Form Approved
OMB No: 0920-1019
Exp. Date: XX/XX/XXXX
Integrating Community Pharmacists and Clinical Sites
for Patient-Centered HIV Care
Attachment 11b Staff Communication Form for Medical Providers
Staff Communication Questionnaire for Medical Providers
Purpose: A key component of the Patient Centered HIV Care Model project is “communication and collaboration” between pharmacists and medical providers (physicians, nurse practitioners and physician assistants). 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.
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 DIRECTLY discussed a patient’s medication therapy* with a pharmacist?
Never
< 1 time per month
1 or 2 times per month
1 time per week
> 1 time per week
Currently, which of the following best describes the frequency at which you discuss a patient’s medication therapy* with a pharmacist?
Never
< 1 time per month
1 or 2 times per month
1 time per week
> 1 time per week
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)
Communication Importance
Prior to project implementation, how would you rate the level of importance of communicating with a pharmacist, as it related to discussing patient care decisions?
N/A- Not applicable because I did not communicate with a pharmacist
Not at all important
Low importance
Moderately important
Very important
Currently, how would you rate the level of importance of communicating with a pharmacist, as it related to discussing patient care decisions?
N/A- Not applicable because I did not communicate with a pharmacist
Not at all important
Low importance
Moderately important
Very important
Prior to project implementation, how would you rate the level of importance of communicating with a pharmacist, as it related to discussing medication related decisions?
N/A- Not applicable because I did not communicate with a pharmacist
Not at all important
Low importance
Moderately important
Very important
Currently, how would you rate the level of importance of communicating with a pharmacist, as it related to discussing medication related decisions?
N/A- Not applicable because I did not communicate with a pharmacist
Not at all important
Low importance
Moderately important
Very important
Prior to project implementation, how would you rate the level of importance of communicating with a pharmacist, in general?
N/A- Not applicable because I did not communicate with a pharmacist
Not at all important
Low importance
Moderately important
Very important
Currently, how would you rate the level of importance of communicating with a pharmacist, in general?
N/A- Not applicable because I did not communicate with a pharmacist
Not at all important
Low importance
Moderately important
Very important
Communication Patterns
Please select the most common mode of communication by which you are contacted by a pharmacist 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)
Secure text message
Fax
Written letter
Please select the most preferred mode of communication to be contacted by a pharmacist 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)
Secure text message
Fax
Written letter
Communication Barriers
Currently, are you encountering any barriers to efficient and meaningful communication with a pharmacist, 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 pharmacist when called.
Pharmacist is difficult to contact in person.
Pharmacist is difficult to contact by telephone.
Pharmacist does not return my phone calls promptly (within 24 hours).
Pharmacist does not return my emails promptly (within 24 hours).
Pharmacist does not routinely contact me by my preferred method of communication.
The success of communication is highly dependent on the specific pharmacist with whom I am communicating.
Other (please describe): ______________________
Pharmacist Referral for MTM
Prior to project implementation, had you ever formally referred a patient to a pharmacist for medication therapy management (MTM) services?
No
Yes
Once the project has been completed, rate the likelihood that you will refer your patients to a pharmacist for MTM services?
Very unlikely
Unlikely
Patient Centered HIV Care Model assessment to date
Comparing prior to project implementation to today, the impact of the patient centered care model on retention in care has been
Not at all important
Low importance
Moderately important
Very important
Comparing prior to project implementation to today, the impact of the patient centered care model on viral load suppression has been:
Not at all important
Low importance
Moderately important
Very important
Comparing prior to project implementation to today, the impact of the patient centered care model on adherence to antiretroviral medications has been:
Not at all important
Low importance
Moderately important
Very important
Comparing prior to project implementation to today, the impact of the patient centered care model on clinic workflow / procedures has been:
Not at all important
Low importance
Moderately important
Very important
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |