. What strategies did you use to identify eligible beneficiaries for participation in Value in Treatment in the last [six months or performance year]? Select all that apply.

• Educated external partners on Value in Treatment services, including how to coordinate care for Medicare patients referred from external partners for OUD services

• Conducted data analysis to identify participant’s current Medicare OUD patients

• Identified eligible Medicare patients with an existing OUD diagnosis or same-day diagnosis during a face-to-face visit

• Other

If other, briefly describe:

____________________________________________________________________

13. Did you screen eligible Medicare beneficiaries with an OUD diagnosis for social needs?

• Yes

• No

14. If yes to Question 13, please select the types of social needs identified in your screening. Select all that apply.

• Housing (permanent or temporary housing, rent subsidies, utility subsidies, etc.)

• Home Modification (remediation for pest, mold, or other issues, modifications for accessibility and safety, etc.)

• Nutrition (medically tailored meals, non-tailored meals, groceries, etc.)

• Transportation (non-emergency transportation for medical and non-medical services)

• Social Support (community engagement groups, substance use support groups, peer support, etc.)

• Safety (physical or psychological violence, toxic stress, etc.)

• Navigation support (legal, employment, child-care, other resource needs)

• Other

• None of the above

15. How would you rate your success in engaging and retaining your eligible Medicare OUD patients in Value in Treatment services? Please indicate your rating on a scale of 1 to 5 (1=Very Unsuccessful, 5=Very Successful)

(Low)				(High)
1	2	3	4	5

For ratings 3 or lower, please discuss challenges encountered.

16. How would you rate your success in engaging family & caregivers in the care of your eligible Medicare OUD patients in Value in Treatment services? Please indicate your rating on a scale of 1 to 5 (1=low, 5=high)

(Low)				(High)
1	2	3	4	5

For ratings 3 or lower, please discuss challenges encountered.

____________________________________________________________________

17. What were some of your lessons learned from efforts to engage Medicare OUD patients and/or their family and caregiver in Value in Treatment (e.g., what worked and what didn’t work)?

______________________________________________________________________

Section 4: Value in Treatment Services

18. In the past [six months or performance year], did you make any changes to the Value in Treatment services furnished to participating beneficiaries within the same period or compared to the previous [six months or performance year], which may include adding new services, modifying existing services, or no longer offering services previously offered?

• Yes

• No

If yes, please list and describe all changes made:

____________________________________________________________________

19. Did you offer any of the following types of visits (Including access during after-hours) to Value in Treatment beneficiaries? Select all that apply.

• Office visits

• Home visits

• Other non-office visits (e.g., telecommunication visits/consults)

• None of the above

For office, home, or other non-office visits, please describe how you determined where and how visits would be provided:

____________________________________________________________________

If none of the above, please explain:

____________________________________________________________________

20. On average, how many office and non-office based visits per beneficiary participating in Value in Treatment did you provide on a quarterly basis (calendar quarters of the performance year)?

• 0

• 1

• 2

• 3

• 4 or more

21. Did you offer after-hours access to OUD treatment services?

• Yes

• No

22. If yes to Question 21, how often did your Value in Treatment beneficiaries seek after-hours care?

• Often

• Sometimes

• Rarely

• Never

23. What was your Value in Treatment follow-up protocol for beneficiaries seen in the ED or hospital? Please select the statement that applies:

• Follow-up generally did not occur

• Follow-up occurred when participant was alerted by the ED or hospital

• Follow-up occurred due to participant’s proactive efforts to identify their OUD patients who’ve been admitted to the ED or hospital

• Follow-up occurred routinely because participant have arrangements in place with the ED and hospital tracking OUD patients to ensure timely follow-up is done.

24. Your Value in Treatment services can best be described as follows. Select all that apply.

• Overdose prevention toolkit/resources (e.g., supply of Naloxone and training on its use)

• Beneficiary treatment incentives (e.g., contingency management)

• Screening and referrals for social support services

• Payment for some social support services

• Counseling, support groups, peer recovery support

• Telecommunication or other mobile outreach

• Home visits

• Staff time spent providing care

• Staff time spent coordinating care and/or following-up with beneficiaries

• Staff training and/or travel expenses (e.g., mileage)

• Other

If other, please specify:

____________________________________________________________________

25. Please rate the participant’s success in initiating and retaining Value in Treatment beneficiaries in Medication Assisted Treatment (MAT). Please indicate rating on a scale of 1 to 5 (1=Very Unsuccessful, 5=Very Successful)

	(Low)				(High)
MAT treatment initiation	1	2	3	4	5
MAT treatment retention	1	2	3	4	5

For ratings 3 or lower, please discuss challenges encountered.

____________________________________________________________________

26. Did the participant encounter cases when Value in Treatment beneficiaries postponed or delayed Medication Assisted Treatment (MAT) or other OUD treatment?

• Yes

• No

If yes, please share any insights that may explain why.

____________________________________________________________________

27. Please rate how strongly the participant agrees or disagrees with each of the following statements.

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Value in Treatment is reducing OUD treatment stigma among providers
Value in Treatment allowed me to expand OUD services to more care settings
Value in Treatment allowed me to increase staff and build capacity for the care of OUD patients

28. Overall, what lessons has the participant learned from efforts to expand and increase access to Value in Treatment services (e.g., what did and didn’t work?)

______________________________________________________________________

Section 5: Overall Participant Implementation Experience

29. Did the participant have any issues with billing the Value in Treatment G-code?

• Yes

• No

If yes, please describe:

____________________________________________________________________

30. Value in Treatment pays a flat Care Management Fee (CMF) of $125 per month per beneficiary minus payment adjustments specified in the Participant Agreement (PA). Did this amount sufficiently cover your Value in Treatment services?

• Yes

• No

If no, please explain:

____________________________________________________________________

31. Did the Value in Treatment performance-based incentive (5% or 10% of Care Management Fee quality withhold) incent the participant’s OUD care team to improve quality of care?

• Yes

• No

If no, please explain:

____________________________________________________________________

32. Please rate how strongly the participant agrees or disagrees with each of the following statements.

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Value in Treatment has been a positive experience
Value in Treatment was easy to implement
Value in Treatment was not administratively burdensome
Value in Treatment empowered me to change my implementation plan throughout the performance period to better meet the changing needs of OUD beneficiaries

33. Did the participant receive sufficient guidance and support from CMS and/or its contractors to effectively implement Value in Treatment?

• Yes

• No

If no, please explain and provide recommendation on what could be improved:

____________________________________________________________________

34. Overall, what lessons did the participant learn from implementing Value in Treatment (e.g., what did or didn’t work?)

______________________________________________________________________

Thank you for your time and sharing your Value in Treatment experiences.

Your comments are very helpful and insightful.