SHIP Evaluation / 2012-2013 /
Minnesota Department of Health /
SHIP Evaluation /
SHIP Prevention in Health Care /

Introduction

The Baseline Data Collection Form is the mandatory evaluation tool required for the SHIP Prevention in Health Care Strategy. The focus of required SHIP evaluation is on reach and changes in the areas of protocol, systems, and environment. The data needed to fulfill evaluation requirements in these areas is described on the form, and instructions on how to complete the survey are provided as follows.

1.Reach: This measurement provides an estimate of the number of patients that could potentially benefit from the strategy implementation. To respond, please furnish an estimate of the number of patients your clinictreats by choosing one of the options to complete. Options a, b and c are based on an estimate of the number of patients seen by your clinic over a period of time.

If options a – cdon’t fit the method your clinic uses to estimate this number, option d allows for a different measure for the number of patients a clinic estimates it might service. Among definitions used for this number are “Active Patients” (a number used by Minnesota Community Measurement) and “non-duplicated patient visits”. Any type of estimate used is acceptable – provided it is used on an ongoing basis and will allow for consistent measurement of reach at baseline and follow-up. Please include a short description of the method used to determine this number in the write-in section of the form.

  1. Patient demographics: Please provide an estimate of the ethnic/racial populations served by your clinic.
  2. Clinic medical records system: Please indicate whether your clinic uses paper charts for patient records or an Electronic Medical Record (EMR) system to maintain patients’ clinical information. If an EMR system is used, please write in the name of the system and the approximate date the system was first implemented.
  3. Chart audits:To implement the SHIP Prevention in Health Care Strategy, a method is needed to systematically measure progress. Please indicate how often chart audits are done on a regular basis excluding special chart audits based on special reporting obligations.
  4. Health Care Strategy steps in place:As part of the data needed for evaluation, it is important to know the implementation status of the Health Care Strategy steps at baseline. Please indicate the current level of implementationin patient care steps that are the same or similar to any of the SHIP Health Care Strategy steps. Please check only one box for each of the steps listed in the left-hand column. If no work has been done on a step at the present time, check the N/A box.
  5. Protocol adoption: To help us measure how much time your clinic has had to work on implementation of the Health Care Strategy, please indicate the date your clinic has adopted a protocol supporting implementation of the Health Care Strategy.
  6. Patient visit type selected: Please check the box indicating the type of patient visit your clinic selected for implementation of the Health Care Strategy steps Screen, Counsel, Refer and Follow-up. If the first three options provided don’t fit your chosen patient visit, please check the “other” box and provide a short description of the patient visit type selected for implementation.
  7. For the patient visit type selected for Health Care Strategy implementation, which screened patients qualify for the remaining Strategy steps:Please indicate which patients qualify for application of the steps counseling and referral (andfollow-up, if selected for implementation) after screening. If the first three choices do not adequately describe what your clinic is doing, please check the “other” box and provide a description of patients who do receive it.
  8. Systems changes:To advance implementation of the Health Care Strategy, clinics will often decide to make changes in their systems to support clinic personnel that are involved in the process of providing patient care. For example, your clinic might decide to change the process used to check in patients by giving them a short survey measuring wellness status and readiness to change their behaviors related to physical activity, nutrition and tobacco use. Please indicate which of the systems changes your clinic decided to make as part of the SHIP implementation. The items listed are not intended to reflect all possible systems changes, but only a representation of changes that could be made. If your clinic made changes not listed here, please check the “other” box and provide a short description.
  9. Environmental changes:In addition to changes in the systems that support patient care, your clinic may have decided to make changes in the clinic environment. For example, your clinic may decide to add posters related to tobacco cessation, increased physical activity and improved nutrition to all patient rooms and waiting areas. As with system changes, please indicate which of the environmental changes your clinic decided to make as part of the SHIP implementation. Again, the items listed are not intended to reflect all possible environmental changes, but only a representation of changes that could be made. If your clinic made changes not listed here, please check the “other” box and provide a short description.
  10. Implementation status:The following grid is provided to measure where in the process of implementing the SHIP Health Care Strategies your clinic is at the time you complete this form. Please check the boxes that best represent where your clinic is in implementation of each strategy step. This is not intended to be an exact measure, only an overall indication of implementation progress. If for example, your clinic has only recently started participation in the SHIP Health Care Strategy, checking “initial stages” might be appropriate. Or if your clinic participated in SHIP during the last funding cycle, checking “In process” or “Completed” might be appropriate depending on the progress made. If implementation has not started for a step, “N/A” would be appropriate.

If you have any questions, please contact you SHIP health care contact for more information.

Thank you for your cooperation!

Baseline Data Collection FormPage 1SHIP Evaluation

Provider/clinic name ______

Date ______

Staff contact ______

  1. Reach: The number of people that the clinic can potentially benefit from implementation of the Health Care strategy. (Please chose one)

a)Patients treated per week______Date determined _____ / ______/ _____

DayMonthYear

b)Patients treated per month______Date determined _____ / ______/ _____

DayMonthYear

c)Patients treated per year______Date determined _____ / ______/ _____

DayMonthYear

d)Other method described below.Date determined _____ / ______/ _____

DayMonthYear

Please provide a brief description of the method used to estimate the reach number provided for d) above.

______

______

______

______

  1. Patient Demographics

Please estimate the percentage of patients seen according to the following ethnic and race descriptions:

____Hispanic/Latino

____American Indian/Native Alaskan

____Asian

____Black/African American

____Native Hawaiian/Other Pacific Islander

100%Total

  1. Clinic medical records system

Please indicate which method is used to maintain medical records for patients:

Paper charts/records

Electronic medical record (EMR)

If EMR is used, please record:

  • EMR software system name here: ______
  • Approximate date EMR system was implemented: _____ / ______/ _____

DayMonthYear

  1. Chart audits

How often does the Clinic do chart audits?

(Please check one)

Monthly

Quarterly

2 times per year

1 time per year

Other: Please describe______

______

______

  1. SHIP Health Care Strategysteps in place

Please indicate which of the following Strategy stepsare in place at the present time.Please check only one box for each of the steps. If implementation for a step has not yet begun, check N/A.

Step / N/A / Screening / Counseling / Referral / Follow up
Tobacco use/exposure /  /  /  /  / 
BMI /  /  /  /  / 
Physical activity /  /  /  /  / 
Nutrition /  /  /  /  / 
  1. Protocoladoption – decision to adopt the SHIP Healthcare Strategy for implementation

Please enter approximate date the strategy was adopted: _____ / ______/ _____

DayMonthYear

  1. Patient visit type selected for strategy implementation

(Please check one)

Annual physical exam

All non-acute care patient visits

All patient visits

Other visit type: Please describe______

______

______

  1. For the patient visit type selected for Health Care Strategy implementation, which patients receive counseling and referral (plus follow-up, if selected for implementation) after screening:

(Please check all that apply)

Patients who screen positive for overweight/obese by BMI

Patients who screen positive for tobacco use or exposure to tobacco

All patients seen for the type of visit selected above

Other: Please describe______

______

______

  1. Systems changes:Changes selected for clinic systems that support implementation of the Health Care Strategy. For sections a b c d and e below, please check all items that apply.
  1. At patient check-in(Please check all that apply)

Patient completessurvey assessingwellness statusreadiness-to-change health behaviors

Patient receives list of community resources for physical activity, nutrition and tobacco cessation referrals

Other: Please describe______

______

______

______

  1. Before clinician visit(Please check all that apply)

Medical assistant/nurse charts height/weight

Medical assistant/nurse calculates and charts BMI

Other: Please describe______

______

______

______

  1. During clinician visit(Please check all that apply)

Clinician reviews BMI with patient

Clinician reviews assessment of wellness status & readiness-to-change with patient

Cliniciandocuments patient goals for health improvement in medical record problems list

Clinician makes referral(s) based on patient’s health improvement goals

Clinician schedules follow-up appointment

Other: Please describe______

______

______

______

  1. At check-out after visit(Please check all that apply)

Patient schedules follow-up visit

Patient referral(s) scheduled

Other: Please describe______

______

______

______

  1. Charting changes(Please check all that apply)

Paper chart is changed to provide space for a clinician reminder regarding the Screen, Counsel, Refer and Follow-up steps.

EMR systems are modified to flag and track the Screen, Counsel, Refer and Follow-up steps as searchable fields.

Increase frequency of chart audits to monitor implementation progress

Other: Please describe______

______

______

______

  1. Environmental changes:Changes selected for the clinic environment that support implementation of the Health Care Strategy.

(Please check all that apply)

Increase staffing to support increased service to patients

Provide care coordination for overweight and obese patients who request it

Pursue Health Care Home certification

Provide additional stadiometers and scales to support BMI screening

Survey assessing wellness status & readiness-to-change health behaviors provided for patients

Listing of community resources available for referral is developed and provided for patients

Put patient education materials supporting SHIP health care strategies in waiting areas and patient rooms

Clinic waiting areas are updated to include furniture designed for overweight patients

Clinic staff receive training on the special needs of patients that are overweight or are tobacco users

Other: Please describe______

______

______

______

  1. Implementation status

What best describes the clinic’s stage of implementation regarding the SHIP Health Care Strategy steps? Please check only one box for each of the steps. If implementation for a step has not yet begun, check N/A.

Step / N/A / Initial stages / In process / Completed
Screen /  /  /  / 
Counsel /  /  /  / 
Refer /  /  /  / 
Follow-up /  /  /  / 
  1. Comments, recommendations

If you have any comments about this form, the data you have provided or any other topic related to evaluation of your clinic’s implementation of the SHIP Health Care Strategy, please share in the space provided below.

______

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Thank you for your participation!

Baseline Data Collection FormPage 1SHIP Evaluation