Basic Information

By April 30, please work with your team to complete this birth site-level survey for the period of January through March 2022.

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* 1. What is your PA PQC Hospital or Affiliation?

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* 2. What is your name?

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* 3. What is your title/role?

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* 4. Is your hospital routinely counseling, offering, and providing IPLARCs (either IUDs or Implants) for postpartum women with OUD and for all postpartum women?

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* 5. Are inpatient IUDs available on your hospital formulary?

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* 6. If selected, “In place (one or more IUDs are available)” in question 5, check all that apply below:

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* 7. Are inpatient implants available on your hospital formulary?

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* 8. Are inpatient LARC devices (with needed supplies) available on labor and delivery and/or on the postpartum unit?

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* 9. What inpatient LARC devices are available on labor and delivery or on the postpartum unit?

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* 10. Do you have immediate postpartum protocols in place for IUDs?

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* 11. Which departments have implemented a protocol to support immediate postpartum placement of IUDs? (Check all that apply)

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* 12. Have you implemented billing codes for IUDs?

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* 13. Have you implemented billing codes for implants?

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* 14. If billing codes are implemented for IUD, implant, or both, with which payers do you have billing strategies in place? (Check all that apply)

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* 15. If selected “Medicaid MCOs” (please check all that apply)

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* 16. If selected “Private insurers” (please check all that apply)

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* 17. Has your hospital billed for the devices you placed?

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* 18. Have you received reimbursement for the devices that you placed? (check all that apply)

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* 19. If you answered “Yes, from MCO(s)” in question 18, select the following that apply.

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* 20. If you selected "Yes, from private payor(s)" in question 18, select the following that apply

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* 21. Does your hospital have IT/EMR revisions implemented for tracking and documentation of immediate postpartum placement of IUDs?

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* 22. If you selected, “In place,” in question 21, where does IUD documentation occur? (check all that apply)

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* 23. If you selected, “In place,” in question 21, which IT/EMR revisions have been completed to assure adequate tracking and documentation for IUDs? (check all that apply)

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* 24. Does your hospital have IT/EMR revisions implemented for tracking and documentation of immediate postpartum placement of implants?

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* 25. If you selected, “In place,” in question 24, where does implant documentation occur? (check all that apply)

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* 26. If you selected, “In place,” in question 24, which IT/EMR revisions have been completed to assure adequate tracking and documentation for implants? (check all that apply)

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* 27. Number of affiliated prenatal care sites: (please answer in whole numbers) 

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* 28. Have you provided patient education materials and counseling protocols for affiliated prenatal care sites regarding IPLARC, including all contraception options?

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* 29. If you selected, “yes, one or more,” in question 28, please specify the number of affiliated prenatal care centers to whom you’ve provided materials: (please answer in whole numbers)

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* 30. What is the cumulative percent of Physicians and Midwives trained on IPLARC evidence, protocols, and counseling at your hospital?

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* 31. What is the cumulative percent of Physicians and Midwives trained on immediate postpartum placement of IUDs?

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* 32. What is the cumulative percent of Physicians and Midwives trained on immediate postpartum placement of implants?

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* 33. What is the cumulative percent of Nurses trained on immediate postpartum placement evidence and protocols?

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* 34. What is the cumulative percent of Lactation Consultants trained on immediate postpartum placement evidence and protocols?

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* 35. What is the cumulative percent of Social Workers trained on immediate postpartum placement evidence and protocols?

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