PA PQC OUD Survey (July through September 2019) Please work with your team to complete this birth site-level survey for the period of July through September 2019. OK Question Title * 1. What is your health system name? OK Question Title * 2. Which site/hospital within your health system are you submitting data for? AHN – Forbes Hospital AHN – Jefferson Hospital AHN – Saint Vincent Hospital AHN – West Penn Hospital Commonwealth Health – Moses Taylor Hospital Conemaugh Memorial Medical Center Crozer-Keystone Health System - Crozer-Chester Medical Center Crozer-Keystone Health System - Delaware County Memorial Hospital Doylestown Hospital Einstein Medical Center Montgomery Einstein Medical Center Philadelphia Evangelical Community Hospital Geisinger – Bloomsburg Hospital Geisinger – Holy Spirit Hospital Geisinger – Lewistown Hospital Geisinger – Medical Center, Danville Geisinger – Wyoming Valley Hospital Geisinger Community Medical Center Guthrie – Robert Packer Hospital Birthing Center Jefferson Health – Abington Hospital Jefferson Health – Thomas Jefferson University Hospital Lehigh Valley Health Network – Cedar Crest Lehigh Valley Health Network – Muhlenberg Lehigh Valley Health Network – Pocono Lehigh Valley Health Network - Schuylkill Main Line Health - Bryn Mawr Hospital Main Line Health - Lankenau Medical Center Main Line Health - Paoli Hospital Main Line Health - Riddle Hospital Mount Nittany Health System - Mount Nittany Medical Center Penn Medicine – Chester County Hospital Penn Medicine – Hospital of the University of Pennsylvania Penn Medicine – Lancaster General/Women and Babies Penn Medicine – Pennsylvania Hospital Penn State Health: Milton S. Hershey Medical Center and Children’s Hospital Punxsutawney Area Hospital St. Clair Hospital St. Luke’s University Health Network – Allentown St. Luke’s University Health Network – Bethlehem Temple Health – Temple University Hospital The Midwife Center for Birth & Women's Health Tower Health Medical Group - Reading Hospital UPMC - Altoona UPMC - Charles Cole UPMC - Hamot UPMC - Horizon UPMC - Magee Womens Hospital UPMC - Northwest UPMC - Pinnacle Harrisburg UPMC - Pinnacle Lititz UPMC - Carlisle UPMC - Pinnacle Hanover UPMC - Pinnacle Memorial in York UPMC -Susquehanna Soldiers + Sailors UPMC - Susquehanna Williamsport Wayne Memorial Hospital WellSpan Ephrata Community Hospital WellSpan Gettysburg Hospital WellSpan Good Samaritan Hospital WellSpan Summit Health Chambersburg Hospital WellSpan Summit Health Waynesboro Hospital WellSpan York Hospital OK Question Title * 3. What is your name? OK Question Title * 4. Does your site currently have a process in place to provide ongoing OUD sensitivity training requirements for staff and providers? Yes No OK Question Title * 5. If you entered yes for question 4, please describe the education: In-Person Web-Based Available for CME credits Other (please specify) OK Question Title * 6. If you entered yes for question 4, is staff education on substance use in pregnancy mandatory or volunteer? Mandatory Volunteer OK Question Title * 7. Does your site have standardized materials for educating women with OUD, regarding OUD and in pregnancy and mother’s role in NAS newborn care (i.e. pediatric consult, patient education materials)? Yes No OK Question Title * 8. If you entered yes for question 8, what patient education material is your health system providing to patients? Institution-developed material NIDA SAMHSA ASAM ACOG CDC Other (please specify) OK Question Title * 9. Does your site use a validated, self-report screening tool for substance use in pregnancy? Yes No OK Question Title * 10. If you entered yes for question 10, which self-report screening tool is your health system using to screen pregnant women for OUD? (You may choose more than one answer. If your health system does not screen pregnant women for OUD, choose "none.") The 4 P's / The 4 P's Plus The 5 P's Institution Developed Tool DAST-10 NIDA Quick Screen SURP-P ASSIST Hospital Screening Questionnaire (HSQ) None Other (please specify) OK Question Title * 11. If you entered yes for question 10, which patients receive self-reported screening? Universal; we screen all pregnant women Risk-based; we only screen select pregnant women Varies by provider; we do not have institutional guidance regarding screening OK Question Title * 12. If you entered yes for question 10, when do patients receive self-reported screening? (Check all that apply) First prenatal appointment At prenatal appointments when substance use is supsected Delivery Varies by provider Other (please specify) OK Question Title * 13. Does your site use urine toxicology to identify substance use during pregnancy? Yes No OK Question Title * 14. If you entered yes for question 14, how would you describe your urine toxicology screening process? Universal; we screen all pregnant women Risk-based; we only screen select pregnant women Varies by provider; we do not have institutional guidance regarding screening OK Question Title * 15. If you entered yes for question 14, when do patients receive urine toxicology screening? (Check all that apply) First prenatal appointment Delivery Varies by provider Other (please specify) OK Question Title * 16. Does your site provide opioid pharmacotherapy for pregnant women with OUD? Yes No OK Question Title * 17. If you entered yes for question 17, which pharmacotherapy services does your site provide? (Check all that apply) Subutex Suboxone Methadone Detoxification Other (please specify) OK Question Title * 18. Has your site developed referral relationships with any OUD treatment programs in your area/county? Yes No OK Question Title * 19. Does your site provide behavioral health services for pregnant women with OUD? Yes No OK Question Title * 20. If you entered yes for question 20, which services? (Check all that apply) Mental health counseling Drug and alcohol counseling Psychiatry Other (please specify) OK Question Title * 21. If you entered yes for question 20, who provides the services? (Check all that apply) Psychiatry Social services/social work Primary care providers/family medicine Obstetrics/prenatal providers Other (please specify) OK Question Title * 22. Has your site developed unique clinical pathways/order sets for pregnant women with OUD? Yes No OK Question Title * 23. If you entered yes for question 23, which pathways (Check all that apply)? Prenatal Care Intrapartum Care Postpartum pain control Postpartum care Other (please specify) OK Question Title * 24. If you entered yes for question 23, do clinical pathways include screening all pregnant women with OUD for additional co-morbidities? Yes No OK Question Title * 25. If you entered yes for question 25, which comorbidities? HIV HCV Psychiatric comorbidities Intimate Partner Violence (IPV) Pregnancy intention Other (please specify) OK Question Title * 26. Is a “Plan of Safe Care” developed for all pregnant women with OUD prior to hospital discharge? Yes No OK Question Title * 27. If you entered yes for question 27, which care team develops this plan? (Check all that apply) Social services/social work Obstetricians/prenatal providers Nursing Other (please specify) OK Question Title * 28. Does your site provide immediate postpartum contraceptive counselling and services? Yes No OK Question Title * 29. If you entered yes for question 29, which contraceptive methods are provided in the immediate postpartum period? (Check all that apply) Nexplanon IUD Oral contraceptives/vaginal ring/patch/injection Tubal ligation Other (please specify) OK DONE