This survey is for participants of the 2017 ICLP 6 month cohort only. Please contact us (firstname.lastname@example.org) if you are interested in using this assessment in other settings.
Due Date: 5:00pm EST Friday, October 20, 2017
Time to Complete: 15-20 Minutes (estimated)
Save & Continue: If you would like to “Save and Continue” your Survey for later, be sure to click the “Save and Continue For Later” button you see located at the beginning or after each section of the Survey below. You will receive an email containing a special url and password to resume and complete submission of your survey.
This questionnaire assesses your practice’s readiness and capabilities to integrate behavioral health in the primary care setting. It will require approximately 10-15 minutes. Please be sure to review your responses prior to submission, as changes to your responses cannot be made after submission. This questionnaire will be administered again during the ICLP to inform how ICLP activities and supports (such as future training and technical assistance) can be best tailored to your developing needs.
As you complete this questionnaire, please keep the following things in mind:
When an item states
it refers to the integration of behavioral health in primary care. This includes things the primary care provider does to improve recognition and/or management of behavioral health (e.g., screening), as well as use of a behavioral health specialist (peer, trained nurse or care manager, clinical social worker, psychologist, and/or psychiatrist to work collaboratively in the management of primary care patients to address co-occurring mental health and substance use disorders)
When an item references
it refers to the individuals that receive healthcare services at your practice.
When an item references
it refers to the geographic area where your practice and population of interest are located.
When you respond to items in this questionnaire, choose the answer that you believe best represents your
practice as a whole, not just your own individual views
. These items refer to your views about how your practice
is, not how it was in the past or how you would like it to be in the future.
We encourage you to distribute a link to this questionnaire to all staff within your practice who would be involved in implementing activities related to integrating behavioral health services into your practice. While only three surveys are required from each applicant organization, there is no limit to the number of respondents per practice, and if your practice is selected to the program we will provide formative feedback about your results. Please note that it is important to encourage those who will complete to survey to answer the questions honestly. We expect growth to occur due to program participation, and we are looking for a diversity of sites in terms of engagement and readiness for integrated care.
At least three (3) members per practice must complete this survey for your application to be marked as complete and reviewed. Each of these three (3) required survey participants should be from a different role at the practice (e.g., primary care provider, behavioral health practitioner, nurse, member of administrative team, quality improvement personnel, front desk staff etc). Additionally, the set of respondents must include the lead administrator and lead physician. We encourage soliciting more than three responses as having more respondents provides a fuller picture of your practice.
Contact Us if you have any questions: email@example.com