1. Organization and Your Contact Information
2. Secondary contact within your organization
3. Please indicate what percentage of your clients fit the following descriptions (these descriptions are not mutually exclusive):
4. Please indicate what percentage of your clients fit into the following service categories:
5. Is your current client assess system computerized?
6. What percent of your staff (care managers, coaches, etc.) are fully functional in using the computerized client assessment system?
7. On average, how many NEW clients do you serve per month?
8. On average, what percentage of your clients receive services through the following methods and/or locations?
9. After the initial assessment, what is your agency's standard for the maximum time between in-home visits by care mangers?
10. After the initial assessment, what is your agency's standard for the maximum time between phone calls to clients by care managers?
11. Currently, do client assessments include documenting vital signs?
12. Currently, do client assessments include recording vital signs?
13. Currently, do client assessments include inventory of the client's medications?
14. How do care mangers document their client's medications?
15. Does your current client contract/agreement contain provisions that would enable you to do the HomeMeds screening and pharmacist intervention without a separate consent?
16. How would you gather client consent?
17. How many full time staff do you currently have (please use full time equivalents if necessary)?
18. How many of your care managers (who will be using HomeMeds) have the following credentials:
19. Do you currently have a relationship with a medication consultant (i.e. pharmacist, physician, or nurse practitioner)?
20. How will you pay for the pharmacist/medication consultant needed for HomeMeds?
21. Please rate the level of agreement to the following statements from the perspective of the CARE MANAGERS/COACHES/HOME VISIT STAFF:
22. What is the likelihood that the following barriers would be an issue within your agency?
23. Which of the following groups within your agency would be included in the decision making about whether or not to adopt the HomeMeds System?