Practice Information Survey: HPSM Assessment

Practice Information Survey: HPSM Assessment

Please share information specific to your practice site (since an organization may have multiple sites). Provide any data that is easy to pull. If you are not able to readily access these numbers, you may simply mark “not readily available.” Estimates are welcome.
Organization Name
Site Name (if applicable)
Your Name

First NameLast Name
Your Email
example@example.com

Staffing

5. For your practice site, please provide a breakdown of each primary care provider (PCP) and their FTE dedicated to direct patient care. Please note that filled FTE and vacant FTE are mutually exclusive.

	Non-Direct Patient Care FTE (filled)	Direct Patient Care FTE (filled)	Non-Direct Patient Care FTE (vacant)	Direct Patient Care FTE (vacant)
Physician (MD/DO)
Advanced Practice Provider (NP/PA)
Resident Physician

6. Describe your practice site’s staffing model by indicating the number of each staff member on the primary care team. Please note that filled FTE and vacant FTE are mutually exclusive.

	Overall FTE (filled)	# Vacancies	Additional Notes
Nursing Staff (LVN, RN/BSN)
Medical Assistants (Patient-Facing, only)
Front Office Staff
Community Health Workers (CHWs), Health Coaches, and/or Patient Navigators
Medical Scribes
Pharmacists
Case Management Staff
Behavioral Health Providers
Dental Providers
Nurse Midwives
Doulas
Other

Empanelment

Definition: The process for ensuring that every patient has an assigned Primary Care Provider (PCP) and every PCP has a defined panel of patients.
7. How do you define active patients in your practice site?

One visit within last 12 monthsOne visit within last 18 monthsOne visit within last 24 monthsOne visit within last 36 monthsWe do not define active patients in our practiceOther
8. How many active patients are in your practice site, using your definition for “active”?
9. Do you calculate ideal panel size? i.e., a target/optimal number of patients for each FTE of primary care provider (PCP) time

YesNo
If so, what is the number of patients per one clinical FTE?

Continuity
10. Which if any of these metrics do you routinely use to track continuity?

Patient-perspective continuityCare team-perspective continuityWe do not routinely track any of theseOther
Definitions:

Continuity: The consistent and seamless provision of ongoing health care management to a patient over time, ensuring coordinated and high-quality treatment across providers and settings.

Patient-perspective continuity: A metric measuring how much patients get to see their own provider or care team.

Care-team perspective continuity: a metric measuring how much care teams/providers get to see their own patients.

Access

Access: The timely use of personal health services to achieve the best health outcomes.
12. Which of these metrics do you routinely use to track access at your practice site (check all that apply)?

Third next available appointmentPercent open appointmentsPercent same day appointmentsWe do not routinely track any of theseOther

Work Experience
13. Do you conduct any routine staff well-being surveys?

NoYes
Should be Empty:

	Number of Patients (Total Assigned Patients, where applicable)	Not readily available
Non-HPSM Medi-Cal
Non-HPSM Medicare / Medicare Advantage
Non-HPSM Commercial
Self-Pay
Other

Practice Information Survey: HPSM Assessment

Payment Mix

Systems

Staffing

Empanelment

Continuity

Access

Work Experience