Form 1 HP Survey
Evaluation of the Maternal and Child Health Bureau Pediatric Mental Health Care Access Program and the Screening and Treatment for Maternal Depression and Related Behavioral Disorders Program
Attachment B1 - HP Survey1 - Copy
HP Survey 2021
OMB: 0906-0074
Attachment B1:
Pediatric Mental Health Care Access Program Health Professional Survey
Health Resources and Services and Administration Evaluation of the Maternal and Child Health Bureau Pediatric Mental Health Care Access and Screening and Treatment for Maternal Depression and Related Behavioral Disorders Programs Project
June 2022
Public Burden Statement: This data collection will provide the Health Resources and Services Administration with information to guide future program and policy decisions regarding increasing health professionals’ (e.g., pediatricians, family physicians, physician assistants, advanced practice nurse/nurse practitioners, licensed practical nurses, registered nurses, counselors, social workers, medical assistants, patient care navigators) capacity to address patients’ behavioral health and access to behavioral health services. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-XXXX and it is valid until XX/XX/202X. This information collection is voluntary. The current project will fully comply with the Privacy Act of 1974 (5 U.S.C. Section 552a, 1998; https://www.justice.gov/opcl/privacy-act-1974). The Privacy Act may apply to some data collection activities (e.g., the study will collect email addresses from some respondents). Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.
Note for OMB Submission and Survey Implementation: We will tailor the text when referring to awardees’ programs (e.g., state, political subdivision of a state, Indian tribe, or tribal organization). Additionally, questions discussing "the last 12 months" will be adjusted to “the last 24 months” based on the year of administration.
HRSA funded [insert name of state] to implement a Pediatric Mental Health Care Access (PMHCA) program, [insert program name]. HRSA also funded JBS International, Inc. (JBS) to conduct an evaluation of the MCHB PMHCA program (hereafter referred to as the HRSA MCHB evaluation). JBS is an independent evaluator of the program and is not part of HRSA or any other federal agency.
Survey Purpose: As part of the HRSA MCHB evaluation, we are conducting a survey of pediatric health professionals (e.g., pediatricians, family physicians, physician assistants, advanced practice nurse/nurse practitioners, licensed practical nurses, registered nurses, counselors, social workers, medical assistants, patient care navigators) who are enrolled/participating in [insert name of state]’s HRSA PMHCA program. The survey is designed to collect information on your experiences with the PMHCA program (e.g., assessing and treating behavioral health conditions, accessing behavioral health care services for your patients, capacity to address behavioral health conditions) and to assist HRSA in future program implementation.
Survey Instructions: This online survey should take less than fifteen (15) minutes for you to complete. Please answer based on your current practice and understanding (you are not required to review data to answer the questions), unless otherwise indicated. There are no right or wrong answers to the survey questions. Please note that your responses will remain private and are voluntary. Survey results will be reported to HRSA in the aggregate, and no identifying information will appear in the evaluation reports without your prior approval. No identifiable data will be provided to HRSA.
About Your State’s Program: Each state’s PMHCA program includes creating a Pediatric Mental Health Care Team; tracking enrollment/participation of pediatric health professionals, such as yourself, into the program; and providing training on how to consult with the Pediatric Mental Health Care Team in your state and/or to provide behavioral health care in your practice. The questions that follow ask about your experiences obtaining training, clinical behavioral health consultation, referral, and community linkage information from your state’s PMHCA program and about your current practices for addressing behavioral health conditions in your pediatric patients.
Please create a Unique Identifier for your survey to maintain the privacy of your responses and to allow us to match your future survey responses.
How to create your Unique Identifier: Use the first two letters of your first name, the first two letters of your last name, and the month of your birthday. For example, for John Smith, born in May, the Unique Identifier would be JOSM05.
Email address used for receiving communication from [insert program name]:
_____________________________________________
Note: Email addresses will only be used to confirm enrollment in the program and to track survey administration and completion.
Helpful Terminology: For the purposes of this survey, a health professional includes pediatricians, family physicians, physician assistants, advanced practice nurses/nurse practitioners, licensed practical nurses, registered nurses, counselors, social workers, medical assistants, patient care navigators, etc.
Behavioral Health Capacity
In the last 12 months, how often have you treated the following behavioral health conditions? (If Other, go to question 2.)
|
Never |
Rarely |
Sometimes |
Often |
Always |
Depressive Disorder (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
Anxiety Disorder (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
Attention-Deficit/Hyperactivity Disorder (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
Substance Use Disorder (SUD) (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
Concomitant Medical and Behavioral Health Conditions (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
Other |
o |
o |
o |
o |
o |
You selected an answer for Other in the question above. Please specify.
[OPEN-ENDED RESPONSE]
In the last 12 months, how did you receive training from the PMHCA program? Select all that apply. (Approved - OMB Control No. 0906-0052)
In-person training event (If selected, go to question 4.)
Webinar (If selected, go to question 4.)
Self-study with program resources (If selected, go to question 4.)
Video conferencing (If selected, go to question 4.)
Learning collaborative (e.g., Project ECHO, Project REACH) (If selected, go to question 4.)
Other (specify) (If selected, go to question 4.)
Did not participate in trainings (If selected, go to question 5.)
In the last 12 months, in how many PMHCA program trainings did you participate? (Approved - OMB Control No. 0906-0052)
1-2 trainings
3-5 trainings
6-7 trainings
8+ trainings
In the last 12 months, my state’s PMHCA program provided training on the impact of discrimination, stereotyping, and stigma on the behavioral health of pediatric patients and their families.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
In the last 12 months, have you contacted the Pediatric Mental Health Care Team for clinical behavioral health consultation?
In the last 12 months, how frequently did you contact the Pediatric Mental Health Care Team?
Less than once a month
1-2 times a month
3-4 times a month
More than 5 times a month
In the last 12 months, what were the most common reasons you contacted the Pediatric Mental Health Care Team? Select up to three. (Approved - OMB Control No. 0906-0052)
Interpret screening results
Determine appropriate assessment steps
Assist with diagnosis
Immediately manage patient safety
Help with referrals
Initiate pharmacotherapy
Discontinue pharmacotherapy
Determine pharmacotherapy effectiveness
Adjust pharmacotherapy to improve effectiveness
Adjust treatment due to change in status
Other (specify)
What patient issue(s) prompted you to contact the Pediatric Mental Health Care Team? Select all that apply. (Approved - OMB Control No. 0906-0052)
Comorbid medical conditions
Behavioral health conditions
Developmental delay
School performance
Behavioral concerns
Child in foster care
Adverse childhood events
Parent/Caregiver mental health/SUD
Social determinants of health (SDOH)/family environment
Other (specify)
In the last 12 months, how frequently did you interact with the Pediatric Mental Health Care Team using the following methods? (If Other, go to question 11.)
Method of Interaction |
Never |
Rarely |
Sometimes |
Often |
Always |
Email (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
Screensharing (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
Telephone (terrestrial and/or wireless communications) (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
Text messaging (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
Video conferencing (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
Face to face (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
Other (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
You selected an answer for Other in the question above. Please specify.
[OPEN-ENDED RESPONSE]
Email (Approved - OMB Control No. 0906-0052)
Screensharing (Approved - OMB Control No. 0906-0052)
Telephone (terrestrial and/or wireless communications) (Approved - OMB Control No. 0906-0052)
Text messaging (Approved - OMB Control No. 0906-0052)
Video conferencing (Approved - OMB Control No. 0906-0052)
Face to face (Approved - OMB Control No. 0906-0052)
Other (specify) (Approved - OMB Control No. 0906-0052)
I can readily obtain input from the Pediatric Mental Health Care Team when I have questions about how to assess or treat pediatric patients with behavioral health conditions. (Approved - OMB Control No. 0906-0052)
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
In the last 12 months, my interaction with the Pediatric Mental Health Care Team informed my:
|
Strongly Disagree |
Disagree |
Neither Agree nor Disagree |
Agree |
Strongly Agree |
N/A |
Assessments of pediatric patients (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
o |
Formulations of diagnoses (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
o |
Use of pharmacotherapy (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
o |
Referrals to social services (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
o |
Referrals to counseling services (Approved - OMB Control No. 0906-0052) |
o |
o |
o |
o |
o |
o |
Ability to address health disparities |
o |
o |
o |
o |
o |
o |
Ability to address disparities in access to behavioral health care |
o |
o |
o |
o |
o |
o |
As a result of participating in my state’s PMHCA program, I am better able to utilize telehealth services to support my patients' access to behavioral health care.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
In the last 12 months, as a result of my state’s PMHCA program, more of my pediatric patients received treatment (e.g., counseling, medication) for a behavioral health condition either in my office or from a behavioral health clinician. (Approved - OMB Control No. 0906-0052)
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
Do Not Know
In the last 12 months, as a result of my interaction with the PMHCA program, I increased my referrals to services in the community to support pediatric patients and their caregivers’ use of behavioral health services. (If Other, go to question 18.)
|
Strongly Disagree |
Disagree |
Neither Agree nor Disagree |
Agree |
Strongly Agree |
N/A |
Child care |
o |
o |
o |
o |
o |
o |
Substance use treatment |
|
|
|
|
|
|
Employment/job-seeking training |
o |
o |
o |
o |
o |
o |
Food programs |
o |
o |
o |
o |
o |
o |
Housing support |
o |
o |
o |
o |
o |
o |
Parenting support |
o |
o |
o |
o |
o |
o |
Support groups |
o |
o |
o |
o |
o |
o |
Transportation support |
o |
o |
o |
o |
o |
o |
Education support |
o |
o |
o |
o |
o |
o |
Other |
o |
o |
o |
o |
o |
o |
You selected an answer for Other in the question above. Please specify.
[OPEN-ENDED RESPONSE]
As a result of your interaction with the PMHCA program, how likely are you to refer patients to services in the community to address issues that you cannot or do not feel comfortable addressing yourself?
Currently, what additional assistance do you still need to improve the behavioral health of your pediatric patients? (Approved - OMB Control No. 0906-0052)
[OPEN-ENDED RESPONSE]
Program Usefulness
We would like to hear from you about how your state’s PMHCA program is accomplishing its purpose of promoting behavioral health integration into pediatric primary care by supporting pediatric mental health care telehealth access programs.
Overall, I feel more confident in my ability to screen, assess, and treat behavioral health conditions as a result of participating in my state’s PMHCA program.
-
Screen
Assess
Treat
Strongly Disagree
o
o
o
Disagree
o
o
o
Neither Agree nor Disagree
o
o
o
Agree
o
o
o
Strongly Agree
o
o
o
I acquired valuable knowledge and information related to screening, assessing, and treating behavioral health conditions, as a result of participating in my state’s PMHCA program.
-
Screening
Assessing
Treating
Strongly Disagree
o
o
o
Disagree
o
o
o
Neither Agree nor Disagree
o
o
o
Agree
o
o
o
Strongly Agree
o
o
o
I plan to use the information and knowledge acquired as a result of participating in my state’s PMHCA program to screen, assess, and treat behavioral health in my practice once the program ends.
-
Screen
Assess
Treat
Strongly Disagree
o
o
o
Disagree
o
o
o
Neither Agree nor Disagree
o
o
o
Agree
o
o
o
Strongly Agree
o
o
o
What clinical practices have you adopted as a result of participating in your state’s PMHCA program? (Approved - OMB Control No. 0906-0052)
[OPEN-ENDED RESPONSE]
Overall, how have your pediatric patients benefited from your participation in the PMHCA program? (Approved - OMB Control No. 0906-0052)
[OPEN-ENDED RESPONSE]
Screening, Assessment, and Treatment of Behavioral Health Conditions
What behavioral health screening tool(s) do you administer, interpret, or act upon? Select all that apply.
ASQ: SE-2 (Approved - OMB Control No. 0906-0052)
BSTAD (Approved - OMB Control No. 0906-0052)
CRAFFT (Approved - OMB Control No. 0906-0052)
EPSDT
GAD-7 (Approved - OMB Control No. 0906-0052)
NICHQ Vanderbilt Assessment Scales (Approved - OMB Control No. 0906-0052)
PSC-17 (Approved - OMB Control No. 0906-0052)
PHQ-2 (Approved - OMB Control No. 0906-0052)
PHQ-9/PHQ-9 modified/PHQ-A (Approved - OMB Control No. 0906-0052)
PIRAT (Approved - OMB Control No. 0906-0052)
RAAPS (Approved - OMB Control No. 0906-0052)
S2BI (Approved - OMB Control No. 0906-0052)
SWYC (Approved - OMB Control No. 0906-0052)
Other (specify) (Approved - OMB Control No. 0906-0052)
What behavioral health interventions do you personally provide? Select all that apply.
I am as comfortable assessing and treating pediatric patients with common behavioral health conditions as I am assessing and treating common medical conditions in pediatric patients. (Approved - OMB Control No. 0906-0052)
Health Equity
A goal of the PMHCA program is to focus on achieving health equity related to SDOH and racial, ethnic, and geographic disparities in access to behavioral health care, especially in rural and other underserved areas. The following questions will be used to inform our goal of improving health equity.
In the last 12 months, how often have you engaged in the following activities to support health equity in access to behavioral health care for your patients as a result of participating in your state’s PMHCA program?
|
Never |
Rarely |
Sometimes |
Often |
Always |
Assess SDOH (e.g., food insecurity, housing insecurity) |
o |
o |
o |
o |
o |
Provide referrals to community linkages to address SDOH-related needs |
o |
o |
o |
o |
o |
Make culturally and linguistically appropriate recommendations to promote behavioral health |
o |
o |
o |
o |
o |
As a result of participating in my state’s PMHCA program, I am better able to address health disparities in access to behavioral health care.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
As a result of participating in my state’s PMHCA program, I have incorporated telehealth services in my practice to reduce health disparities in access to behavioral health care.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
What would be helpful from your state’s PMHCA program to address health disparities in access to behavioral health care among your patients?
[OPEN-ENDED RESPONSE]
Demographic Information
What type of health professional are you?
Pediatrician (Approved - OMB Control No. 0906-0052)
Family physician (Approved - OMB Control No. 0906-0052)
Physician assistant (Approved - OMB Control No. 0906-0052)
Advanced practice nurse/nurse practitioner (Approved - OMB Control No. 0906-0052)
Licensed practical nurse
Registered Nurse
Counselor
Social worker
Medical assistant
Patient care navigator
Which best describes your primary clinical practice site? Choose one option.
University-based practice (Approved - OMB Control No. 0906-0052)
Non-academic, hospital-based practice (Approved - OMB Control No. 0906-0052)
Emergency department (Approved - OMB Control No. 0906-0052)
Managed care organization (Approved - OMB Control No. 0906-0052)
Private practice (Approved - OMB Control No. 0906-0052)
Community health center/Federally Qualified Health Center (Approved - OMB Control No. 0906-0052)
School-based health center (Approved - OMB Control No. 0906-0052)
Tribal Health System
Other (specify) (Approved - OMB Control No. 0906-0052)
In what setting(s) does your patient population live? Select all that apply.
Urban
Suburban
Rural
Frontier
Please provide the ZIP Code for the primary location in which you practice. (Approved – OMB Control No. 0906-0052)
[OPEN-ENDED RESPONSE]
Including yourself, how many health professionals (including pediatricians, family physicians, physician assistants, advanced practice nurse/nurse practitioners, licensed practical nurses, registered nurses, counselors, social workers, medical assistants, patient care navigators) work in your practice?
1 (just me) (Approved - OMB Control No. 0906-0052)
2-5 (Approved - OMB Control No. 0906-0052)
6-10 (Approved - OMB Control No. 0906-0052)
11-15
16-20
21-25
26-30
≥ 31
What is your ethnicity? (Approved - OMB Control No. 0906-0052)
Hispanic or Latino
Not Hispanic or Latino
What is your race? Select all that apply. (Approved - OMB Control No. 0906-0052)
Black or African American
White
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Please specify your tribal affiliation(s): _____
Other (specify)
Additional Feedback
How can your state’s PMHCA program be improved to better suit the needs of health professionals and/or patients?
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Amanda Gmyrek |
| File Modified | 0000-00-00 |
| File Created | 2023-08-31 |
© 2024 OMB.report | Privacy Policy