Community Care Hub: Key Informant Questionnaire

Your Organization(Required)

Your Name(Required)

First Last

Your Title(Required)

Your Email(Required)

Your Phone(Required)

What services does your organization provide? (Check all that apply.)(Required)

If "Other", please list.(Required)

How does your organization currently share or access electronic clinical information with/from other medical providers (outside your organization) involved in the care of your patients? (Check all that apply.)(Required)

We offer other providers read-only access to our EHR (directly or through a portal)

We have read-only access to another provider's EHR (directly or through a portal)

We have read-only access to a Health Information Exchange (HIE) such as Contexture/CORHIO

We participate in two-way data exchange (sending and receiving) through an HIE

We make and/or receive electronic referrals

We provide and/or receive electronic test results

We send electronic prescriptions to pharmacies

Not applicable

Other

If other, please explain.(Required)

Which of the following areas do you screen for with your clients/patients?(Required)

If "Other", please explain.(Required)

Roughly, how many clients/patients does your organization serve per month?(Required)

Roughly, what percentage of these clients/patients do you estimate are La Plata County residents?(Required)

What are your sources of funding?(Required)

If "Other", please explain.(Required)

How many staff does your organization have that are able to either send or receive client/patient referrals as part of their regular duties?(Required)

None

1-3

4-6

How many client/patient referrals each month does your organization typically receive from external organizations (i.e. other than your own)?(Required)

If "None", why do you think other organizations are not referring patient/clients to you? (Check all that apply.)(Required)

Not enough demand for our services

They don't know about us

They don't have enough time or capacity

They don't have systems in place to make referrals

They prefer their clients to refer themselves

We're perceived as competition

No idea

Other

If "Other", please explain.(Required)

Where do these client/patient referrals typically come from? (Check all that apply.)(Required)

If "Other", please explain.(Required)

What methods do external organizations typically use to refer clients/patients to you? (Check all that apply)(Required)

They provide their clients/patients with our info and have them contact us.

They call us with the client/patient present.

They email us and include their client's/patient's contact info.

They generate the referral using their electronic referral platform.

Other

If "Other", please explain.(Required)

How many times per month is your organization unable to accept a client/patient referral?(Required)

What are typically the reasons for turning away clients/patients? (Check all that apply.)(Required)

If "Other", please list.(Required)

How many client/patient referrals each month does your organization typically make to external organizations (i.e. other than your own)?(Required)

If "None", please explain why. (Check all that apply.)(Required)

We are able to provide for our client/patient needs

We don't have the staff or resources to make referrals

We provide information on local resources

We prefer our clients/patients to self-refer

Client/patient confidentiality issues

Not enough demand

Other

If "Other", please explain.(Required)

What type of organizations do you typically make client/patient referrals to? (Check all that apply.)(Required)

If "Other", please explain.(Required)

Do you currently use software in any way to manage how you send or receive referrals?(Required)

Yes

If "No" please explain why. (Check all that apply.)(Required)

If "Other", please explain.(Required)

If yes, what type of software do you use? (Check all that apply.)(Required)

Spreadsheet (i.e. Excel, Google Sheets, etc.)

Electronic health record (i.e. EHR, EMR, etc.)

Customer Relationship Management (i.e. CRM)

Web-based referral platform (e.g. Unite Us)

Email program (e.g. Outlook, Gmail, Apple Mail, etc.)

Calendar program

Other

If "Other", please explain.(Required)

How do you typically make referrals to external organizations? (Check all that apply.)(Required)

If "Other", please explain.(Required)

Please indicate your level of satisfaction with the following aspects of your software systems or processes for managing referrals?(Required)

	Very dissatisfied	Dissatisfied	Neutral	Satisfied	Very satisfied	Not applicable
Subscription and/or maintenance cost
Time required to learn
Time required to use
Ease of use
Client/patient security & privacy
Tracking & reporting capabilities
Customer support
Ability to customize

For each of the following, please indicate which method(s) your organization uses for client/patient management.(Required)

	Software (e.g. EHR, CRM, Unite Us, etc.)	Non-software method (paper-based)	Multiple methods	Not applicable
Creating client/patient records
Identifying local client/patient resources
Sending referrals to other organizations
Receiving referrals from other organizations
Tracking when unable to accept a referral
Conducting client/patient screening
Tracking client/patient encounters
Tracking & reporting on client outcomes
Scheduling appointments
Setting follow-up reminders

Phone

This field is for validation purposes and should be left unchanged.