Home PIC C-WHO Resource Hub Who We Are PCBH Advisory Council PIC Strategic Leadership Practice Network Research Patient Experience Population Health (Patient Outcomes) Reducing Costs Care Team Well-Being (Provider Experience) IBH Collaborative DonateLogin Organizational Information Please complete this form to add your site to the directoryPlease enable JavaScript in your browser to complete this form. - Step 1 of 5Organization Name *Contact Name *FirstLastOrganization Website / URLWhere patients can acquire more informationContact Email *EmailConfirm EmailStreet Address of Primary Organization *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNext - PCBH CharacteristicsPCBH CharacteristicsIn your Clinics that Have a BHC, What is the Usual Ratio Of BHC To PCP?1:1 - 1:21:3 - 1:41:5 - 1:61:7 - 1:81:9 - 1:101:11 +Which Age Groups Do Your BHCs Engage With? (Check All That Apply)Younger Pediatric (0-11)Older Pediatric (12-18)AdultsOlder Adults (65+)Our BHCs Vary In Terms Of Patient Ages SeenAre There Certain Types Of Problems Or Problem Severities/Complexities That Your BHCs Do NOT Engage With?YesNoIf no, Please Explain: How Long Are The Visits On BHC Schedule Templates In Your Organization? (Check All That Apply)15 Minutes30 Minutes45 Minutes60 MinutesDo Your BHCs Typically See Patients For a Visit on the Same Day They Were Referred?YesNoDo Your BHCs Regularly Inform/Educate Team Members About Behavior Change Topics?YesNoWhich Statement Best Applies to BHCs In Your Organization?BHCs Have Their Own Office And Mostly See Patients ThereBHCs Have Their Own Office But Mostly See Patients In An Exam RoomBHCs Have A Workstation in a Team Pod And See Patients in an Exam RoomOtherPlease ElaborateIf Your Organization has a Goal For BHC Visits Per Day, What is the Goal?0-45-67-89-1011-1213+We Don't have a GoalDo BHCs In Your Organization Regularly Look for Ways to Extend PCPs?YesNoNot SurePreviousNext - Services & SitesServices & SitesWhich of the below best describes your organization?FQHC/CHCHealthcare for the HomelessPrivate Non-ProfitDoDRural Health ClinicPrivate For-ProfitVAOtherPlease Provide a brief description:Types of Primary Care Your Organization Offers (Check all that apply)Family MedicineInternal MedicinePediatricsGeriatric MedicineNumber of Primary Care Clinics Your Organization Has1-34-1011-2021-3031-4040+Number of Clinics With At Least 1 BHC1-34-1011-2021-3031-4040+If you would like to have multiple clinics on the PCBH Map, please list them here (no need to re-submit entire form):Please Include: Clinic Name, Address, Contact information, Services OfferedPrevious - PCBH CharacteristicsNext - Additional InformationAdditional InformationType Of Integrated Care Or Co-Located Services Offered By Your OrganizationPCBH (embedded clinician, real-time access)Collaborative Care (care management & consulting psychiatry)SBIRT (substance abuse brief treatment)Medication Assisted Treatment (opioid)Specialty Psychotherapy (referral-based therapy)Consulting Psychiatry (psychiatry supporting primary care)AvailabilityOffered at All SitesOffered at Some SitesNot OfferedEstimate The Number Of Unique Patients Served Annually by Your OrganizationIs Your Organization Accepting New Patients?YesNoIs Your Organization a Medical Residency Site?YesNoIf Yes, Approximately what percent of your organization’s visits are done by medical residents?1-1011-2526-5051-7576-100Does Your Organization Train Behavioral Health Learners (e.g., Students, Interns, Post-Docs)?”YesNoIf Yes, How Many Learners Do You Train Each Year?”1-34-67-1011-1516+Previous - Services & SitesNext - Review & SubmitUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.Previous - Additional InformationSubmit jQuery Change HREF Attribute of Anchor Tag Dynamically Anthony LeonOrganizational Information04.04.2022
