Now M-D-Y H:M
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First Name
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Last Name
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E-mail
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Phone number
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Include Area Code
Job Title
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Credentials
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MD
DO
RN
NP
FNP
CRNP
PhD
DC
PT
DPT
CGC
LCGC
PA-C
LCSW
LSW
Other
DNP
Doctoral student
PMHS
MD
DO
RN
NP
FNP
CRNP
PhD
DC
PT
DPT
CGC
LCGC
PA-C
LCSW
LSW
Other
DNP
Doctoral student
PMHS
Please select your highest credentials
Specialty
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Dermatology Emergency Medicine Family Medicine General Internal Medicine Neurology Obstetrics and Gynecology Pediatrics Psychiatry Addiction Other
If you selected "Other", what is your specialty?
Secondary contact information
(administrative assistant, office manager, etc.)
Are you a Penn State or Penn State Health employee?
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Yes No
What is your Penn State mailcode?
In which setting do you work?
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Private Practice
Academic Medical Center
Hospital Clinician
Academic Institution
Health Center
Other
Private Practice
Academic Medical Center
Hospital Clinician
Academic Institution
Health Center
Other
Allegheny Health Network
Geisinger
Temple Health
Wellspan Health
The Wright Center
UPMC
UPMC Pinnacle
Other
Allegheny Health Network
Geisinger
Temple Health
Wellspan Health
The Wright Center
UPMC
UPMC Pinnacle
Other
If other, please describe here:
Is your clinic a Federally Qualified Health Center?
Yes No
Is your clinic a PA Opioid Use Disorder Center of Excellence (OUD-COE)?
Yes
No
Clinic Name
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Please list your primary site, where the majority of your clinic time is spent.
Street Address
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State
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PA
Outside of PA
Alabama - AL Alaska - AK Arizona - AZ Arkansas - AR California - CA Colorado - CO Connecticut - CT District of Columbia - DC Delaware - DE Florida - FL Georgia - GA Hawaii - HI Idaho - ID Illinois - IL Indiana - IN Iowa - IA Kansas - KS Kentucky - KY Louisiana - LA Maine - ME Maryland - MD Massachusetts - MA Michigan - MI Minnesota - MN Mississippi - MS Missouri - MO Montana - MT Nebraska - NE Nevada - NV New Hampshire - NH New Jersey - NJ New Mexico - NM New York - NY North Carolina - NC North Dakota - ND Ohio - OH Oklahoma - OK Oregon - OR Rhode Island - RI South Carolina - SC South Dakota - SD Tennessee - TN Texas - TX Utah - UT Vermont - VT Virginia - VA Washington - WA West Virginia - WV Wisconsin - WI Wyoming - WY
County (PA)
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Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Franklin Forest Fulton Greene Huntingdon Indiana Jefferson Juniata Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter Philadelphia Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Westmoreland Wyoming York
Zip Code
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My mailing address is different than my clinic address
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Yes
No
Have you participated in Project ECHO before?
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Yes
No
Which institution hosted the teleECHO sessions you participated in?
Which disease conditions did these teleECHO sessions cover?
I am a provider who sees patients
Yes
No
Are you MAT waiver trained to allow prescription of buprenorphine?
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Yes No Not Applicable
Approximate date of waiver receipt:
Today M-D-Y If you are unsure of the exact date, please ensure month and year is correct
Are you treating any patients for Opioid Use Disorder (OUD)?
Yes No
How many patients with OUD are under your care?
What Medication Assisted Treatment (MAT) medications are being used in your practice?
Buprenorphine
Extended release naltrexone
Oral naltrexone
MAT for alcohol use disorder (i.e. naltrexone, acamprosate, outpatient medically managed withdrawal protocols, off label medications)
MAT for tobacco use disorder (nicotine replacement, bupropion, varenicline)
Buprenorphine
Extended release naltrexone
Oral naltrexone
MAT for alcohol use disorder (i.e. naltrexone, acamprosate, outpatient medically managed withdrawal protocols, off label medications)
MAT for tobacco use disorder (nicotine replacement, bupropion, varenicline)
Check all that apply
Are you interested in becoming MAT waiver trained?
Yes No
Do you/your clinical site routinely screen patients for substance use disorders?
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Yes No
Which screening tools do you/your clinical site use?
CAGE CAGE-AID AUDIT AUDIT C ORT Other CAGE
CAGE-AID
AUDIT
AUDIT C
ORT
Other
Which screening tools do you use?
What types of support are you receiving (or will you receive) to provide OUD treatment in your practice setting?
* must provide value
None
Financial incentive to obtain my DATA-2000 waiver
Longer clinic appointments (RVU support) for MAT patients
Support staff
Advertising or marketing assistance for your MAT program
Other
None
Financial incentive to obtain my DATA-2000 waiver
Longer clinic appointments (RVU support) for MAT patients
Support staff
Advertising or marketing assistance for your MAT program
Other
Check all that apply
If you selected "other", please describe:
What are the most significant barriers for starting or expanding office based OUD treatment within your practice?
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Access to patients who have OUD
Patient readiness for MAT treatment
Appropriateness of patients with OUD for treatment in an OBOT setting
Insurance coverage or other patient financial barriers
Your personal capacity to accept new patients into your panel
Your ability to access counseling or therapy services for MAT patients
Lack of connections with higher levels of addiction care if needed
Legal or liability concerns on your part or on the part of your organization
Knowledge and skills of staff within your local practice
Ability to have longer visits with MAT patients
Access to case management support
Your confidence in your own knowledge or skills
Difficulty in addressing polysubstance abuse
Responding to stigmatization of MAT
Lack of back up coverage within the organization for MAT patients
Provider burnout
Other
Access to patients who have OUD
Patient readiness for MAT treatment
Appropriateness of patients with OUD for treatment in an OBOT setting
Insurance coverage or other patient financial barriers
Your personal capacity to accept new patients into your panel
Your ability to access counseling or therapy services for MAT patients
Lack of connections with higher levels of addiction care if needed
Legal or liability concerns on your part or on the part of your organization
Knowledge and skills of staff within your local practice
Ability to have longer visits with MAT patients
Access to case management support
Your confidence in your own knowledge or skills
Difficulty in addressing polysubstance abuse
Responding to stigmatization of MAT
Lack of back up coverage within the organization for MAT patients
Provider burnout
Other
Check all that apply
If you selected "other", please describe:
Which topics are you most interested in learning more about during this ECHO clinic?
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MOUD
Peer Recovery Support Services
Co-Occurring Mental Health
Introduction to Motivational Interviewing (MI)
Risk Reductions and Safe Use of Opioids
Adolescents and Young Adults with OUD/ACEs and Addiction
COVID and OUD
Perioperative Management of the Opioid Dependent Patient
Evidence-based screening and SBIRT
Co-Occurring Physical Health of OUD/Hep C
OUD in the ED
Pregnancy/Post-partum care
Other
MOUD
Peer Recovery Support Services
Co-Occurring Mental Health
Introduction to Motivational Interviewing (MI)
Risk Reductions and Safe Use of Opioids
Adolescents and Young Adults with OUD/ACEs and Addiction
COVID and OUD
Perioperative Management of the Opioid Dependent Patient
Evidence-based screening and SBIRT
Co-Occurring Physical Health of OUD/Hep C
OUD in the ED
Pregnancy/Post-partum care
Other
Check all that apply
If you selected other, please describe here:
Additional topics you are interested in learning more about OUD MAT
Which session(s) could you present a patient case?
January 18, 2023
February 1, 2023
February 15, 2023
March 1, 2023
March 15, 2023
March 29, 2023
April 12, 2023
April 26, 2023
May 10, 2023
May 24, 2023
June 7, 2023
June 21, 2023
January 18, 2023
February 1, 2023
February 15, 2023
March 1, 2023
March 15, 2023
March 29, 2023
April 12, 2023
April 26, 2023
May 10, 2023
May 24, 2023
June 7, 2023
June 21, 2023
Participation-Dropped Out
Yes
No
Yes
No
Particpation-Remove from email list
Yes
No
Participation-Include in future cohort
Yes
No
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