Staff Communication Form - pharmacist

Form Approved

OMB No: 0920-1019

Exp. Date: XX/XX/XXXX

Integrating Community Pharmacists and Clinical Sites

for Patient-Centered HIV Care

Attachment 11a Staff Communication Form

Staff Communication Questionnaire

Purpose: A key component of the Patient Centered HIV Care Model project is “communication and collaboration” between pharmacists and medical providers. The project aims to describe the communication between the project pharmacist and medical provider that occurs throughout the project, as well as explore the relationship between communication and project outcomes. Please note that, for purposes of this questionnaire, the term “medical provider” includes physicians, nurse practitioners, and physician assistants.

Instructions: Unless otherwise noted, select one response to each of the following questions that best describes the frequency, importance, patterns, and barriers to communication with a medical provider.

* For the purpose of this questionnaire, the phrase “patient’s medication therapy” refers to clinical aspects of the patient’s medication therapy, such as medication recommendations based on indication, identifying preferred or optimal therapies, drug interaction management, dosage adjustments, side effect management, or polypharmacy issues; but does not refer to refill authorizations, prior authorizations, or similar issues.

Communication Frequency

Prior to project implementation, which of the following best described the frequency at which you discussed a patient’s medication therapy* with a medical provider? 

1. Never

2. < 1 time per month

3. 1 or 2 times per month

4. 1 time per week

5. > 1 time per week

Currently, which of the following best describes the frequency at which you discuss a patient’s medication therapy* with a medical provider?

1. Never

2. < 1 time per month

3. 1 or 2 times per month

4. 1 time per week

5. > 1 time per week

Communication Importance

Prior to project implementation, how would you rate the level of importance (or meaningfulness) of your communication with a medical provider, as it related to discussing patient care and treatment issues?

N/A- Not applicable because I did not communicate with a medical provider

1. Not at all important

2. Low importance

3. Moderately important

4. Very important

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1019)

Currently, how would you rate the level of importance (or meaningfulness) of your communication with a medical provider, as it relates to discussing patient care and treatment issues?

N/A- Not applicable because I did not communicate with a medical provider

1. Not at all important

2. Low importance

3. Moderately important

4. Very important

Appendix B.4:

Pharmacist Completed Communication Questionnaire (page 2 of 2)

Communication Patterns

Please select the most common mode of communication by which you are contacted by a medical provider to discuss a non-urgent/routine issue related to a patient’s medication therapy:

• In person (e.g. during clinic hours, morning huddle, or team case conferences)

• Telephone (live)

• Telephone (message)

• Email

• Secure text message

• Fax

• Written letter

Please select the mode of communication by which you prefer to be contacted by a medical provider to discuss a non-urgent/routine issue related to a patient’s medication therapy:

• In person (e.g. during clinic hours, morning huddle, or team case conferences)

• Telephone (live)

• Telephone (message)

• Email

• Secure text message

• Fax

• Written letter

Please select the most common type of medical provider with whom you communicate about patients’ medication therapy:

• Physicians

• Nurse practitioners

• Physician assistants

• Registered or licensed practical nurse

• Other: ___________________

Communication Barriers

Currently, are you encountering any barriers to efficient and meaningful communication with a medical provider, as it relates to a patient’s medication therapy*? (Select all that apply)

• No, I am not encountering any communication barriers at this time.

• I am generally unavailable to speak directly to the provider when called.

• Medical provider is difficult to contact in person.

  • Medical provider is difficult to contact by telephone.

  • Medical provider does not return my phone calls promptly (within 24 hours).

  • Medical provider does not return my emails promptly (within 24 hours).

  • Medical provider does not routinely contact me by my preferred method of communication.

  • The success of communication is highly dependent on the specific medical provider with whom I am communicating.

  • Other (please describe): ______________________