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* 1. In which county is your facility located 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 Member is first referred to treatment, the facility receives sufficient clinical information about the Member from the referral source.

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* 3. When a Member is first referred 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 referred to treatment, the facility receives timely (within 10 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, in-home services, probation officers, PerformCare Care Manager) 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, in-home services, probation officers, PerformCare Care Manager) 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 or provide the barriers in treatment team meetings?

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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 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 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, such as outpatient providers, Targeted Case Managers, in-home service, 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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