TRAUMA-INFORMED ACES SCREENING & INTERVENTION EVALUATION (TASIE) DEMONSTRATION PROJECT

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $960,000 with no percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

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* 1. Medical Practice Name:

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* 2. Medical Practice Address:

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* 3. Please share the following information for your Primary Contact (person completing application):

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* 4. Type of community in which your practice is located:

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* 5. Where did you learn about this opportunity?

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* 6. Please designate the Provider Champion, the Team Lead, the Data Lead and the Administrative Lead, who will be the main points of contact for the program team, and provide the following information:

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* 7. Are you an exclusively pediatric-focused practice?

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* 8. Medical Practice Type: (check all that apply)

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* 9. Number of physicians in your practice:

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* 10. How many of each type of staff members are in your practice?

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* 11. How many physical clinic sites does your medical practice have?

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* 12. Approximately how many unique pediatric (birth-19 y/o) patients does your practice/clinic see annually?

(Please respond based on the scope of your screening efforts (e.g., if they are localized to one clinic site or across your entire practice) to help us estimate potential patients impacted by screening.)

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* 13. In a typical month, approximately how many pediatric patients does your practice see? 

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* 14. Of the patient's your practice sees in a typical month, what percentage (%) are within the following age ranges?

Please use whole numbers only, not a range of percentages. If you have no patients in a specific group, please place a zero (0) in that space.

Note: Percent should sum to 100%.

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* 15. What is the approximate percentage (%) of your pediatric patients covered by the following insurance types?

Please use whole numbers only, not a range of percentages. If you have no patients in a specific group, please place a zero (0) in that space.

Note: Percent should sum to 100%.

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* 16. Per your last annual report, what is the approximate percentage (%) of pediatric patients that your practice sees monthly?

Please use whole numbers only, not a range of percentages. If you have no patients in a specific group, please place a zero (0) in that space.

Note: Percent should sum to 100%.

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* 17. Per your last annual report what is the approximate percentage (%) of Providers?

Please use whole numbers only, not a range of percentages. If you have no providers in a specific group, please place a zero (0) in that space.

Note: Percent should sum to 100%.

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* 18. Per your last annual report what is the approximate percentage (%) of Board Members?

Please use whole numbers only, not a range of percentages. If you have no Board Members in a specific group, please place a zero (0) in that space.

Note: Percent should sum to 100%.

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* 19. Per your last annual report what is the approximate percentage (%) of your Leadership Team?

Please use whole numbers only, not a range of percentages. If you have no Leadership Team members in a specific group, please place a zero (0) in that space.

Note: Percent should sum to 100%.

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* 20. Has your practice participated in any previous:

  Yes No
Quality Improvement Projects
Project ECHO Programs

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* 21. Does your clinic have the capacity to start screening a small pilot population for ACEs within 3 months of starting the program?

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* 22. Does the Physician Lead have the capacity to attend the majority of the required meetings for this program (please see overview for list of meetings and dates)?

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* 23. What would the benefits of ACEs screening be in your practice setting?

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* 24. Where do you think screening for ACEs fits into your organizational priorities or projects (PCMH Designation, FQHC Quality Improvement program, etc.)? Are there any other quality-improvement initiatives the organization is undertaking within the next year?

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* 25. What support resources do you have in place that will contribute to your success in this program?

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* 26. Why are you applying to this program? Has anything in your practice recently changed that you feel would contribute to your success in this program (i.e. leadership now fully on-board, new partnership with mental health services, new support staff hired)?

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* 27. What are the barriers to screening all your pediatric patients for ACEs (current or anticipated)?

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* 28. Which of your sites will administer the pilot? (If applicable)

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* 29. What patient population will be part of the pilot? 

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* 30. How many pediatric medical providers at your practice will be screening as part of the pilot?

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* 31. Do you use an EHR? Which one? 

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* 32. How easy or difficult is it to add new data fields to your EHR and design reports to review those new data points? How long might that process take?

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* 33. How would you describe your practice’s current ability to address mental or behavioral health concerns in your patients and families?

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* 34. We are currently tracking referrals to mental, behavioral and social resources outside our clinic.

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* 35. We are currently tracking the success or outcome of these referrals to mental, behavioral, and social resources outside our clinic (e.g. whether the service was accessed).

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* 36. If you answered Yes or Somewhat to Q 35, please explain.

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* 37. Please describe your process for screening for and addressing Social Determinants of Health (SDOH):

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* 38. Does your practice have access to onsite or in-system/in-network referrals to a social worker or mental/behavioral health practitioner for at-risk patients/families?

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* 39. In which languages other than English do you carry patient education materials (check all that apply)?

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* 40. Do you currently work with (select all that apply):

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