CTRC Telehealth Organizational Readiness Assessment

Please fill this assessment to the best of your knowledge. If you have any questions please reach out us at CalTRC@ochin.org

Please submit the form no later than 9/23/22

o Notice: this survey will take 15-20 minutes to complete, allow for ample time.

o Do not submit until the form is fully completed.

Primary point of contact for this survey*

Email address of primary point of contact*

Job title*

Names and email address of additional contacts who will be involved in the project.*

If there are no additional participants, please indicate NA

Name of the organization*

Physical address*

Website*

What types of services does your site provide?*

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What modalities do you use to deliver service?*

Select

What level of training and or experience does your site have with telehealth?*

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How many locations do you have?*

How many providers do you have at each location?*

Select

What is your provider daily visit average?*

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What is your current no-show rate for in person visits?*

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What is your current no-show rate for telehealth visits?*

Select

Please provide percentage of your payers' mix ( For Ex: Private/commercial insurance, MediCal , Medicare)*

Does your site provide any specialty services in person or via telehealth? (please explain)*

What billing model is used with these service providers?*

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Do you provide store and forward services? If yes, please list the specialties and platforms. If no, please enter NA*

Does your EHR support telehealth encounters via live video?*

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Please list any telehealth tools, platforms, and or software used for telehealth.*

Is staff trained to use telehealth as a part of your onboarding process?*

Select or enter value

What services does your site plan to implement or expand on in the next 12 months?*

How are you promoting telehealth among your patient population?*

How are the current telehealth visits being conducted? (in clinic, remote? please explain)*

Where are the support staff located? (in clinic or remote? please explain)*

Have you conducted any needs assessment to identify gaps for specific services? (if yes, please explain)*

Please provide a short summary of your referral process*

Is this standard across your organization?*

Select

Which of the following do you perceive to be barriers to implementing and sustaining your telemedicine program?(Check all that apply)*

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Is there staff assigned or responsible for your telehealth program? If so, what is their role and job duties*

Does your staff have capacity to take on additional job duties?*

Are your providers willing to incorporate telehealth into their daily practice?*

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Please list your IT champions including leadership, on-site supervisors, or management*

What are your staff's needs related to training for telehealth?*

check all that apply

Select or enter value

What are the barriers to administrative or management buy-in? check all that apply*

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Are there any providers within your organization at a different location, that could provide services via telehealth?*

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How can CTRC help you reach your goals related to telehealth?

Did this form help you identify any additional needs within your organization?*

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