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* 1. In which county is your agency located? 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, your program 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, your program 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, your program receives timely (within 7 calendar days) 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, Certified Recovery Specialist, in-home providers, Parole Officers) 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, Certified Recovery Specialist, in-home providers, Parole Officers) to coordinate 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 who decline aftercare, left against medical advice, or this is the last level of treatment.

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* 9. Is this a true statement? Ninety-five percent of the time when discharge planning is being 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 decline natural support involvement.

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* 10. Do the majority of other providers (e.g., outpatient, Targeted Case Managers, Certified Recovery Specialist, in-home providers and Residential Treatment Facilities) respond to your outreach calls 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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