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* 1. In which county is your facility located (where you are treating Members) or state if not in Pennsylvania? Although all responses are kept confidential, you may decline to respond to this question.

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* 2. When a PerformCare Member is first admitted to treatment, the facility receives sufficient clinical information about the Member from the referral source:

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* 3. When a PerformCare Member is first admitted to treatment, the facility receives accurate clinical information about the Member from the referral source:

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* 4. When a PerformCare Member is first admitted to treatment, the facility receives timely (within 24 hours of the request) clinical information about the Member from the referral source:

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* 5. How often do you invite other providers (e.g., outpatient, Targeted Case Managers, and in-home providers) to treatment team meetings to obtain additional information or provide updates on treatment progress? (Telephonically or in-person)

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* 6. How often do you contact other providers (e.g., outpatient, Targeted Case Managers, or in-home service providers) involved in the Member’s care to coordinate care or share discharge information?

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* 7. When barriers are identified or pertinent clinical information arises, how often do you contact PerformCare Clinical Care Managers?

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* 8. Is this a true statement? Ninety-five percent of the time when discharge planning is set up for the next level of care, the Member has a specific date and time of the first appointment. This excludes Members/parent/guardian who declined aftercare or left against medical advice.

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* 9. Is this a true statement? Ninety-five percent of the time when discharge planning is set up, the discharge planner includes the natural supports (e.g., parent/guardian/family member or friend), and they are agreeable with the date and time of the first appointment. This excludes Members who declined natural support involvement.

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* 10. Do the majority of other providers, such as outpatient, Targeted Case Managers, in-home service, and Residential Treatment Facilities, respond to your outreaches within two business days?

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* 11. When a PerformCare Member reports they smoke cigarettes or use vaping products, do you offer to discuss tobacco recovery, offer educational materials, or provide nicotine replacement treatment?

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* 12. When a PerformCare Member is interested in tobacco cessation treatment, do you assist the Member in finding providers for follow up or outreach to PerformCare for assistance?

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