PCP Post-discharge survey

Attachment E4: Primary Care Provider Post-discharge Questionnaire

Form Approved

OMB No: 0920-xxxx
Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 5 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 NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-xxxx).

Thank you for participating in this important study. Your responses to this questionnaire will be kept confidential and will not be shared outside our research and quality-improvement team.

This survey asks about your impressions of the usefulness of recommendations for post-hospital management of pain and mobility for older patients found to be at increased risk for falls contained in UCSF medical center discharge summaries. This should take no more than 5 minutes to complete.

If you have questions, please call Dr. Andrew Auerbach (4155021414) or email (TBD)

I have seen an older adult (age 65+) patient discharged from UCSF in my clinic

1

In the last day

In the last 2-5 days

In the last 6-10 days

More than 10 days ago

I have not seen an older adult patient discharged from UCSF in the past 14 days

Please rate the usefulness (in terms of improving your understanding or ability to address each area) of the information you received via discharge summary, communications with inpatient physicians, or via direct access to UCSF’s electronic health record (APeX)

		Not useful at all				Most useful	Don’t recall receiving
2	Information regarding your patient’s functional status and rehabilitation goals at time of discharge from UCSF
3	Information about your patient’s risk for falls
4	Suggestions about how and when to refer your patient to pain specialists (e.g. Chronic pain services)
5	Suggestions regarding your patient’s need for continued physical therapy or occupational therapy
6	Suggestions regarding your patient’s needs for other rehabilitation approaches such as Tai Chi or group exercise classes
7	Suggestions around appropriate use of vitamin D and/or calcium
8	Suggestions for use of non-opioid medications in patients with pain
9	Suggestions for tapering opioid medications
10	Suggestions for identifying patients at risk for adverse events due to opioid medications
11	Suggestions for non-medication therapies for pain (e.g. cognitive therapy, yoga)