Form 1 National Hypertension Control Initiative (NHCI) Communit

Form Approved

OMB No. 0990-0379

Exp. Date XX/XX/20XX

NHCI – Initial Health Center Assessment Survey

Health Center Site Information

What is the name of the HRSA-funded health center you represent?

[pulldown list of HRSA funded Health Centers]

[Other: Open text if not found in list]

Health Center Services

Do any of your health center sites offer services or programs to assist patients with transportation to and from healthcare visits?

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Approximately what proportion of your health center sites offer services or programs to assist patients with transportation to and from healthcare visits?

1. 100% of health center sites

2. 51-75% of health center sites

3. 25-50% of health center sites

4. Less than 25% of health center sites

5. I don’t know/I’m not sure

Do any of your health center sites routinely perform assessments or screenings with patients to help identify social factors that may influence their health? (Examples include PRAPARE, WE CARE)

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Approximately what proportion of your health center sites routinely perform assessments or screenings with patients to help identify social factors that may influence their health? (Note: Examples include PRAPARE, WE CARE)

1. 100% of health center sites

2. 51-75% of health center sites

3. 25-50% of health center sites

4. Less than 25% of health center sites

5. I don’t know/I’m not sure

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Which of the following social assessments or screeners are used with patients at your health care sites?

1. PRAPARE

2. X

3. Y

4. X

5. Other. Please describe: [Open text box]

Pharmacy Services

Do any of your health center sites have an on-site pharmacy?

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Approximately what proportion of your health center sites have an on-site pharmacy?

1. 100% of health center sites

2. 51-75% of health center sites

3. 25-50% of health center sites

4. Less than 25% of health center sites

5. I don’t know/I’m not sure

Do any of the on-site pharmacies have a PharmD on staff?

1. Yes

2. No

3. I don’t know/I’m not sure

Do any of the on-site pharmacies participate in the 340(B) Drug Pricing Program?

1. Yes

2. No

3. I don’t know/I’m not sure

Do your patients insured by Medicaid have access to any of the on-site pharmacies?

1. Yes

2. No

3. I don’t know/I’m not sure

Do your patients insured by Medicare have access to any of the on-site pharmacies?

1. Yes

2. No

3. I don’t know/I’m not sure

Do any of the on-site pharmacies have a site-specific formulary?

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Does the formulary include a single pill combination therapy for blood pressure control?

1. Yes

2. No

3. I don’t know/I’m not sure

SMBP Program and Technology

Do your staff at your health centers encourage patients to use Self-Monitoring Blood Pressure (SMBP)?

1. Yes

2. No

3. I don’t know/I’m not sure

Does your health center site currently have a SMBP Program?

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Are SMBP machines provided to patients by the health center?

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Under what circumstances are the SMBP machines provided to patients?

1. They are loaned and patients are asked to return them

2. They are given to the patient at no charge and they do not need to be returned

3. Other: Please describe

4. I don’t know/I’m not sure

Do any of your health centers that use SMBP have a system for monitoring which patients are using SMBP?

1. Yes

2. No

3. I don’t know/I’m not sure

Does your health center staff use SMBP measurements in the management of hypertension?

1. Yes

2. No

3. I don’t know/I’m not sure

Does your electronic health records system have a way that staff can add SMBP measurements into the patient record?

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

In what ways can staff at your health center site add the SMBP measurements into the patient record in your EHR system? (Please check all that apply)

1. Staff manually enter SMBP measurements into patient records in areas NOT specifically designed to collect SMBP measurements

2. Staff manually enter the SMBP measurements in unique data fields specific for SMBP

3. SMBP measurements can be uploaded directly into the patient record with no manual data entry needed by staff

4. Other: [Please describe]

5. I don’t know/I’m not sure

Are staff trained on the guideline-directed uses of SMBP?

1. Yes

2. No

3. I don’t know/I’m not sure

Are patients trained by health center staff on how to correctly self-measure blood pressure?

1. Yes

2. No

3. I don’t know/I’m not sure

Health Center Staffing

Does your health center currently have a Quality Improvement Coordinator on staff?

Note: The healthcare quality improvement coordinator is often responsible for managing the development, implementation, and evaluation of the healthcare center’s overall quality improvement (QI) program to identify trends, prioritize and recommend improvements, decrease duplication, and ensure compliance with accreditation organizations. The QI Coordinator may also investigate incident reports, patient complaints, patient care issues, and other issues related to healthcare delivery and quality.

1. Yes

2. No

3. I don’t know/I’m not sure

Does your health center currently have a licensed clinical social worker (LCSW) on staff?

1. Yes

2. No

3. I don’t know/I’m not sure

Does your health center currently have a patient care coordinator on staff?

Note: A patient care coordinator or care coordinator is a trained health professional who manages patients' health care, such as the elderly or disabled. Patient care coordinators educate patients about their health conditions and develop a plan to address their personal health care needs.

1. Yes

2. No

3. I don’t know/I’m not sure

Does your health center currently have a community health worker on staff?

Note: Community health workers (CHWs) are lay members of the community who work either for pay or as volunteers in association with the local health care system in both urban and rural environments. CHWs usually share ethnicity, language, socioeconomic status, and life experiences with the community members they serve.

1. Yes

2. No

3. I don’t know/I’m not sure

Blood Pressure Measurement Protocols

Are the blood pressure measurement devices used at your health center validated devices? (Note: A list of validated devices are listed here)

1. Yes

2. No

3. I don’t know/I’m not sure

Which of the following types of blood pressure (BP) measurement devices are used in your healthcare center sites?

(These answer options will be put into a table with the images)

Automated Office BP Device (AOBP): Automated device that can be programmed to take multiple measurements without the individual measuring BP in the room

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Are multiple adult cuff sizes available for this device? (e.g. small, regular, large, extra-large)?

1. Yes

2. No

3. I don’t know/I’m not sure

Semi-automated - An automated device that takes only one reading and requires the individual measuring BP to be in the room with patient during measurement.

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Are multiple adult cuff sizes available for this device? (e.g. small, regular, large, extra-large)?

1. Yes

2. No

3. I don’t know/I’m not sure

Manual (mounted aneroid)

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Are multiple adult cuff sizes available for this device? (e.g. small, regular, large, extra-large)?

1. Yes

2. No

3. I don’t know/I’m not sure

Manual (portable aneroid)

1. Yes

2. No

3. I don’t know/I’m not sure

Do you have a protocol in place for device calibration?

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Are multiple cuff sizes available for this device? (e.g., pediatric sizes, adult extra-large)

1. Yes

2. No

3. I don’t know/I’m not sure

Does your health center site currently have a standardized procedure to measure blood pressure?

1. Yes

2. No

3. I don’t know/I’m not sure

Does your health center currently have a standardized procedure to assess the competency of staff regarding proper blood pressure measurement techniques?

1. Yes

2. No

3. I don’t know/I’m not sure

Does your health center currently have a standard procedure for confirming elevated blood pressure measured during a routine office visit?

1. Yes

2. No

3. I don’t know/I’m not sure

Team-Based Care and Hypertension Management

Does your health center currently utilize team-based care for hypertension management?

Note: Team-based health care is the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers — to the extent preferred by each patient — to accomplish shared goals within and across settings to achieve coordinated, high-quality care.

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

At your health center, do you practice “task sharing” for hypertension management?

Note: We define “task sharing” as the rational movement of primary care duties from physicians

to non-physician health-care workers, such as nurses, pharmacists, or community health workers.

What type of healthcare professionals are responsible for measuring blood pressure during a routine patient visit? (Please check all that apply)

1. Physicians (MD/DO)

2. Nurse Practitioners (NP)

3. Advanced Nurse Practitioners (ANP)

4. Physician Assistants (PA)

5. Registered Nurses (RN)

6. Medical Assistants (MA)

7. Licensed Practical Nurse (LPN)

8. Other: Please explain

9. I don’t know/I’m not sure

What type of healthcare professionals are responsible for checking blood pressure accuracy during a routine patient visit? (Please check all that apply)

1. Physicians (MD/DO)

2. Nurse Practitioners (NP)

3. Advanced Nurse Practitioners (ANP)

4. Physician Assistants (PA)

5. Registered Nurses (RN)

6. Medical Assistants (MA)

7. Licensed Practical Nurse (LPN)

8. Other: Please explain

9. I don’t know/I’m not sure

Does your health center site currently use a standardized hypertension treatment protocol/algorithm?

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

What hypertension protocol does your health center site use?

1. Your practice’s customized protocol

2. Clinical decision support guidance within EHR (including embedded treatment protocol)

3. AHA/ACC/CDC high blood pressure algorithm

4. Million Hearts® protocol for controlling hypertension in adults

5. Kaiser Permanente Clinical Practice Guideline for Adult Hypertension

6. National Institute for Health and Care Excellence (NICE) protocol for hypertension in adults

7. Specify Other

Patient Portal

Does your health center have a patient portal?

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Which of the following can be performed by patients when using the patient portal?

1. Communication between patients and members of healthcare team

2. Appointment scheduling

3. Access results from laboratory tests or medical procedures

4. Access educational content

5. Coordination of healthcare services

6. I don’t know/I’m not sure

Approximately what proportion of your adult (18+ years) patient population have accessed the patient portal within the past year? (Please estimate if info not easily accessible)

__ __ % (Open Text/Number boxes)

Population Health Management

Does your health center site have a disease registry?

Note: We define a disease registry as a tool for tracking the clinical care and outcomes of a defined patient population.

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Does your disease registry provide estimates of the proportion of patients with hypertension that are controlled?

1. Yes

2. No

3. I don’t know/I’m not sure

Do your health center teams review their healthcare quality performance data to make adjustments in care at a site level? (QI, performance, etc.)?

1. Yes

2. No

3. I don’t know/I’m not sure

Population Health Management

Does your health center provide healthcare services using telemedicine services?

Note: Telemedicine refers to the practice of caring for patients remotely when the provider and patient are not physically present with each other. Modern technology has enabled healthcare professionals to consult patients by using HIPAA compliant video-conferencing tools.

1. Yes

2. No

3. I don’t know/I’m not sure

If yes:

Which of the following types of health services are provided using telemedicine at your health center? (Please check all that apply)

1. Routine clinical visits

2. Behavioral health visits

3. Urgent Care/Emergency Visits

4. Other (Please explain)

Public Burden Statement: The purpose of this information collection is to determine how to parse out the 350 health centers into cohorts based on capabilities and needs, as well as identify Technical Assistance (TA) focus to support improved use of best practices within the health Centers – to improve blood pressure control rates. 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 0990-0379, and it is valid until XX/XX/XXXX. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 3 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.