Form 2 Practice Level 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 B2 - Practice-Level Survey2 - Copy
PMHCA Practice Level Survey
OMB: 0906-0074
Attachment B2:
Pediatric Mental Health Care Access Program Practice-Level 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 Evaluation of the Maternal and Child Health Bureau Pediatric Mental Health Care Access and Screening and Treatment for Maternal Depression and Related Behavioral Disorders Programs Project
Pediatric Mental Health Care Access Program Practice-Level Survey
Funding for data collection supported by the Maternal and Child Health Bureau (MCHB) Health Resources and Services Administration (HRSA) U.S. Department of Health and Human Services |
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 Maternal and Child Health Bureau (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 practices that have health professionals who are enrolled/participating in [insert name of state]’s HRSA PMHCA program. The survey is designed to collect information on your practice’s experiences with the PMHCA program (e.g., assessing and treating behavioral health conditions, accessing behavioral health care services for your practice’s patients, and capacity to address behavioral health conditions) and 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 and practices 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
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 practice’s Unique Identifier: Use your state abbreviation, last three digits of your practice’s ZIP code, and first two letters of your practice name. For example, for the Good Health practice located in Ohio in the ZIP Code 44101, the Unique Identifier would be OH101GO.
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:
Behavioral health encompasses mental health and substance use disorders.
Staff refers to all staff in your practice, not just physicians.
Health professional refers to 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 Services
Does your practice screen for behavioral health conditions among pediatric patients? (Approved – OMB Control No. 0906-0052)
Yes (If yes, go to question 1a.)
No (If no, go to question 4.)
Question 1a: If yes, when does your practice screen for behavioral health conditions? Select all that apply.
Well-Child/Health Maintenance visits
New patients
Provider discretion
Patient complaint
Other (specify)
What behavioral health screening tool(s) are used in your practice? Select all that apply. (Approved – OMB Control No. 0906-0052)
ACE Screening Tool
ASQ: SE-2
BSTAD
CRAFFT
EPSDT
GAD-7
NICHQ Vanderbilt Assessment Scales
PSC-17
PHQ-2
PHQ-9/PHQ-9 modified/PHQ-A
PIRAT
RAAPS
S2BI
SWYC
Other (specify)
Which staff administer behavioral health screening tools in your practice? Select all that apply.
Pediatricians (Approved – OMB Control No. 0906-0052)
Family physicians (Approved – OMB Control No. 0906-0052)
Physician assistants (Approved – OMB Control No. 0906-0052)
Advanced practice nurses/Nurse practitioners (Approved – OMB Control No. 0906-0052)
Licensed practical nurses (Approved – OMB Control No. 0906-0052)
Registered nurses (Approved – OMB Control No. 0906-0052)
Counselors
Social workers
Medical assistants (Approved – OMB Control No. 0906-0052)
Patient care navigators
Not applicable – self-administered by caregiver/youth (Approved – OMB Control No. 0906-0052)
Other (specify) (Approved – OMB Control No. 0906-0052)
In the last 12 months, what changes has your practice made as a result of enrolling/participating in your state’s PMHCA program? Select all that apply.
Screen more patients (Approved – OMB Control No. 0906-0052)
Adopt screening instrument(s) (Approved – OMB Control No. 0906-0052)
Refer more patients to specialty behavioral health treatment (Approved – OMB Control No. 0906-0052)
Provide behavioral health treatment (e.g., counseling, medication) in your practice (Approved – OMB Control No. 0906-0052)
Coordinate care with behavioral health clinicians (Approved – OMB Control No. 0906-0052)
Build professional relationship(s) with community-based service providers (Approved – OMB Control No. 0906-0052)
Refer more patients to community-based service providers (Approved – OMB Control No. 0906-0052)
Provide more information or resources to patients/families
No changes have been made
In the last 12 months, as a result of your state’s PMHCA program, more pediatric patients of your practice are... (Approved – OMB Control No. 0906-0052)
|
Strongly Disagree |
Disagree |
Neither Agree nor Disagree |
Agree |
Strongly Agree |
N/A |
Screened for behavioral health conditions |
o |
o |
o |
o |
o |
o |
Referred for behavioral health conditions |
o |
o |
o |
o |
o |
o |
Treated for behavioral health conditions |
o |
o |
o |
o |
o |
o |
Practice Behavioral Health Capacity
In the last 12 months, approximately what percentage of pediatric patients were seen for a behavioral health concern related to a behavioral health condition? (Approved – OMB Control No. 0906-0052)
[PROGRAM AS PERCENTAGE SLIDER]
In the last 12 months, approximately what percentage of pediatric patients received treatment for a behavioral health condition by one or more health professionals in your practice? (Approved – OMB Control No. 0906-0052)
[PROGRAM AS PERCENTAGE SLIDER]
In the last 12 months, approximately what percentage of pediatric patients were referred for a behavioral health condition by your practice?
[PROGRAM AS PERCENTAGE SLIDER]
To what extent are behavioral health professional services integrated into your practice?
Not at all
Provided at a co-location
Integrated directly into the practice
As a result of participating in my state’s PMHCA program, my practice is better able to meet the needs of pediatric patients with behavioral health conditions. (Approved – OMB Control No. 0906-0052)
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
As a result of participating in my state’s PMHCA program, the continuum of care available for pediatric patients with behavioral health conditions at my practice has improved. (Approved – OMB Control No. 0906-0052)
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
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)
Other (specify) (Approved – OMB Control No. 0906-0052)
How easy was it for your practice to incorporate these telehealth mechanism(s) listed above for consulting with the Pediatric Mental Health Care Team?
Very Difficult
Difficult
Neutral
Easy
Very Easy
Email
o
o
o
o
o
Screensharing
o
o
o
o
o
Telephone (terrestrial and/or wireless communications)
o
o
o
o
o
Text messaging
o
o
o
o
o
Video conferencing
o
o
o
o
o
Other (specify)
o
o
o
o
o
As a result of participating in my state’s PMHCA program, my practice is better able to utilize telehealth services to support patients' access to behavioral health care.
Community Linkages
How does your practice identify community resources (e.g., counseling, substance use treatment, child care, employment, food programs, housing support) to link your patients to? Select all that apply.
The PMHCA program facilitates linkages. (Approved – OMB Control No. 0906-0052)
The practice is approached by service providers in the community. (Approved – OMB Control No. 0906-0052)
Health professionals or staff at the practice build professional relationships with community service providers.
Community coalitions or governmental entities facilitate linkages. (Approved – OMB Control No. 0906-0052)
Other (specify) (Approved – OMB Control No. 0906-0052)
As a result of your state’s PMHCA program, with which of the following types of community resources, programs, or services has your practice established linkages to support the behavioral health of pediatric patients and their caregivers. Select all that apply.
Substance use treatment
Child care (Approved – OMB Control No. 0906-0052)
Employment/job-seeking training (Approved – OMB Control No. 0906-0052)
Food programs (Approved – OMB Control No. 0906-0052)
Housing support (Approved – OMB Control No. 0906-0052)
Parenting support (Approved – OMB Control No. 0906-0052)
Support groups (Approved – OMB Control No. 0906-0052)
Transportation support (Approved – OMB Control No. 0906-0052)
Education support (Approved – OMB Control No. 0906-0052)
Other (specify) (Approved – OMB Control No. 0906-0052)
With what percentage of these community linkage partners did your practice establish memoranda of understanding? (Approved – OMB Control No. 0906-0052)
Practice Operations
What additional costs, if any, have been incurred by the practice because of changes related to behavioral health care for pediatric patients?
How does your practice expect to cover these costs? (Approved – OMB Control No. 0906-0052)
[OPEN-ENDED RESPONSE]
Which one factor did you expect would be most challenging in implementing screening, assessment, and treatment for behavioral health conditions in your practice? Select one.
-
Screening
Assessment
Treatment
Insufficient time
o
o
o
Health professional/staff acceptance
o
o
o
Communication and coordination
o
o
o
Institutional policies
o
o
o
Leadership and support from a clinician champion
o
o
o
Staffing
o
o
o
Reimbursement by payers
o
o
o
Telehealth technology
o
o
o
Workflow
o
o
o
Addressing identified social determinants of health (SDOH)-related needs
o
o
o
Staff knowledge and skills
o
o
o
Impact of public health emergency (e.g., COVID-19)
o
o
o
Other (specify)
o
o
o
Which one factor actually presented the greatest challenge to implementing screening, assessment, and treatment of behavioral health conditions in your practice? Select one.
-
Screening
Assessment
Treatment
Health professional/staff acceptance
o
o
o
Communication and coordination
o
o
o
Institutional policies
o
o
o
Leadership and support from a clinician champion
o
o
o
Staffing
o
o
o
Reimbursement by payers
o
o
o
Telehealth technology
o
o
o
Workflow
o
o
o
Addressing identified SDOH-related needs
o
o
o
Staff knowledge and skills
o
o
o
Impact of public health emergency (e.g., COVID-19)
o
o
o
Other (specify)
o
o
o
Which one factor do you expect will be most challenging in sustaining screening, assessment, and treatment for behavioral health conditions in your practice when HRSA MCHB PMHCA grant-funded support is no longer available? Select one.
-
Screening
Assessment
Treatment
Health professional/staff acceptance
o
o
o
Communication and coordination
o
o
o
Institutional policies
o
o
o
Leadership and support from a clinician champion
o
o
o
Staffing
o
o
o
Reimbursement by payers
o
o
o
Telehealth technology
o
o
o
Workflow
o
o
o
Addressing identified SDOH-related needs
o
o
o
Staff knowledge and skills
o
o
o
Impact of public health emergency (e.g., COVID-19)
o
o
o
Other (specify)
o
o
o
Once cooperative agreement funding ends, what support will your practice need to continue offering the behavioral health services that are currently being provided through your state’s PMHCA program?
[OPEN-ENDED RESPONSE]
How does your practice disseminate information about practice changes related to behavioral health care to pediatric patients and their caregivers? Select all that apply. (Approved – OMB Control No. 0906-0052)
Staff Training
Where does your staff receive behavioral health training? Select all that apply. (Approved – OMB Control No. 0906-0052)
State licensing board
Professional organization
PMHCA program training
Other publicly funded training
Other (specify)
How do staff access training in behavioral health care through your state’s PMHCA program? Select all that apply. (Approved – OMB Control No. 0906-0052)
In-person training event
Webinar
Self-study with program resources
Video conferencing
Learning collaborative (e.g., Project ECHO, Project REACH)
No staff have been trained through the PMHCA program.
Other (specify)
How often do staff participate in trainings through your state’s PMHCA program? (Approved – OMB Control No. 0906-0052)
What other behavioral health care training resources are utilized by your staff? (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, as a result of participation in my state’s PMHCA program, my practice increased provision of resources to pediatric patients and their caregivers to address the following SDOH-related needs:
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
Education |
o |
o |
o |
o |
o |
Food security |
o |
o |
o |
o |
o |
Housing |
o |
o |
o |
o |
o |
Transportation |
o |
o |
o |
o |
o |
Language/Translation services |
o |
o |
o |
o |
o |
In the last 12 months, as a result of participation in my state’s PMHCA program, my practice has incorporated telehealth services to reduce health disparities in access to behavioral health care.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
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.
Please describe steps your practice has taken to improve health equity in access to behavioral health care for pediatric patients and their families, as a result of participation in your state’s PMHCA program.
[OPEN-ENDED RESPONSE]
How does your practice recruit and engage health professionals who are representative of underserved and underrepresented populations in your state?
[OPEN-ENDED RESPONSE]
Practice Demographics
Which best describes your primary clinical practice site?
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)
How would you describe your practice setting? (Select all that apply)
Urban
Suburban
Rural
Frontier
Please provide the ZIP Code in which your practice is located. If your practice has multiple locations, please indicate the ZIP Code for the primary location. (Approved – OMB Control No. 0906-0052)
[OPEN-ENDED RESPONSE]
Is your practice in a federally designated medically underserved area? (Approved – OMB Control No. 0906-0052)
Yes
No
Do not know
Is your practice in a federally designated rural area? (Approved – OMB Control No. 0906-0052)
Yes
No
Do not know
What types of clinical and support staff work in your practice? Select all that apply.
Pediatricians (Approved – OMB Control No. 0906-0052)
Family physicians (Approved – OMB Control No. 0906-0052)
Physician assistants (Approved – OMB Control No. 0906-0052)
Advanced practice nurses/Nurse practitioners (Approved – OMB Control No. 0906-0052)
Licensed practical nurses (Approved – OMB Control No. 0906-0052)
Registered nurses (Approved – OMB Control No. 0906-0052)
Counselors
Social Workers
Medical assistants (Approved – OMB Control No. 0906-0052)
Patient care navigators
Other (specify) (Approved – OMB Control No. 0906-0052)
How many health professionals work in your practice?
What is the ethnicity mix for pediatric patients in your practice? Assign approximate percentage to all that apply. (Approved – OMB Control No. 0906-0052)
Hispanic or Latino ____%
Not Hispanic or Latino ____%
What is the race mix for pediatric patients in your practice? Assign approximate percentage to all that apply. (Approved – OMB Control No. 0906-0052)
Black or African American ____%
White ____%
Asian ____%
Native Hawaiian or Other Pacific Islander ____%
American Indian or Alaskan Native ____%
Other ____%
What is the payer mix for pediatric patients in your practice? Assign approximate percentage to all that apply.
Medicaid ____% (Approved – OMB Control No. 0906-0052)
Medicare ____% (Approved – OMB Control No. 0906-0052)
Commercial ____% (Approved – OMB Control No. 0906-0052)
Sliding fee scale/self-pay ____% (Approved – OMB Control No. 0906-0052)
Indian Health Service (IHS) ____%
Respondent Information
What is your current title?
[OPEN-ENDED RESPONSE]
How many years have you been in this position?
[OPEN-ENDED RESPONSE]
Additional Feedback
How can your state’s PMHCA program be improved to better suit the needs of your practice?
[OPEN-ENDED RESPONSE]
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Amanda Gmyrek |
| File Modified | 0000-00-00 |
| File Created | 2023-08-17 |
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