www.oralhealthsolutions.com
Oral Health Solutions
1. Default Section
1
. Please select the identification of your position below:
Please select the identification of your position below:
Provider /Agency
Family Member
2
. What is the name of your agency, or the agency that your family member recieves services and supports from?
What is the name of your agency, or the agency that your family member recieves services and supports from?
3
. Please indicate the Indiana county in which you provide, or your family member recieves, services and supports.
Please indicate the Indiana county in which you provide, or your family member recieves, services and supports.
4
. Designate what type of services and supports you provide, or those that your family member recieves. Select all that apply.
Designate what type of services and supports you provide, or those that your family member recieves. Select all that apply.
Sheltered living home
Intensive training home
Developmental training home
Basic developmental home
Medically fragile home
Extensive support needs home
Supportive Living Facility, less than 35 hours of care per week
Supportive Living Facility, more than 35 hours of care per week
Community Based vocational Training
Community Based habilitation Training
Therapy services
Agency Based vocational Training
Agency Based habilitation Training
5
. How would you describe the locations where you provide, or recieve, these services?
How would you describe the locations where you provide, or recieve, these services?
Urban
Rural
Suburban
6
. If you are a provider, give the percentage of Individuals you serve for each of these categories. (The total should equal 100%)If you are a family member select "not appliciable."
If you are a provider, give the percentage of Individuals you serve for each of these categories. (The total should equal 100%)If you are a family member select "not appliciable."
Need only verbal assistance with activities of daily living (ADL)
Need verbal and some physical assistance with ADL
Need physical and verbal assistance for all ADL
Need continuous assistance due to behavioral issues
Need continuous assistance due to chronic medical conditions
Not applicable
7
. If you are a provider, what type of training does the staff receive in providing oral hygiene assistance for Individuals who are unable to take care of their own oral hygiene? If you are a family member please select "not applicable."
If you are a provider, what type of training does the staff receive in providing oral hygiene assistance for Individuals who are unable to take care of their own oral hygiene? If you are a family member please select "not applicable."
Training is included in job orientation
Receive annual in-service training
Training is provided when the need arises
Other
Not applicable
Other (please specify)
8
. Would you estimate that most of the Individuals you serve, or your family member, have?
Would you estimate that most of the Individuals you serve, or your family member, have?
Excellent oral health - Receive preventive dental care routinely and regularly perform tooth cleaning
Fair oral health - Receive dental care intermittently and occasionally perform tooth cleaning
Poor oral health –Receive dental treatment only for emergency situations, has many unmet treatment needs, and no regular tooth cleaning is performed
9
. Providers, what percent of the Individuals you serve fall into each level of independence? (The total should equal 100%) Family members, which best describes your family member?
Providers, what percent of the Individuals you serve fall into each level of independence? (The total should equal 100%) Family members, which best describes your family member?
Brush their teeth adequately on their own
Require assistance to brush their teeth
Refuse to brush their teeth
10
. Select the three greatest barriers that you experience in getting optimal dental care for the individuals you serve, or your family member. Use the numbers 1-3 to indicate the order in which you observe these, 1 being the greatest barrier:
Select the three greatest barriers that you experience in getting optimal dental care for the individuals you serve, or your family member. Use the numbers 1-3 to indicate the order in which you observe these, 1 being the greatest barrier:
Dentists unwilling to accept Medicaid
Dentists unwilling to accept patients with intellectual/developmental disabilities
Dentist and/or office staff unwelcoming, unkind, or unable to work effectively with your residents
Long waiting periods
Distance to available office
Individual refused dental treatment
Individuals’ behavior issues
Payment for services
None
11
. The individuals you serve, or your family member, receive dental care in the following locations (check all that apply)?
The individuals you serve, or your family member, receive dental care in the following locations (check all that apply)?
Private dental office
Dental or dental hygiene school
Hospital
Public health, community health center dental clinic, other safety-net clinic
12
. What is the closest distance you travel to obtain dental services?
What is the closest distance you travel to obtain dental services?
1-5 miles
6-15 miles
16-25 miles
26 or more miles
13
. What is the farthest distance you travel to obtain dental services?
What is the farthest distance you travel to obtain dental services?
1-5 miles
6-15 miles
16-25 miles
26 or more miles
14
. Have you experienced dental offices refusing to provide services for the Individuals you serve, or your family member?
Have you experienced dental offices refusing to provide services for the Individuals you serve, or your family member?
No
Yes
15
. If yes, what are the two most common reasons?
If yes, what are the two most common reasons?
Inadequate Medicaid reimbursement
Dental office not properly equipped
Behavioral Issues
No hospital privileges for extensive services with uncooperative patients
Dentist not trained to provide treatment for intellectually/developmentally disabled patients
Other
Other (please specify)
16
. Have any of the Individuals you serve, or your family member(s), been denied continued/ follow-up dental treatment for any reason?
Have any of the Individuals you serve, or your family member(s), been denied continued/ follow-up dental treatment for any reason?
No
Yes
17
. If yes, what was the reason for the discontinuation of care?
If yes, what was the reason for the discontinuation of care?
Inadequate Medicaid reimbursement
Dental office not properly equipped
Behavioral Issues
No hospital privileges for extensive services with uncooperative patients
Dentist not trained to provide treatment for intellectually/developmentally disabled patients
Other
Other
18
. On a scale of 1-5, with 5 being the most difficult, how would you rate your level of difficulty in finding dentists in your community who will treat your the individuals you serve, or your family member, and will accept Medicaid payment?
On a scale of 1-5, with 5 being the most difficult, how would you rate your level of difficulty in finding dentists in your community who will treat your the individuals you serve, or your family member, and will accept Medicaid payment?
1
2
3
4
5
19
. Providers, please estimate the percent of Individuals you serve who utilize funding from each of the categories below to pay for dental care (The total should equal 100%). Family members, please designate what type(s) of funding they use to pay for dental care.
Providers, please estimate the percent of Individuals you serve who utilize funding from each of the categories below to pay for dental care (The total should equal 100%). Family members, please designate what type(s) of funding they use to pay for dental care.
Medicaid
Parents/family
Private dental insurance
Other
20
. What percent of Individuals you serve that fall into each of the categories below (categories indicate the frequency in which they visit the dentist). The total should equal 100%. Family members, indicate the frequency that your family member visits the dentist.
What percent of Individuals you serve that fall into each of the categories below (categories indicate the frequency in which they visit the dentist). The total should equal 100%. Family members, indicate the frequency that your family member visits the dentist.
Every 3 months
Every 6 months
Once per year
Once every two years (approximately)
Once every five years (approximately)
Only when in pain
21
. Providers,what percentage of the Individuals you serve fall into each of the categories below. (The total should equal 100%) Family members, which best describes your family member?
Providers,what percentage of the Individuals you serve fall into each of the categories below. (The total should equal 100%) Family members, which best describes your family member?
Cooperative for dental treatment
Moderately resistant to dental treatment
Very resistant to dental treatment
Unwilling or unable to cooperate to enable being treated by a general practice dentist
22
. What dentist(s) currently provide(s) treatment for your family member, or the Individuals you serve? (please list all who provide care for your residents)
What dentist(s) currently provide(s) treatment for your family member, or the Individuals you serve? (please list all who provide care for your residents)
a. Name of dentist and name of practice (if different than name of dentist) Location (town/city) telephone
b. Name of dentist and name of practice (if different than name of dentist) Location (town/city) telephone
c. Name of dentist and name of practice (if different than name of dentist)Location (town/city)telephone
23
. Name of person completing this questionnaire.
Name of person completing this questionnaire.
24
. May we contact you in the future if we need to follow up with additional questions?
May we contact you in the future if we need to follow up with additional questions?
Yes
No
25
. Please provide your phone number in the box below.
Please provide your phone number in the box below.
26
. Please provide your e-mail address in the box below.
Please provide your e-mail address in the box below.
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