Form 3A 2022 PMHCA Program Implementation 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 B3 - Program Implementation Survey PMHCA3 - Copy

2022 PMHCA Program Implementation Survey

OMB: 0906-0074

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OMB No. 0906-0047

Expiration Date: 12/31/2025

Attachment B3:









Pediatric Mental Health Care Access Program Program Implementation 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: The purpose of this information collection is to obtain performance data for the following: HRSA Grantees and cooperative agreement recipients, public health, and applications. In addition, these data will facilitate the ability to demonstrate alignment between MCHB and the Pediatric Mental Health Care Access (PMHCA), and the Screening and Treatment for Maternal Depression and Related Behavioral Disorders (MDRBD) Programs. An OMB control number for this information collection is 0906-0047 and it is valid until 12/31/2025. Public reporting burden for this collection of information is estimated to average 0.75 hours 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.

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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

Program Implementation 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. 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 to learn more about the implementation of [insert name of state]’s HRSA PMHCA program. The survey is designed to collect information on your experiences with the PMHCA program (e.g., program implementation activities, health professional enrollment, health professional training, behavioral health service delivery, care coordination support, community linkages, sustainability) and to assist HRSA in future program implementation.

Survey Instructions: This online survey should take twenty (20) minutes or less 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 feel free to consult with your colleagues to gather information, as necessary, to complete this survey. Please note that your responses will remain private. 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.

Helpful Terminology: For the purposes of this survey, 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.

Program Involvement

  1. What is your project role in your PMHCA program? (Approved – OMB Control No. 0906-0052)

    • Project Director

    • Principal Investigator

    • Program Manager

    • Other (specify)



  1. How long have you been in this role?

    • [RESPONSE TO BE PROVIDED IN MONTH/YEAR FORMAT]


Clinical Behavioral Health Consultation Service Development

  1. How many health professional full-time equivalents (FTEs), by professional type, are funded by the HRSA cooperative agreement for your clinical behavioral health consultation service? For example, if two (2) psychiatrists are funded, the first at 1 FTE and the second at .5 FTE, indicate 2 in the Number column and 1.5 in the FTE column. (Approved – OMB Control No. 0906-0052)


Number

FTE

Psychiatrists



Psychologists



Advanced practice nurses



Social workers



Licensed mental health counselors



Substance use disorder counselors



Case or care coordinators



Other (specify)



Health Professional/Practice Enrollment/Participation

  1. Are you recruiting individual health professionals or health care practices to enroll/participate into your PMHCA program? Select one. (Approved – OMB Control No. 0906-0052)

    • Only individual health professionals (If selected, move on to Question 5.)

    • Only health care practices (If selected, move on to Question 7.)

    • Both health care practices and individual health professionals (If selected, move on to Question 5.)


  1. How many individual health professionals are enrolled/participating in your PMHCA program to date?

    • [OPEN-ENDED RESPONSE – allow numbers only]

  1. What types of health professionals are enrolled/participating in your PMHCA program to date? Select all that apply.

    • Pediatricians

    • Family physicians

    • Physician assistants

    • Advanced practice nurses/nurse practitioners

    • Licensed practical nurses

    • Registered nurses

    • Counselors

    • Social workers

    • Medical assistants

    • Patient care navigators

    • Other (specify)



  1. How many health care practices are enrolled/participating in your PMHCA program to date? (Approved – OMB Control No. 0906-0052)

    • [OPEN-ENDED RESPONSE – allow numbers only]


  1. What type(s) of health care practices are enrolled/participating in your PMHCA program to date? Select all that apply.

    • University-based practice(s) (Approved – OMB Control No. 0906-0052)

    • Non-academic, hospital-based practice(s) (Approved – OMB Control No. 0906-0052)

    • Emergency department(s) (Approved – OMB Control No. 0906-0052)

    • Managed care organization(s) (Approved – OMB Control No. 0906-0052)

    • Private practice(s) (Approved – OMB Control No. 0906-0052)

    • Community health center(s)/Federally Qualified Health Center(s) (Approved – OMB Control No. 0906-0052)

    • School-based health center(s)

    • Tribal Health Center(s)

    • Other (specify)


Health Professional Training

  1. How many health professionals have been trained by your PMHCA program to date (e.g., via webinar, in-person trainings)? (Approved – OMB Control No. 0906-0052)

    • [OPEN-ENDED RESPONSE]


  1. What factor(s) facilitated your implementation of health professional training? Select all that apply.

    • Provider acceptance (Approved – OMB Control No. 0906-0052)

    • Ability to offer Continuing Medical Education (CME)/Continuing Education (CE) credits (Approved – OMB Control No. 0906-0052)

    • Champion support (Approved – OMB Control No. 0906-0052)

    • Community resource partner support (whether informal or formal)

    • Participant engagement (Approved – OMB Control No. 0906-0052)

    • Scheduling (Approved – OMB Control No. 0906-0052)

    • Length of training/training sessions (Approved – OMB Control No. 0906-0052)

    • Training format (Approved – OMB Control No. 0906-0052)

    • Training promotion (Approved – OMB Control No. 0906-0052)

    • Other (specify) (Approved – OMB Control No. 0906-0052)

    • None

  1. What challenges did you encounter while implementing health professional training? Select all that apply.

    • Lack of health professional acceptance

    • Inability to offer CME/CE credits (Approved – OMB Control No. 0906-0052)

    • Infrastructure challenges (e.g., facilities, technology, staffing) (Approved – OMB Control No. 0906-0052)

    • Lack of champion support (Approved – OMB Control No. 0906-0052)

    • Lack of community resource partner support (whether informal or formal)

    • Lack of participant engagement (Approved – OMB Control No. 0906-0052)

    • Scheduling (Approved – OMB Control No. 0906-0052)

    • Length of training/training sessions (Approved – OMB Control No. 0906-0052)

    • Training format (Approved – OMB Control No. 0906-0052)

    • Training promotion (Approved – OMB Control No. 0906-0052)

    • Impact of public health emergency (e.g., COVID-19)

    • Other (specify) (Approved – OMB Control No. 0906-0052)

    • None


Clinical Behavioral Health Consultation, Including Use of Telehealth

  1. [Note: This question will only be asked in Year 2 for 2021 PMHCA awardees.] When did you/will you begin implementing clinical behavioral health consultation in your PMHCA program? (Approved – OMB Control No. 0906-0052)

    • [RESPONSE TO BE PROVIDED IN MONTH/YEAR FORMAT]


  1. What telehealth mechanism(s) do you use in your PMHCA program for clinical behavioral health consultation? Select all that apply.

    • 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)


Care Coordination Support, Including Use of Telehealth

  1. [Note: This question will only be asked in Year 2 for 2021 PMHCA awardees.] When did you/will you begin implementing care coordination support (i.e., communication/collaboration, accessing resources, referral services) in your PMHCA program? (Approved – OMB Control No. 0906-0052)

    • [RESPONSE TO BE PROVIDED IN MONTH/YEAR FORMAT]


  1. What telehealth mechanism(s) do you use in your PMHCA program for care coordination support? Select all that apply.

    • 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)

Health Equity

A goal of the PMHCA program is to focus on achieving health equity related to social determinants of health (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.

  1. To what extent, if any, has your PMHCA program encountered or identified health disparities in access to behavioral health care?

    • Not at all (If selected, move on to Question 18.)

    • To a small extent (If selected, move on to Question 17.)

    • To a moderate extent (If selected, move on to Question 17.)

    • To a great extent (If selected, move on to Question 17.)

    • To a very great extent (If selected, move on to Question 17.)


  1. Please describe an example of how your program worked to achieve health equity related to behavioral health care access to address racial, ethnic, and geographic disparities.

    • [OPEN-ENDED RESPONSE]



  1. On what health equity-related topics has your PMHCA program provided training for health professionals? Select all that apply.

    • Barriers to health care

    • Foundational knowledge of health equity and health disparities

    • Implicit biases

    • Systemic racism

    • Sensitivity to patients’ race, ethnicity, and language

    • Impact of adversity, adverse childhood experiences, trauma, or toxic stress

    • Trauma- and resilience-informed care


  1. To what extent have you developed an Advisory Committee, comprising interested parties and agencies, to support a statewide or regional PMHCA program? (Key stakeholders may include mental health, public health, pediatric health, and behavioral health clinicians; human services; health insurers; education and diversity, equity, and inclusion subject matter experts; and families.)

    • Not at all

    • To a small extent

    • To a moderate extent

    • To a great extent

    • To a very great extent


  1. What supports related to health equity does your PMHCA program need to address racial, ethnic, and geographic disparities?

    • [OPEN-ENDED RESPONSE]

Community Linkages

  1. What types of community linkages has your PMHCA program established to support behavioral health care? Select all that apply.

    • Counseling (Approved – OMB Control No. 0906-0052)

    • 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)


  1. To what extent is your PMHCA program using the established community linkages? (Approved – OMB Control No. 0906-0052)

    • Not at all

    • To a small extent

    • To a moderate extent

    • To a great extent

    • To a very great extent


  1. How difficult was the process of establishing the following community linkages?

Very difficult

Difficult

Neutral

Easy

Very easy

N/A

Counseling

o

o

o

o

o

o

Child care

o

o

o

o

o

o

Substance use treatment

o

o

o

o

o

o

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 (specify)

o

o

o

o

o

o



  1. What community linkages have been the most effective in addressing health disparities in access to behavioral health care in your state?

    • Counseling

    • Child care

    • Substance use treatment

    • Employment/job-seeking training

    • Food programs

    • Housing support

    • Parenting support

    • Support groups

    • Transportation support

    • Education support

    • Other (specify)

  1. Please describe any goals your program has established with community linkages to support health equity in access to behavioral health care.

    • [OPEN-ENDED RESPONSE]


Program Outreach and Dissemination

  1. To whom does your PMHCA program disseminate information about program services? Select all that apply. (Approved – OMB Control No. 0906-0052)

    • Health professionals

    • Behavioral health professionals

    • Patients

    • Partners

    • Public

    • Other (specify)



  1. How are you promoting your PMHCA program? Select all that apply.

    • Brochures/Briefs

    • Email/E-blasts

    • Journal publications

    • Newsletters

    • Posters/Infographics

    • Presentations

    • Social media

    • Videos

    • Websites

    • Other (specify)


Sustainability

  1. Did your state have funding in place to support activities similar to your PMHCA program prior to receiving HRSA cooperative agreement funding?

    • Yes (If yes, move on to Question 29.)

    • No (If no, move on to Question 30.)

    • Do not know


  1. What additional funding did your state have in place to support activities similar to your PMHCA program prior to receiving HRSA cooperative agreement funding? (Select all that apply.)

    • Medicaid

    • Third-party payer reimbursement

    • Other federal funding

    • State budget allocation

    • State/tribal/jurisdiction grants

    • Foundation/nonprofit organization grants

    • Other (specify)



  1. Since receiving HRSA cooperative agreement funding, has your state received other funding to support PMHCA program activities?

    • Yes (If yes, move on to Question 31.)

    • No (If no, move on to Question 33.)

  1. What additional funding has your state received for your PMHCA program? Select all that apply, and specify the dollar amount your state has received.

    • Medicaid (Please specify amount.)

    • Third-party payer reimbursement (Please specify amount.)

    • Other federal funding (Please specify amount.)

    • State budget allocation (Please specify amount.)

    • State/tribal/jurisdiction grants (Please specify amount.)

    • Foundation/nonprofit organization grants (Please specify amount.)

    • Other (specify) (Please specify amount.)



  1. What percentage of your state’s PMHCA program activities are supported by the funding sources your state has received? Assign approximate percentage to all that apply.

    • HRSA funding: ___%

    • Third-party payer reimbursement: ___%

    • Other federal funding: ___%

    • State budget allocation: ___%

    • State/tribal/jurisdiction grants: ___%

    • Foundation/nonprofit organization grants: ___%

    • Other (specify): ___%


  1. Do you have a sustainability plan for funding for your PMHCA program once HRSA cooperative agreement funding ends?

    • Yes

    • No


  1. Please describe your local data collection activities used to support PMHCA program sustainability planning.

    • [OPEN-ENDED RESPONSE]


  1. How do you anticipate supporting your PMHCA program once HRSA cooperative agreement funding ends? Select all that apply.

    • Medicaid

    • Third-party payer reimbursement

    • Other federal funding

    • State budget allocation

    • State/tribal/jurisdiction grants

    • Foundation/nonprofit organization grants

    • Other (specify)

Program Implementation Facilitators and Barriers

  1. What factors have facilitated your program implementation? Select all that apply.

    • Health professional recruitment (Approved – OMB Control No. 0906-0052)

    • Health professional engagement (Approved – OMB Control No. 0906-0052)

    • Stakeholder communication and coordination (Approved – OMB Control No. 0906-0052)

    • Champion support (Approved – OMB Control No. 0906-0052)

    • Community resource partner support (whether informal or formal)

    • Telehealth technology (Approved – OMB Control No. 0906-0052)

    • Workflow (Approved – OMB Control No. 0906-0052)

    • Data collection/reporting (Approved – OMB Control No. 0906-0052)

    • Advisory Committee involvement (Approved – OMB Control No. 0906-0052)

    • Other (specify) (Approved – OMB Control No. 0906-0052)

  1. What factors have challenged your program implementation? Select all that apply.

    • Health professional recruitment (Approved – OMB Control No. 0906-0052)

    • Health professional engagement (Approved – OMB Control No. 0906-0052)

    • Stakeholder communication and coordination (Approved – OMB Control No. 0906-0052)

    • Champion support (Approved – OMB Control No. 0906-0052)

    • Community resource partner support (whether informal or formal)

    • Telehealth technology (Approved – OMB Control No. 0906-0052)

    • Workflow (Approved – OMB Control No. 0906-0052)

    • Data collection/reporting (Approved – OMB Control No. 0906-0052)

    • Advisory Committee involvement (Approved – OMB Control No. 0906-0052)

    • Impact of public health emergency (e.g., COVID-19)

    • Other (specify) (Approved – OMB Control No. 0906-0052)


Evaluation Capacity-Building Support

  1. Will your PMHCA program require any of the following evaluation capacity-building support or technical assistance in the upcoming year? Select all that apply.

  • Program evaluation design refinement (Approved – OMB Control No. 0906-0052)

  • Development of data collection tools/instruments (Approved – OMB Control No. 0906-0052)

  • Systems/platforms used for data collection

  • Collection and reporting of HRSA-required measures (Approved – OMB Control No. 0906-0052)

  • Health professional training evaluation (Approved – OMB Control No. 0906-0052)

  • Data analysis (Approved – OMB Control No. 0906-0052)

  • Dissemination of evaluation results (Approved – OMB Control No. 0906-0052)

  • Other (specify) (Approved – OMB Control No. 0906-0052)


Additional Feedback

  1. What else would you like to share with HRSA about the PMHCA program?

    1. [OPEN-ENDED RESPONSE] (Approved – OMB Control No. 0906-0052)


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