12- and 18-month Provider Survey 2.8.22

Assessment of a Pharmacist-Led Transitions of Care Service Utilizing an Admissions Enhanced Patient Risk Evaluation Approach: the ICARE Program

OMB Control Number: 0910-0847

Expiration Date: 12/31/2022

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this voluntary information collection is 0910-0847. The burden time required to complete this portion of the information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information.

Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov. DO NOT SEND YOUR COMPLETED FORM TO THIS PRA STAFF EMAIL ADDRESS.

Acceptability, Impact, and Satisfaction Survey

The following survey is anonymous. Please select the most appropriate answer for each of the following items.

What is your profession? 

□ Physician  □ Nurse Practitioner  □ Nurse  □ Physician Assistant         □ Pharmacist   □ Social Worker 

□ Medical Assistant      □ Other ___________________________ 

What is your medical specialty?  ___________________________ 

In your current position do you have administrative/financial responsibilities? □ Yes  □ No 

How long have you worked for East Alabama Medical Center (EAMC)?

□ 0-5 years □ 6-10 years

□ 11-15 years □ 16-20 years

□ 21+ years

1. The ICARE transitions of care (TOC) team works effectively.

□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree

2. The ICARE TOC service runs smoothly.

□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree

3. The ICARE TOC service disrupts my normal workflow.

□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree

4. The ICARE TOC service aligns with my goals for patient care.

□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree

5. I understand how the ICARE TOC service operates.

□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree

6. The ICARE TOC service saves time and money for both myself and the hospital.

□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree

7. The ICARE TOC service reduces readmission rates.

□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree

8. The ICARE TOC service improves patient care and understanding.

□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree

9. The ICARE TOC service has benefited my patients.

□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree

10. I am confident that I can continue to effectively work with the ICARE TOC team.

□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree

11. My overall experience with the ICARE TOC team has been________.

□ Excellent □ Good □ Average □ Poor □ Very Poor

12. My overall experience with the ICARE TOC service has been________.

□ Excellent □ Good □ Average □ Poor □ Very Poor