Common use of Strategic Goals Clause in Contracts

Strategic Goals. The goal of this new statewide program is to help health care practices identify, diagnose, and manage depression, anxiety, and substance use in pregnant and postpartum women (the 12-week period after giving birth). Support prenatal care practices in screening, identification, and management of perinatal depression, anxiety and substance use; Improve prenatal care provider confidence and skills in managing mild-to-moderate cases of perinatal depression, anxiety, and substance use; Improve universal screening rates of eligible pregnant and postpartum patients for perinatal depression, anxiety, and substance use using evidenced-based screening tools Participating Prenatal Care Practices will receive monthly on-site consultation and coaching from a trained Clinical Quality Improvement Facilitator; Data Management Training and Support; In-person professional education presented quarterly by Perinatal Behavioral Health Specialists including Best Practice Sharing; Assumptions: Systems of care will provide practices with IT support needed to effectively capture and report screening rates for perinatal depression, anxiety, and substance use MomsPRN Practices will participate from October 2019 through December 2020 with expectation that practice will participate in October 2019 Orientation Program, and quarterly learning collaborative. Practice QI Team will participate in monthly meetings with Practice QI Facilitator. All Clinical Providers to complete Self-Efficacy Surveys at beginning and end of initiative. (Please see Attachment A). Practices will submit baseline and quarterly reports of Screening Rates as outlined in Attachment B) 3-Month Preparation Period QI Initiative Activities (October – December 2019): Participate in October 2019 Orientation Program; Identify members of the practice quality improvement (QI) team. The team should consist of 3 to 4 staff in different roles and include a practice clinical champion and an IT/EHR staff member; Practice QI team participation in monthly meetings with the practice QI facilitator; Practice QI team attendance and participation at in-person kick-off learning session; Plan and test practice workflows to implement screening for perinatal depression, anxiety and substance use with validated screening tool(s); Test EMR system to determine workflow for documentation of screening results; Submit a baseline report of screening rates for perinatal depression, anxiety, and substance use; Complete baseline clinical provider self-efficacy survey within 45 days of award notification; In conjunction with the QI practice facilitator, identify quality improvement activities to optimize perinatal behavioral health screening, treatment and referral Implement screening for perinatal depression, anxiety and substance use with validated screening tool(s); Utilize the RI Moms PRN provider teleconsultation line as needed; Report de-identified practice screening rates and proportion of positive screens quarterly and by zip code; Practice QI team participation in monthly meetings with the practice QI facilitator; Practice QI team attendance and participation in quarterly in-person learning network meetings; Complete provider self-efficacy surveys on an annual basis Practices will be eligible to receive: Infrastructure payment of $5,000 that practices can use to offset costs associated with EMR modifications, staff time, and participation in quality improvement activities; $5,000 of incentive payments based on increasing perinatal depression, anxiety, and substance use screening rates using evidenced-based tools CTC will make incentive payment to the practice at the end of the Performance Period (December 2020). CTC reserves the right to delay/withhold payments if Practice fails to meet any of the practice requirements as outlined in Milestone Document (Please see Attachment C). Care Transformation Collaborative of RI Prenatal Care Practice name. _______________________________________ _____________________________________ Signature: ▇▇▇▇▇ ▇▇▇▇▇▇▇, Signature of authorized staff: Executive Director, CTC-RI Name: _________________________ Positon: ________________________ Survey Monkey Link: Provider Baseline Self Efficacy Survey: ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/r/ProviderSelfEfficacy aseline Questionnaire Thank you for taking a few minutes to complete this questionnaire. The following questions address your experiences with perinatal mental health. Provider name: _______________________ Date of assessment: _________________ Practice name: ________________________ What is your primary medical specialty? ☐
Obstetrics only ☐
Gynecology only ☐
General Obstetrics and Gynecology ☐
Maternal-Fetal Medicine Specialist ☐
General Psychiatry ☐
Perinatal Psychiatry ☐
Primary Care/Family Medicine ☐
Other (Specify) How many years have you been in practice? Which of the following best describes your practice location? ☐
Urban – inner city ☐
Urban – non-inner city ☐
Suburban ☐
Mid-sized town (10,000-50,000) ☐
Rural ☐
Military ☐
Other (Specify) Which of the following best describes your type of practice? ☐
Solo Private Practice ☐
Partnership or Group Practice ☐
Multi-Specialty Group ☐
HMO/Staff Model ☐
University Full-Time Faculty and Practice ☐
Military ☐
Other (Specify) What is your gender? ☐
Female ☐
Male ☐
Other (Specify) ☐
Prefer not to answer What race do you consider yourself? (select all that apply) ☐
American Indian/Native American ☐
Alaska Native ☐
Asian/Asian American ☐
Black/African American/African ☐
Native Hawaiian/Other pacific Islander ☐
White/Caucasian ☐
Other (Specify) ☐
Prefer not to answer What ethnicity do you consider yourself? ☐
Hispanic or Latino ☐
Non-Hispanic or Latino ☐
Prefer not to answer What is your professional title? ☐
Physician ☐
Attending ☐
Fellow ☐
Resident ☐
Certified Nurse Midwife ☐
Nurse Practitioner ☐
Nurse Manager ☐
Social Worker or Case Manager ☐
Other (Specify) At the following time points, which of the following do you consistently screen for (using a validated screening tool)? Never Rarely Sometimes Often Always Not applicable Early pregnancy (0-20 wks. GA) Late pregnancy (21 wks. or more GA) Hospitalization for delivery Early postpartum (0-3 months PP) Late postpartum (4-12 months PP) Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Please consider the following statements regarding your pregnant and postpartum patients and indicate the most appropriate response: Never Rarely Sometimes Often Always Not applicable I am able to provide education around depression and anxiety to my patients. I discuss depression and anxiety and their treatment options with my patients. I discuss the risks and benefits of antidepressant use during pregnancy and postpartum. I discuss the risks and benefits of other psychiatric medications during pregnancy and postpartum. I am able to treat my patients with antidepressant medications. I am able to treat my patients with other psychiatric medications. I am confident determining when to refer for therapy vs. when to start medications for depression or anxiety in my patients. I am able to adequately access non-medication treatments for my patients with depression and anxiety. When I need a perinatal psychiatric consultation, I am able to receive one in a timely manner. I can facilitate referrals for my patients to depression/anxiety treatment. I am able to ensure that my patients with depression and anxiety receive treatment in a timely manner. I am confident monitoring depression/anxiety and adjusting medications for depression/anxiety in my patients. When my patient’s care is complete, I am able to transition her for ongoing depression or anxiety follow-up if needed. Please consider the following statements regarding your pregnant and postpartum patients and indicate the most appropriate response: Never Rarely Sometimes Often Always Not applicable I am able to provide education around substance use disorders to my patients. I discuss substance use disorders and treatment options with my patients. I am able to treat my patients with opioid use disorders by prescribing medications such as buprenorphine or methadone. I am confident determining when to refer for therapy vs. when to start medications for substance use disorders in my patients. I am able to adequately access non-medication treatments for my patients with substance use disorders. When I need a perinatal substance use consultation, I am able to receive one in a timely manner. I can facilitate referrals for my patients to substance use disorder treatment. I am able to ensure that my patients with substance use disorders receive treatment in a timely manner. I am confident monitoring substance use disorders and adjusting medications for substance use disorders. When my patient’s care is complete, I am able to transition her for ongoing substance use disorder follow-up if needed. Survey Monkey Link: Practice Level Self Efficacy Survey: ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/r/PracticeSelfEfficacy aseline Questionnaire Provider name: _______________________ Date of assessment: _________________ Person responding to the interview:_______________________ Title:_________________ Type of Practice: ☐
Private with no health system or university affiliation ☐
Private with health system or university affiliation ☐
Health system with no university affiliation ☐
Health system with university affiliation ☐
Academic medical center ☐
Federally qualified health center ☐
Public clinic with no university/academic affiliation ☐
Public clinic with university/academic affiliation ☐
Other (Specify) Please enter the number of the following staff in this practice: Number of Obstetrics/Gynecology (OB/GYN) providers __________ Number of Obstetrics (OB) only providers __________ Number of Gynecology (GYN) only providers __________ Number of Family Medicine providers __________ Number of Primary Care providers __________ Number of Medical Residents __________ Number of Licensed independent practitioners (PAs, RNCS, NPs) __________ Number of Nurse midwives __________ Number of MAs, RNs, PCAs, CIPs __________ Other __________ Does the practice have an onsite behavioral health professional available? ☐
Yes ☐
No If yes, is this a: ☐
Psychiatric prescriber ☐
Psychotherapist ☐
Masters’ level clinician ☐
Other_________________ Does the practice have a system in place to facilitate access to a behavioral specialist? ☐
Yes ☐
No If yes, which one? ☐
co-located behavioral health specialist ☐
case manager to assist with referral ☐
access to telephone consultation with mental health specialist ☐
ensure that all patients are referred to a behavioral health specialist Is this location part of a larger practice with multiple locations? ☐
Yes ☐
No If yes, name of the larger practice: ____________________________ Number of locations in the larger practice where prenatal services are provided: _______________ Total # locations Number of locations in the larger practice where prenatal services are provided: _______________ Total # births for the larger practice What is the total number of births per year for all providers/clinicians in this location? _______________ Total # of births across all providers Approximate payer mix: For the list of payers that follows, regarding the approximate payer mix for this practice location/office, list the percent for each payer. Please provide an estimate if the exact percent is not known. The total percentage of all payers cannot be greater than 100%. Tricare/Other Military __________% Medicaid __________% Other Public __________% Private or Commercial __________% Self-Pay __________% Other __________% Other – Specify ____________________% Observed or reported ethnicity of first prenatal care visit patients: For the first prenatal care visit patients at this medical practice location/office, please indicate the percent of those patients with the following observed or reported ethnicity. Please provide an estimate if the exact percent is not known. Hispanic, Latina, or Spanish origin __________% Observed or reported primary race of first prenatal care visit patients: Using the following categories, list the observed or reported primary race of patients at this medical practice location/office. Again, the focus is on patients seen at the first prenatal care visits. Please provide an estimate if the exact percent is not known. Black/African American/African __________% White/Caucasian __________% Asian/Asian American __________% Native Hawaiian/Other Pacific Islander __________% American Indian/Native American __________% Alaska Native __________% More than one race __________% Other __________% Other - Specify ___________________________ Unknown/not reported __________% Observed or reported primary language preferred by first prenatal care visit patients: Using the following options, indicate the reported primary language preferred by first prenatal care visit patients at this medical practice location/office. Please provide an estimate if the exact percent is not known. The total percentage of all languages cannot be greater than 100%. English __________% Spanish __________% Other __________% Specify: ____________________________ How well do you feel you know this practice? ☐
Extremely well ☐
Quite well ☐
Fairly well ☐
Not very well Depression? Please indicate tool (check all that apply): ☐
PHQ2 ☐
PHQ9 ☐
EPDS ☐
Other-Specify:___________ Never Rarely Sometimes Often Always Don’t know/NA Early pregnancy (0-20 wks. GA) Late pregnancy (21 wks. or more GA) Hospitalization for delivery Early postpartum (0-3 months PP) Late postpartum (4-12 months PP) Anxiety? Please indicate tool (check all that apply): ☐
GAD2 ☐
GAD7 ☐
PASS ☐
Other-Specify:___________ Never Rarely Sometimes Often Always Don’t know/NA Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Bipolar disorder? Please indicate tool (check all that apply): ☐
MDQ ☐
CIDI ☐
Other-Specify:___________ Never Rarely Sometimes Often Always Don’t know/NA Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Substance use disorders? Please indicate tool (check all that apply): ☐
NIDA/ASSIST ☐
4Ps ☐
DASS ☐
Other-specify:________ Never Rarely Sometimes Often Always Don’t know/NA Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Trauma/PTSD? Please indicate tool (check all that apply): ☐
PCL-C ☐
Intimate Partner Violence ☐
Other-specify:_______ Never Rarely Sometimes Often Always Don’t know/NA Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Does your practice have a system in place to monitor and follow up on patients who screen positive for perinatal mental health and substance use disorders? ☐
Yes ☐
No Is it explained to patients that screening for perinatal mental health and substance use disorders will happen routinely as part of their obstetric care? ☐
Yes ☐
No Does your practice have procedures for providing education and treatment options for patients with perinatal mental health and substance use disorders? ☐
Yes ☐
No Does your practice have procedures for obtaining mental health and substance use disorders care for pregnant and postpartum women? ☐
Yes ☐
No Please consider the following statements regarding this practice and its pregnant and postpartum patients: Never Rarely Sometimes Often Always Not applicable Providers meet the needs of patients with depression and anxiety. Providers ensure that patients with depression and anxiety receive timely treatment. Providers treat patients with antidepressant medications for depression and anxiety. When a patient is prescribed an antidepressant, providers will follow up with the patient. When a patient is prescribed an antidepressant, providers will monitor the patient’s depression and/or anxiety severity with a validated screening tool at subsequent visits. Providers facilitate referrals for patie

Strategic Goals. The goal of this new statewide program is to help health care practices identify, diagnose, and manage depression, anxiety, and substance use in pregnant and postpartum women (the 12-week period after giving birth). Support prenatal care practices in screening, identification, and management of perinatal depression, anxiety and substance use; Improve prenatal care provider confidence and skills in managing mild-to-moderate cases of perinatal depression, anxiety, and substance use; Improve universal screening rates of eligible pregnant and postpartum patients for perinatal depression, anxiety, and substance use using evidenced-based screening tools Participating Prenatal Care Practices will receive monthly on-site consultation and coaching from a trained Clinical Quality Improvement Facilitator; Data Management Training and Support; In-person professional education presented quarterly by Perinatal Behavioral Health Specialists including Best Practice Sharing; Assumptions: Systems of care will provide practices with IT support needed to effectively capture and report screening rates for perinatal depression, anxiety, and substance use MomsPRN Practices will participate from October 2019 through December 2020 with expectation that practice will participate in October 2019 Orientation Program, and quarterly learning collaborative. Practice QI Team will participate in monthly meetings with Practice QI Facilitator. All Clinical Providers to complete Self-Efficacy Surveys at beginning and end of initiative. (Please see Attachment A). Practices will submit baseline and quarterly reports of Screening Rates as outlined in Attachment B) 3-Month Preparation Period QI Initiative Activities (October – December 2019): Participate in October 2019 Orientation Program; Identify members of the practice quality improvement (QI) team. The team should consist of 3 to 4 staff in different roles and include a practice clinical champion and an IT/EHR staff member; Practice QI team participation in monthly meetings with the practice QI facilitator; Practice QI team attendance and participation at in-person kick-off learning session; Plan and test practice workflows to implement screening for perinatal depression, anxiety and substance use with validated screening tool(s); Test EMR system to determine workflow for documentation of screening results; Submit a baseline report of screening rates for perinatal depression, anxiety, and substance use; Complete baseline clinical provider self-efficacy survey within 45 days of award notification; In conjunction with the QI practice facilitator, identify quality improvement activities to optimize perinatal behavioral health screening, treatment and referral Implement screening for perinatal depression, anxiety and substance use with validated screening tool(s); Utilize the RI Moms PRN provider teleconsultation line as needed; Report de-identified practice screening rates and proportion of positive screens quarterly and by zip code; Practice QI team participation in monthly meetings with the practice QI facilitator; Practice QI team attendance and participation in quarterly in-person learning network meetings; Complete provider self-efficacy surveys on an annual basis Practices will be eligible to receive: Infrastructure payment of $5,000 that practices can use to offset costs associated with EMR modifications, staff time, and participation in quality improvement activities; $5,000 of incentive payments based on increasing perinatal depression, anxiety, and substance use screening rates using evidenced-based tools CTC will make incentive payment to the practice at the end of the Performance Period (December 2020). CTC reserves the right to delay/withhold payments if Practice fails to meet any of the practice requirements as outlined in Milestone Document (Please see Attachment C). Care Transformation Collaborative of RI Prenatal Care Practice name. _______________________________________ _____________________________________ Signature: ▇▇▇▇▇ ▇▇▇▇▇▇▇, Signature of authorized staff: Executive Director, CTC-RI Name: _________________________ Positon: ________________________ Survey Monkey Link: Provider Baseline Self Efficacy Survey: ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/r/ProviderSelfEfficacy aseline Questionnaire Thank you for taking a few minutes to complete this questionnaire. The following questions address your experiences with perinatal mental health. Provider name: _______________________ Date of assessment: _________________ Practice name: ________________________ What is your primary medical specialty? ☐
Obstetrics only ☐
Gynecology only ☐
General Obstetrics and Gynecology ☐
Maternal-Fetal Medicine Specialist ☐
General Psychiatry ☐
Perinatal Psychiatry ☐
Primary Care/Family Medicine ☐
Other (Specify) How many years have you been in practice? Which of the following best describes your practice location? ☐
Urban – inner city ☐
Urban – non-inner city ☐
Suburban ☐
Mid-sized town (10,000-50,000) ☐
Rural ☐
Military ☐
Other (Specify) Which of the following best describes your type of practice? ☐
Solo Private Practice ☐
Partnership or Group Practice ☐
Multi-Specialty Group ☐
HMO/Staff Model ☐
University Full-Time Faculty and Practice ☐
Military ☐
Other (Specify) What is your gender? ☐
Female ☐
Male ☐
Other (Specify) ☐
Prefer not to answer What race do you consider yourself? (select all that apply) ☐
American Indian/Native American ☐
Alaska Native ☐
Asian/Asian American ☐
Black/African American/African ☐
Native Hawaiian/Other pacific Islander ☐
White/Caucasian ☐
Other (Specify) ☐
Prefer not to answer What ethnicity do you consider yourself? ☐
Hispanic or Latino ☐
Non-Hispanic or Latino ☐
Prefer not to answer What is your professional title? ☐
Physician ☐
Attending ☐
Fellow ☐
Resident ☐
Certified Nurse Midwife ☐
Nurse Practitioner ☐
Nurse Manager ☐
Social Worker or Case Manager ☐
Other (Specify) At the following time points, which of the following do you consistently screen for (using a validated screening tool)? Never Rarely Sometimes Often Always Not applicable Early pregnancy (0-20 wks. GA) Late pregnancy (21 wks. or more GA) Hospitalization for delivery Early postpartum (0-3 months PP) Late postpartum (4-12 months PP) Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Please consider the following statements regarding your pregnant and postpartum patients and indicate the most appropriate response: Never Rarely Sometimes Often Always Not applicable I am able to provide education around depression and anxiety to my patients. I discuss depression and anxiety and their treatment options with my patients. I discuss the risks and benefits of antidepressant use during pregnancy and postpartum. I discuss the risks and benefits of other psychiatric medications during pregnancy and postpartum. I am able to treat my patients with antidepressant medications. I am able to treat my patients with other psychiatric medications. I am confident determining when to refer for therapy vs. when to start medications for depression or anxiety in my patients. I am able to adequately access non-medication treatments for my patients with depression and anxiety. When I need a perinatal psychiatric consultation, I am able to receive one in a timely manner. I can facilitate referrals for my patients to depression/anxiety treatment. I am able to ensure that my patients with depression and anxiety receive treatment in a timely manner. I am confident monitoring depression/anxiety and adjusting medications for depression/anxiety in my patients. When my patient’s care is complete, I am able to transition her for ongoing depression or anxiety follow-up if needed. Please consider the following statements regarding your pregnant and postpartum patients and indicate the most appropriate response: Never Rarely Sometimes Often Always Not applicable I am able to provide education around substance use disorders to my patients. I discuss substance use disorders and treatment options with my patients. I am able to treat my patients with opioid use disorders by prescribing medications such as buprenorphine or methadone. I am confident determining when to refer for therapy vs. when to start medications for substance use disorders in my patients. I am able to adequately access non-medication treatments for my patients with substance use disorders. When I need a perinatal substance use consultation, I am able to receive one in a timely manner. I can facilitate referrals for my patients to substance use disorder treatment. I am able to ensure that my patients with substance use disorders receive treatment in a timely manner. I am confident monitoring substance use disorders and adjusting medications for substance use disorders. When my patient’s care is complete, I am able to transition her for ongoing substance use disorder follow-up if needed. Survey Monkey Link: Practice Level Self Efficacy Survey: ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/r/PracticeSelfEfficacy aseline Questionnaire Provider name: _______________________ Date of assessment: _________________ Person responding to the interview:_______________________ Title:_________________ Type of Practice: ☐
Private with no health system or university affiliation ☐
Private with health system or university affiliation ☐
Health system with no university affiliation ☐
Health system with university affiliation ☐
Academic medical center ☐
Federally qualified health center ☐
Public clinic with no university/academic affiliation ☐
Public clinic with university/academic affiliation ☐
Other (Specify) Please enter the number of the following staff in this practice: Number of Obstetrics/Gynecology (OB/GYN) providers __________ Number of Obstetrics (OB) only providers __________ Number of Gynecology (GYN) only providers __________ Number of Family Medicine providers __________ Number of Primary Care providers __________ Number of Medical Residents __________ Number of Licensed independent practitioners (PAs, RNCS, NPs) __________ Number of Nurse midwives __________ Number of MAs, RNs, PCAs, CIPs __________ Other __________ Does the practice have an onsite behavioral health professional available? ☐
Yes ☐
No If yes, is this a: ☐
Psychiatric prescriber ☐
Psychotherapist ☐
Masters’ level clinician ☐
Other_________________ Does the practice have a system in place to facilitate access to a behavioral specialist? ☐
Yes ☐
No If yes, which one? ☐
co-located behavioral health specialist ☐
case manager to assist with referral ☐
access to telephone consultation with mental health specialist ☐
ensure that all patients are referred to a behavioral health specialist Is this location part of a larger practice with multiple locations? ☐
Yes ☐
No If yes, name of the larger practice: ____________________________ Number of locations in the larger practice where prenatal services are provided: _______________ Total # locations Number of locations in the larger practice where prenatal services are provided: _______________ Total # births for the larger practice What is the total number of births per year for all providers/clinicians in this location? _______________ Total # of births across all providers Approximate payer mix: For the list of payers that follows, regarding the approximate payer mix for this practice location/office, list the percent for each payer. Please provide an estimate if the exact percent is not known. The total percentage of all payers cannot be greater than 100%. Tricare/Other Military __________% Medicaid __________% Other Public __________% Private or Commercial __________% Self-Pay __________% Other __________% Other – Specify ____________________% Observed or reported ethnicity of first prenatal care visit patients: For the first prenatal care visit patients at this medical practice location/office, please indicate the percent of those patients with the following observed or reported ethnicity. Please provide an estimate if the exact percent is not known. Hispanic, Latina, or Spanish origin __________% Observed or reported primary race of first prenatal care visit patients: Using the following categories, list the observed or reported primary race of patients at this medical practice location/office. Again, the focus is on patients seen at the first prenatal care visits. Please provide an estimate if the exact percent is not known. Black/African American/African __________% White/Caucasian __________% Asian/Asian American __________% Native Hawaiian/Other Pacific Islander __________% American Indian/Native American __________% Alaska Native __________% More than one race __________% Other __________% Other - Specify ___________________________ Unknown/not reported __________% Observed or reported primary language preferred by first prenatal care visit patients: Using the following options, indicate the reported primary language preferred by first prenatal care visit patients at this medical practice location/office. Please provide an estimate if the exact percent is not known. The total percentage of all languages cannot be greater than 100%. English __________% Spanish __________% Other __________% Specify: ____________________________ How well do you feel you know this practice? ☐
Extremely well ☐
Quite well ☐
Fairly well ☐
Not very well Depression? Please indicate tool (check all that apply): ☐
PHQ2 ☐
PHQ9 ☐
EPDS ☐
Other-Specify:___________ Never Rarely Sometimes Often Always Don’t know/NA Early pregnancy (0-20 wks. GA) Late pregnancy (21 wks. or more GA) Hospitalization for delivery Early postpartum (0-3 months PP) Late postpartum (4-12 months PP) Anxiety? Please indicate tool (check all that apply): ☐
GAD2 ☐
GAD7 ☐
PASS ☐
Other-Specify:___________ Never Rarely Sometimes Often Always Don’t know/NA Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Bipolar disorder? Please indicate tool (check all that apply): ☐
MDQ ☐
CIDI ☐
Other-Specify:___________ Never Rarely Sometimes Often Always Don’t know/NA Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Substance use disorders? Please indicate tool (check all that apply): ☐
NIDA/ASSIST ☐
4Ps ☐
DASS ☐
Other-specify:________ Never Rarely Sometimes Often Always Don’t know/NA Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Trauma/PTSD? Please indicate tool (check all that apply): ☐
PCL-C ☐
Intimate Partner Violence ☐
Other-specify:_______ Never Rarely Sometimes Often Always Don’t know/NA Early pregnancy Late pregnancy Hospitalization for delivery Early postpartum Late postpartum Does your practice have a system in place to monitor and follow up on patients who screen positive for perinatal mental health and substance use disorders? ☐
Yes ☐
No Is it explained to patients that screening for perinatal mental health and substance use disorders will happen routinely as part of their obstetric care? ☐
Yes ☐
No Does your practice have procedures for providing education and treatment options for patients with perinatal mental health and substance use disorders? ☐
Yes ☐
No Does your practice have procedures for obtaining mental health and substance use disorders care for pregnant and postpartum women? ☐
Yes ☐
No Please consider the following statements regarding this practice and its pregnant and postpartum patients: Never Rarely Sometimes Often Always Not applicable Providers meet the needs of patients with depression and anxiety. Providers ensure that patients with depression and anxiety receive timely treatment. Providers treat patients with antidepressant medications for depression and anxiety. When a patient is prescribed an antidepressant, providers will follow up with the patient. When a patient is prescribed an antidepressant, providers will monitor the patient’s depression and/or anxiety severity with a validated screening tool at subsequent visits. Providers facilitate referrals for patiepatients to mental health specialists. This practice has standard processes for directing patients to appropriate mental health resources in the community. Support staff have the knowledge and skills they need to detect and address depression and anxiety disorders. Providers meet the needs of patients with substance use disorders. Providers ensure that patients with substance use disorders r