A
Form
Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX
Survey (Pre-Implementation)
Demonstration of Health Literacy Universal Precautions Toolkit
Date:
Instructions:
As part of its participation in the Health Literacy Project, your practice will work to improve patient care by implementing the Health Literacy Universal Precautions Toolkit. To help us see whether using the Toolkit results in changes in clinical and other practices, we ask that the leader of the practice’s Health Literacy Team complete this Health Literacy Team Leader Survey at the beginning and the end of the project.
Brown-Bag Medication Review
For how many medication reviews did your practice bill in the past month (ICD-9 = V58.69)? If you do not know the answer to this question, please check with your billing manager.
(If none, please enter 0.)
Which of the following strategies does your practice use to help facilitate the review of patient medications? (Please mark all that apply.)
During a visit, asking patients to bring medications to a future appointment
Providing patients with a sack in which to carry medications
Reminding patients to bring medications when making appointment reminder calls
Reminding patients to bring medications on an appointment or reminder card
Placing medication reconciliation forms in patient charts
Other (please specify: )
Patient Education Materials
Does your practice have a central location where patient education materials are stored (e.g., written materials, videos, models)?
Yes
No
Don’t Know
Public
reporting burden for this collection of information is estimated to
average 15 minutes per response, the estimated time required to
participate in this survey. 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: AHRQ Reports Clearance Officer Attention:
PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road,
Room # 5036, Rockville, MD 20850.
Does your practice have a staff person who manages all patient education materials (e.g., keeps them organized, keeps materials updated)?
Yes
No
What sorts of patient education materials are available?
Written materials
Videos, DVDs or other audio/visual resources
Models
Other (please specify: )
How often does your practice update its patient education materials?
Monthly
Quarterly
Twice a year
Once a year
Less than once a year
Don’t know
Have all clinicians and other staff members who interact with patients been informed about what patient education materials are available?
Yes
No
Don’t Know
How many clinicians and staff members have received training on how to use patient education materials in conjunction with spoken instruction?
(If none, please enter 0.)
Don’t Know
Has your practice evaluated the reading level of its patient education materials?
Yes
No
Has your practice had patients review and provide feedback on its patient education materials?
Yes
No
Improving Medication Adherence
Does your practice have a system for setting up reminder aids for patients who have trouble understanding how or remembering to take their medications (e.g., pill boxes, pill cards)?
Yes
No
Don’t Know
Health and Literacy Resources
Does your practice refer patients to health-related programs, such as support groups or health education/management classes (e.g., weight management, diabetes education, exercise/fitness, stress management, smoking cessation)?
Yes
No go to question 20
Don’t Know
Does your practice maintain a list of health-related resources in the community (e.g., weight management/exercise programs; stress management; diabetes education; support groups)?
Yes
No go to question 20
Don’t Know go to question 20
How often is that list updated?
Monthly
Quarterly
Twice a year
Once a year
Less than once a year
Don’t know
What types of services are provided by the organizations on the list? (Please mark all that apply.)
Weight management programs
Fitness/exercise programs
Stress management programs
Diabetes education classes
Healthy cooking/eating classes
Smoking cessation programs
Drug/alcohol abuse programs
Support groups
Other (please specify: )
Does your practice have a referral form that is used to refer patients to health-related resources in the community?
Yes
No
In the past month, how many patients have been referred to one of these resources?
(If none, please enter 0.)
Don’t Know
Is there a place in the written or electronic health record where a referral to a health-related resource in the community can be documented?
Yes
No
Is there a place in a patient’s written or electronic health record where the results of such a referral can be documented?
Yes
No
Does your practice refer patients to education and literacy programs, such as adult education classes, general equivalency degree (GED) programs, reading or math classes, or English classes for non-English speakers?
Yes
No You are done with this survey. Thank you for your time!
Don’t Know
Does your practice maintain a list of education and literacy resources available in the community (e.g., adult education programs; general equivalency degree [GED] programs; educational programs related to math, reading, English as a second language)?
Yes
No You are done with this survey. Thank you for your time!
Don’t Know You are done with this survey. Thank you for your time!
How often is that list updated?
Monthly
Quarterly
Twice a year
Once a year
Less than once a year
Don’t know
What types of services are provided by the organizations on the list? (Please mark all that apply.)
General equivalency degree (GED) programs for those who have not completed high school
Educational programs related to math and/or reading
English as a second language classes
Other (please specify: )
Does your practice have a referral form that is used to refer patients to education or literacy resources in the community?
Yes
No
In the past month, how many patients have been referred to one of these resources?
(If none, please enter 0.)
Don’t Know
Is there a place in the written or electronic health record where a referral to an education or literacy resource in the community can be documented?
Yes
No
Is there a place in a patient’s written or electronic health record where the results of such a referral can be documented?
Yes
No
Thank you for taking the time to complete this survey!
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Demonstration of Health Literacy Universal Precautions Toolkit
|
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Health Literacy Universal Precautions Toolkit: Practice Staff |
| Author | Ameers |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |