Copy of Phase 2: HealthEquitySurvey2022-2023

Health Equity Improvement Plan

Colorado Primary Care Clinic is re-developing and re-designing its action plan to improve upon and better provide community resources for those in need. To best target our efforts to help meet your needs, please complete this survey in total. All of your data is confidential! Thank you for taking the time to complete this survey! Dr. Dawn

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* 1. What is your age?

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* 2. What race do you identify with the most?

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

Other (please specify)

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* 3. What ethnicity do you identify with the most?

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another ethnicity

Other (please specify)

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* 4. Gender: How do you identify?

Female

Male

Transgender Female

Transgender Male

Prefer to self-describe, below

Self-describe:

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* 5. Do you think your race, ethnicity and/or gender identity create barriers to medical and/or mental healthcare?

Yes

If YES, (please describe)

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* 6. Chronic Disease Recognition...A Chronic disease includes any condition lasting longer than 3 consecutive months without interruption. A chronic disease or condition could be diabetes, high blood pressure, high cholesterol, asthma, depression, anxiety to name a few. Please select the appropriate answer for you to this question. I have,

1-3 conditions

4-6 conditions

7 or more conditions

None of the above

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* 7. Economic Stability- Financial Strain
How often does this describes you? I have enough money to pay my bills?

Never

Rarely

Sometimes

Often

Always

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* 8. Can you pay all your bills in one month (Gas, electric, rent water, oil, gasoline, medical bills)?

Yes

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* 9. Employment: Do you want help finding or keeping work or a job?

Yes, help finding work

Yes, help keeping job

No, do not need or want help

Other (please specify)

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* 10. Neighborhood and Physical Environment
What is your zip Code

ZIP/Postal Code

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* 11. Housing instability: Do you have problems with any of the following?
Select all that apply.

Bug infestation

Mold

Lead paint or lead pipes

Inadequate heat

Oven or stove not working

No or not working smoking detectors

Water leaks

None of the above

Other (please specify)

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* 12. Transportation: Do you put off or neglect going to the doctor because of distance or transportation?

Yes

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* 13. Does your neighborhood provide safe parks and the ability to walk in the area safely?

Yes

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* 14. Do you feel safe at home?

Yes

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* 15. Education
Please indicate the following:

Highest level of school completed:

Primary Language Spoken:

Other Language(s) Spoken:

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* 16. Food
Do you have access to healthy foods on a daily basis?

Yes

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* 17. Food
Is healthy food cost a barrier to purchasing healthy food on a daily basis?

Yes

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* 18. Community Context and Social Context
Have you successfully identified with appropriated resources to help you with transition in the community where you live such as: faith organizations, family, friends, schools and community resources?

Yes

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* 19. Do you feel like you are under stress?

Yes

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* 20. Do you feel like you are being discriminated against at school, at work, other?

Yes

If YES, (please describe how)

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* 21. Health Care System
Do you think your health insurance creates barriers for your physical health care or mental health care?

Yes

If YES, (please describe)

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* 22. Health Insurance: Do you have health insurance with adequate provider availability, culturally sensitive providers and focus on quality of care?

Yes

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* 23. Mental Health and Substance Use Disorder
Mental Health
*Over the past 2 weeks, how often have you been bothered by any of the following problems?

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
a. Little interest or pleasure in doing things?	a. Little interest or pleasure in doing things? Not at all (0)	a. Little interest or pleasure in doing things? Several days (1)	a. Little interest or pleasure in doing things? More than half the days (2)	a. Little interest or pleasure in doing things? Nearly every day (3)
b. Feeling down, depressed, or hopeless?	b. Feeling down, depressed, or hopeless? Not at all (0)	b. Feeling down, depressed, or hopeless? Several days (1)	b. Feeling down, depressed, or hopeless? More than half the days (2)	b. Feeling down, depressed, or hopeless? Nearly every day (3)
c. Thoughts that you would be better off dead or of hurting yourself in some way	c. Thoughts that you would be better off dead or of hurting yourself in some way Not at all (0)	c. Thoughts that you would be better off dead or of hurting yourself in some way Several days (1)	c. Thoughts that you would be better off dead or of hurting yourself in some way More than half the days (2)	c. Thoughts that you would be better off dead or of hurting yourself in some way Nearly every day (3)

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* 24. Substance Use
The next set of questions relate to your experience with alcohol, cigarettes, and other drugs. Answer the questions if you use non-prescribed substances, or substances in higher quantities than prescribed by your provider. One question is about illicit or illegal drug use; we ask to best identify community services that may be available to help you.

	Never	Once or Twice	Monthly	Weekly	Daily or Almost Daily
a. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits.	a. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Never	a. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Once or Twice	a. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Monthly	a. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Weekly	a. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Daily or Almost Daily
b. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)?	b. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? Never	b. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? Once or Twice	b. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? Monthly	b. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? Weekly	b. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? Daily or Almost Daily
c. How many times in the past year have you used prescription drugs for non-medical reasons?	c. How many times in the past year have you used prescription drugs for non-medical reasons? Never	c. How many times in the past year have you used prescription drugs for non-medical reasons? Once or Twice	c. How many times in the past year have you used prescription drugs for non-medical reasons? Monthly	c. How many times in the past year have you used prescription drugs for non-medical reasons? Weekly	c. How many times in the past year have you used prescription drugs for non-medical reasons? Daily or Almost Daily
d. How many times in the past year have you used illegal drugs?	d. How many times in the past year have you used illegal drugs? Never	d. How many times in the past year have you used illegal drugs? Once or Twice	d. How many times in the past year have you used illegal drugs? Monthly	d. How many times in the past year have you used illegal drugs? Weekly	d. How many times in the past year have you used illegal drugs? Daily or Almost Daily

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* 25. We are screening for 7 social determinants of health (SDoH). Each social determinant of health plays a role in our everyday lives. Rank each social determinant of health with a number, 1-2-3-4-5-6-7. 1 means it impacts you the most, and 7 means it impacts you the least. How does each social determinant of health impact you directly. The ranking does not have to be listed in order. It can be random, such as 5, 3, 7, 1, 2, 4, 6.

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* 26. Are you using community resources to manage your social determinant of health need(s), such as finding a job, food assistance, housing assistance, etc?

Yes

If yes, list the resources you use...
If no, explain the reason why you do not use community resources...

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* 27. Do you know what community resources are available to meet your needs?

Yes

Other (please specify)

Copy of Phase 2: HealthEquitySurvey2022-2023

Health Equity Improvement Plan

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* 1. What is your age?

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* 2. What race do you identify with the most?

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* 3. What ethnicity do you identify with the most?

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* 4. Gender: How do you identify?

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* 5. Do you think your race, ethnicity and/or gender identity create barriers to medical and/or mental healthcare?

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* 7. Economic Stability- Financial StrainHow often does this describes you? I have enough money to pay my bills?

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* 8. Can you pay all your bills in one month (Gas, electric, rent water, oil, gasoline, medical bills)?

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* 9. Employment: Do you want help finding or keeping work or a job?

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* 10. Neighborhood and Physical EnvironmentWhat is your zip Code

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* 11. Housing instability: Do you have problems with any of the following? Select all that apply.

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* 12. Transportation: Do you put off or neglect going to the doctor because of distance or transportation?

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* 13. Does your neighborhood provide safe parks and the ability to walk in the area safely?

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* 14. Do you feel safe at home?

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* 15. EducationPlease indicate the following:

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* 16. FoodDo you have access to healthy foods on a daily basis?

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* 17. Food Is healthy food cost a barrier to purchasing healthy food on a daily basis?

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* 18. Community Context and Social Context Have you successfully identified with appropriated resources to help you with transition in the community where you live such as: faith organizations, family, friends, schools and community resources?

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* 19. Do you feel like you are under stress?

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* 20. Do you feel like you are being discriminated against at school, at work, other?

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* 21. Health Care SystemDo you think your health insurance creates barriers for your physical health care or mental health care?

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* 22. Health Insurance: Do you have health insurance with adequate provider availability, culturally sensitive providers and focus on quality of care?

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* 23. Mental Health and Substance Use Disorder Mental Health*Over the past 2 weeks, how often have you been bothered by any of the following problems?

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* 26. Are you using community resources to manage your social determinant of health need(s), such as finding a job, food assistance, housing assistance, etc?

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* 27. Do you know what community resources are available to meet your needs?

* 7. Economic Stability- Financial Strain
How often does this describes you? I have enough money to pay my bills?

* 10. Neighborhood and Physical Environment
What is your zip Code

* 11. Housing instability: Do you have problems with any of the following?
Select all that apply.

* 15. Education
Please indicate the following:

* 16. Food
Do you have access to healthy foods on a daily basis?

* 17. Food
Is healthy food cost a barrier to purchasing healthy food on a daily basis?

* 18. Community Context and Social Context
Have you successfully identified with appropriated resources to help you with transition in the community where you live such as: faith organizations, family, friends, schools and community resources?

* 21. Health Care System
Do you think your health insurance creates barriers for your physical health care or mental health care?

* 23. Mental Health and Substance Use Disorder
Mental Health
*Over the past 2 weeks, how often have you been bothered by any of the following problems?