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{"sheet":"Instructons and Scoring","index":0,"n_rows":10,"n_cols":2,"rows_kept":10,"cut":false,"hidden":false,"merged":[[0,1,0,7],[2,1,8,7],[9,1,15,7]]}
[null,"Instructions and Scoring"]
[]
[null,"Those completing the tool are asked to rate a number of items. These ratings will assist organizations in creating their own customized action plan for implementing or strengthening their navigation services program. Respondents also have the option of completing an online version of the tool at www.resourcesforintegratedcare.com where you can print or save a customized action plan that is generated based on your responses to the assessment questions."]
[]
[]
[]
[]
[]
[]
[null,"Rate each item as it applies to your organization on the provided scale. Aciton Plan Items will be added to the Results tabs (Results I and Results II) for those items with a mid-range or lower self-assessment rating (e.g. yes/no items with “no” or “sometimes” answers).  "]

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[null,"I. Organizational Capacity to Support Navigation Services"]
[]
[null,"A. Population Considerations"]
[null,"Item","Response",null,"Action Step"]
[null,"1) Is your organization able to document, in a way that can be easily shared with all care team members, the number of clients with key characteristics/conditions (e.g. substance use, comorbidities, trauma, disabilities, etc.)?",null,"Yes","I.A.1"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"2) Is there an acuity measure in place (taking into account mental health, physical health, and substance abuse information) to identify higher risk clients (e.g. those most at risk of needing acute care and/or a more restrictive environment of care)?\n\nAn acuity measure categorizes or quantifies the severity of an illness and the level of associated risk. \n",null,"Yes","I.A.2"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[]
[]
[null,"3) Are social and financial barriers to care (e.g. housing, benefits, social support) consistently assessed for the population?",null,"Yes","I.A.3"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"4) Are cultural and linguistic barriers to care consistently assessed and addressed for the population (e.g. using in-person or telephonic interpretation, ensuring that provider and staff practices are culturally competent, developing patient materials in the most common non-English languages)?",null,"Yes","I.A.4"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[]
[]
[null,"B. Population Considerations"]
[null,"1. Integration of Services"]
[null,"Item","Response",null,"Action Step"]
[null,"a) Is integrated primary care and behavioral healthcare provided onsite?",null,"Yes","I.B.1.a"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"b) Is pertinent information necessary for client care stored, tracked, and shared among the client’s care team within the organization?",null,"Always","1.B.1.b"]
[null,null,null,"Usually"]
[null,null,null,"Sometimes"]
[null,null,null,"Rarely"]
[null,null,null,"Never"]
[null,"c) Is there an electronic health record (EHR) in use?",null,"Yes","I.B.1.c"]
[null,null,null,"No"]
[null,"d) If the organization is part of a co-located model (e.g. an FQHC offers primary care services onsite in your behavioral health center), are agencies using a single EHR?",null,"Yes","I.B.1.d"]
[null,null,null,"No"]
[null,null,null,"N/A"]
[null,"e) Does the organization have the necessary technology and workflows/processes in place that enable use of an HIE (Health Information Exchange)?",null,"Yes","I.B.1.e"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"f) If primary care and behavioral healthcare services are co-located, is a combined Release of Information (ROI) in use?",null,"Yes","I.B.1.f"]
[null,null,null,"No"]
[null,null,null,"N/A"]
[null,"g) Does the organization consistently have timely access (e.g. within 48 hours) to information about hospitalizations and emergency room visits?",null,"Yes","I.B.1.g"]
[null,null,null,"Sometimes"]
[null,null,null,"No"]
[null,"h) Does the organization have the ability to participate in discharge planning with inpatient facilities?",null,"Yes","I.B.1.h"]
[null,null,null,"Sometimes"]
[null,null,null,"No"]
[null,"i) Does the organization have a consistent and reliable process to link clients to community resources either onsite or via referral (e.g. employment assistance, help with entitlement programs, transportation, housing, social activities)?",null,"Yes","I.B.1.i"]
[null,null,null,"Sometimes"]
[null,null,null,"No"]
[]
[null,"2. Funding and Resource Considerations"]
[null,"Item","Response",null,"Action Step"]
[null,"a) Has the agency determined which, if any, navigation services are reimbursable by Medicaid, Medicare, or through a third party payer?",null,"Yes","I.B.2.a"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"b) Has the organization identified grant funding available to support existing navigation services and/or navigation services that you wish to begin offering? ",null,"Yes","I.B.2.b"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"c) Have you determined if existing staff can be “re-tooled” to perform navigator functions (either additional functions or new functions you wish to begin offering)?",null,"Yes","I.B.2.c"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[]
[null,"3. Organizational Culture"]
[null,"Item","Response",null,"Action Step"]
[null,"a) How many staff members are experienced in working in integrated settings with clients that have both SMI and serious medical comorbidities?",null,"All staff","I.B.3.a"]
[null,null,null,"Most staff"]
[null,null,null,"Some staff"]
[null,null,null,"A few staff"]
[null,null,null,"No staff"]
[null,"b) What is the level of success that staff exhibit when required to collaborate and work as a team? (e.g. are staff comfortable giving and receiving constructive criticism, voicing concerns or asking questions of leadership, or acknowledging when they do not know an answer and need to ask a colleague?) ",null,"High","1.B.3.b"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"c) If physical health services are provided onsite (by partners or your own staff), do leaders and clinicians from both organizations agree on the need for and scope of navigation services?",null,"Yes","I.B.3.c"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,null,null,"N/A"]
[null,"d) Does the organization have tobacco usage policies in place at facilities for staff members and clients?",null,"Yes","I.B.3.d"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"e) Is Trauma-Informed Care (TIC) embedded in the organizational culture (e.g. is there a TIC committee, is TIC language included in job postings and policies, and are staff members trained in TIC?)\n\nTrauma Informed Care is an organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of all types of trauma.",null,"Yes","I.B.3.e"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[]
[null,"f) Are the efforts of staff members providing navigation services valued by leadership, providers, and other staff members (e.g. communicating with navigators, inclusion of navigators in the agency’s management structure, inclusion of navigation services in strategic planning)?",null,"Yes","I.B.3.f"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"g) In a recent situation requiring your organization to change culture, processes, and/or workflows, rate the level of success your organization experienced in effectively responding to this change.",null,"High","I.B.3.g"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"h) Rate the level of “client-centeredness” in organizational culture (e.g. active involvement of clients in their care, responsiveness of staff to client preferences, internal decision-making driven by client needs)?",null,"High","I.B.3.h"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"i) To what extent does the organizational culture support navigators in performing social support functions (e.g. expressing empathy and caring emotions, listening to client problems, and providing advice and suggestions) while ensuring appropriate boundaries between staff and clients?",null,"Yes","I.B.3.i"]
[null,null,null,"Sometimes"]
[null,null,null,"No"]
[]
[null,"4. Workforce"]
[null,"Item","Response",null,"Action Step"]
[null,"a) Has your organization outlined the core functions of navigation that would best meet the needs of your clients and determined which of these functions are already being addressed by current staff?",null,"Yes","I.B.4.a"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"b) Has your organization matched navigator functions to existing (and future) staff roles?",null,"Yes","I.B.4.b"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"c) Has the organization created a comprehensive curriculum to be used for initial and ongoing navigator training?",null,"Yes","I.B.4.c"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[]
[null,"C. Partnerships"]
[null,"Item","Response",null,"Action Step"]
[null,"1) Are there memoranda of understanding (MOUs) and/or linkage agreements with partner organizations that provide integrated care services? (e.g., primary care, HIV testing, substance abuse counseling, wellness coaching) ",null,"Yes","I.C.1"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"2) Have you determined if existing partnerships can be expanded or potential community partners developed to share the costs of providing navigation services?",null,"Yes","I.C.2"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[]
[null,"D. Program Processes"]
[null,"1. Care Team Workflow"]
[null,"Item","Response",null,"Action Step"]
[null,"a) Is there a plan to ensure that navigators have easy access to the rest of the care team (e.g. establishing regular care team meetings)?",null,"Yes","I.D.1.a"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"b) Is there an established process for referrals to navigators?",null,"Yes","I.D.1.b"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"c) If navigators include (or will include) peers or unlicensed staff, is there a plan for supervision by a nurse or another health professional?",null,"Yes","I.D.1.c"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,null,null,"N/A"]
[]
[null,"2. Data Documentation"]
[null,"Item","Response",null,"Action Step"]
[null,"a) Is an individualized integrated client health assessment - connecting medical, psychiatric, disability, trauma, social, and other elements - consistently in use for all clients during the intake process? \n\nAn individualized assessment is typically completed during an initial client encounter or incrementally over the first few client encounters.\n",null,"Yes","I.D.2.a"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[]
[null,"b) Is key clinical and operational information readily available to navigators in a format that supports the creation and regular update of a navigation plan for each client as well as the tracking of client progress at the individual and population level? \n\nSuch data may include information related to upcoming and past appointments, prior utilization of services, diagnoses, and other information.\n",null,"Yes","I.D.2.b"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[]
[]
[null,"c) Is collaborative documentation used to enhance client participation in recognizing progress towards goals? \n\nCollaborative documentation is the collaboration between clinicians and clients in the documentation of assessments, planning of services, and progress notes. This practice allows clients to provide input into services and their progress and assists in clarifying understanding of key issues.\n",null,"Yes","I.D.2.c"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[]
[]
[null,"d) Is information on client’s receipt of recommended health screenings and preventive services readily available to navigators?",null,"Yes","I.D.2.d"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[]
[null,"3. Evaluating Services"]
[null,"Item","Response",null,"Action Step"]
[null,"a) Does the agency have an evaluation plan that includes the assessment of key program outcomes for the navigation program at regular intervals?",null,"Yes","I.D.3.a"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"b) Has the agency determined what additional outcomes may need to be measured related to navigation services?",null,"Yes","I.D.3.b"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"c) Is feedback from clients elicited on a regular basis (e.g. client self-assessment tools, client satisfaction surveys, client input on services needed)?",null,"Yes","I.D.3.c"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]

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[null,"Results: I. Organizational Capacity to Support Navigation Services"]
[]
[null,"A. Population Considerations"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"I.A.1"]
[]
[null,"I.A.2"]
[]
[]
[null,"I.A.3"]
[null,"I.A.4"]
[]
[]
[null,"B. Population Considerations"]
[null,"1. Integration of Services"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"I.B.1.a"]
[]
[null,"I.B.1.b"]
[]
[]
[null,"I.B.1.c"]
[null,"I.B.1.d"]
[]
[null,"I.B.1.e"]
[]
[null,"I.B.1.f"]
[null,"I.B.1.g"]
[null,"I.B.1.h"]
[]
[null,"I.B.1.i"]
[]
[]
[]
[null,"2. Funding and Resource Considerations"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"I.B.2.a"]
[null,"I.B.2.b"]
[]
[null,"I.B.2.c"]
[]
[]
[]
[]
[null,"3. Organizational Culture"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"I.B.3.a"]
[null,"I.B.3.b"]
[]
[]
[null,"I.B.3.c"]
[null,"I.B.3.d"]
[]
[null,"I.B.3.e"]
[]
[]
[null,"I.B.3.f"]
[]
[null,"I.B.3.g"]
[]
[null,"I.B.3.h"]
[]
[]
[null,"I.B.3.i"]
[]
[]
[null,"4. Workforce"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"I.B.4.a"]
[null,"I.B.4.b"]
[]
[]
[]
[]
[]
[null,"I.B.4.c"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"C. Partnerships"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"I.C.1"]
[]
[null,"I.C.2"]
[]
[]
[null,"D. Program Processes"]
[null,"1. Care team Workflow"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"I.D.1.a"]
[]
[null,"I.D.1.b"]
[null,"I.D.1.c"]
[]
[]
[null,"2. Data Documentation"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"I.D.2.a"]
[]
[]
[]
[]
[]
[null,"I.D.2.b"]
[]
[]
[]
[null,"I.D.2.c"]
[]
[]
[null,"I.D.2.d"]
[]
[]
[]
[null,"3. Evaluating Services"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"I.D.3.a"]
[]
[]
[null,"I.D.3.b"]
[]
[]
[]
[null,"I.D.3.c"]

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[null,"II. Pillars of Navigation Support Services "]
[]
[null,"A. Building Client Relationships"]
[null,"1. Communication"]
[null,"Item","Response",null,"Action Step"]
[null,"a) To what extent do navigators consistently treat each client interaction as an opportunity to build a therapeutic relationship and further establish trust? ",null,"High","II.A.1.a"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"b) To what extent do schedules and communication channels allow for necessary inter-staff communications (e.g. between navigators and clinicians) that support effective navigation services?",null,"High","II.A.1.b"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"3) Are social and financial barriers to care (e.g. housing, benefits, social support) consistently assessed for the population?",null,"High","II.A.1.c"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[]
[null,"2. Cultural and Linguistic Competency"]
[null,"Item","Response",null,"Action Step"]
[null,"a) To what extent are the cultural and linguistic characteristics of the client population are represented in the organization’s workforce? ",null,"High","II.A.2.a"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"b) Are health information materials and other documents available for clients in their primary language? ",null,"Yes","II.A.2.b"]
[null,null,null,"Sometimes"]
[null,null,null,"No"]
[null,"c) Have you reviewed Standards for Culturally and Linguistically Appropriate Services (National CLAS Standards) and assessed the extent to which organizational structures/processes reflect these standards? ",null,"Yes","II.A.2.c"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[]
[null,"B. Health Literacy"]
[null,"Item","Response",null,"Action Step"]
[null,"1) Is an initial assessment of health literacy level conducted for each client? ",null,"Yes","II.B.1"]
[null,null,null,"Sometimes"]
[null,null,null,"No"]
[null,"2) Does your organization consistently provide regular group or individual sessions for clients to increase health literacy? For example, topics may include reading nutrition labels, medication side effects, self-care for illness, advance directives, etc.",null,"Yes","II.B.2"]
[null,null,null,"Sometimes"]
[null,null,null,"No"]
[]
[null,"C. Health Coaching and Wellness Planning"]
[null,"1. Goal Setting"]
[null,"Item","Response",null,"Action Step"]
[null,"a) To what degree are clients actively engaged in the process of setting health and other goals?",null,"High","II.C.1.a"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"b) To what degree are client goals shared with the team and updated in a timely and efficient way? ",null,"High","II.C.1.b"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"c) To what degree are nursing or other clinical staff available to consult with navigators when developing health goals with clients (if navigators do not have the necessary training/licensing to ensure sufficient knowledge of physical health issues)?",null,"High","II.C.1.c"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"d) If navigators are directly providing health coaching, is there a process in place that ensures a feedback loop between client/navigator/provider to assess progress and modify goals?",null,"Yes","II.C.1.d"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,null,null,"N/A"]
[]
[null,"2. Self-Management Support"]
[null,"Item","Response",null,"Action Step"]
[null,"a) To what extent do agency policies, procedures and infrastructure support navigators and other staff in their efforts to promote client self-management skills?",null,"High","I.C.2.a"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"b) To what extent do navigators model behaviors with clients that support self-advocacy (e.g. suggesting questions to ask a specialty healthcare provider in a follow-up appointment)?",null,"High","I.C.2.b"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"c) To what extent do navigators treat clients in a way that respects their independence and takes into account client understanding of health issues? ",null,"High","I.C.2.c"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"d) Are important members of clients’ natural support system identified and appropriately involved in their self-management activities?\n\nNatural supports include relationships that occur in everyday life that may support client recovery and health. This could include – but is not limited to – immediate family, extended family, friends, neighbors, co-workers, employers, mentors, sponsors, coaches, landlords, etc.\n",null,"Yes","I.C.2.d"]
[null,null,null,"Sometimes"]
[null,null,null,"No"]
[]
[]
[null,"D. Care Coordination"]
[null,"Item","Response",null,"Action Step"]
[null,"1) To what degree do navigators have the necessary infrastructure to easily access and share client information across providers (e.g. clear policies, access to electronic tools, data-sharing arrangements with partners, etc.)?",null,"High","II.D.1"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"2) To what degree are clear information sharing and confidentiality policies established, in compliance with 42CFR and HIPAA? ",null,"High","II.D.2"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"3) Are navigators trained to be able to appropriately recognize the need for referrals? ",null,"Yes","II.D.3"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"4) To what degree are processes consistently followed for navigators to make referrals to appropriate internal and external resources?\n\nConsider a diverse range of referral situations, such as emergent care, specialty care follow-up, psychiatric interventions, wellness and health education, and preventive services.\n",null,"High","II.D.4"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[]
[]
[null,"5) To what degree are processes consistently followed for tracking and following up on referrals (including soliciting and addressing reasons for non-completion)?",null,"High","II.D.5"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[]
[null,"E. Linkages to Community Services"]
[null,"Item","Response",null,"Action Step"]
[null,"1) Is a regularly updated list of linkages to quality social support resources in the community available for clients?",null,"Yes","II.E.1"]
[null,null,null,"Somewhat"]
[null,null,null,"No"]
[null,"2) To what extent is client feedback on linkages to social support resources sought and used to refine lists and patterns of referrals?",null,"High","II.E.2"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]
[null,"3) To what extent is there strategic engagement by leadership in the maintenance of positive working relationships with community resource organizations (e.g. proactively identifying agencies to regularly connect with based on client needs, maintaining relationships with key leaders at identified organizations)?",null,"High","II.E.3"]
[null,null,null,"Moderate"]
[null,null,null,"Low"]

{"sheet":"Results II","index":4,"n_rows":87,"n_cols":4,"rows_kept":87,"cut":false,"hidden":false,"merged":[]}
[]
[null,"Results: II. Pillars of Navigation Support Services"]
[]
[null,"A. Building Client Relationships"]
[null,"1. Communication"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"II.A.1.a"]
[]
[]
[null,"II.A.1.b"]
[]
[null,"II.A.1.c"]
[]
[]
[]
[null,"2. Cultural and Linguistic Competency"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"II.A.2.a"]
[]
[]
[null,"II.A.2.b"]
[]
[]
[]
[null,"II.A.2.c"]
[]
[]
[]
[]
[]
[]
[null,"B. Health Literacy"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"II.B.1"]
[null,"II.B.2"]
[]
[]
[]
[]
[null,"C. Health Coaching and Wellness Planning"]
[null,"1. Goal Setting"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"II.C.1.a"]
[null,"II.C.1.b"]
[]
[]
[null,"II.C.1.c"]
[null,"II.C.1.d"]
[]
[null,"2. Self-Management Support"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"II.C.2.a"]
[]
[null,"II.C.2.b"]
[]
[null,"II.C.2.c"]
[]
[]
[]
[null,"II.C.2.d"]
[]
[]
[]
[null,"D. Care Coordination"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"II.D.1"]
[]
[]
[]
[null,"II.D.2"]
[null,"II.D.3"]
[]
[]
[null,"II.D.4"]
[]
[]
[]
[null,"II.D.5"]
[]
[]
[]
[null,"E. Linkages to Community Services"]
[null,"Item","Response","Description (click cell for full description)"]
[null,"II.E.1"]
[]
[null,"II.E.2"]
[null,"II.E.3"]