Appendix D. Clinical-Community Relationships Measures Instruments (continued)

Clinical-Community Relationships Measures (CCRM) Atlas

Alzheimer's Service Coordination Program (ASCP) Physician Survey

CCRM Atlas Measure(s): 9, 10, 11, 12, 13
Contact Information: Richard H. Fortinsky, PhD, UConn Center on Aging, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-5215; Email: fortinsky@uchc.edu; Phone: 860-679-8069
Copyright Details: Developed and used with permission by Richard H. Fortinsky, PhD

Alzheimer's Service Coordination Program

Physician Survey—April 1998

Dear Doctor __________:

Thank you for referring _____ patients and their family caregivers to the Service Coordinator for the Alzheimer's Service Coordination Program (ASCP). Please take a few minutes to answer the questions below. Your answers will help us understand how well the ASCP has been working for you.

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1. After you referred your patients and family caregivers to the ASCP, did you receive a treatment plan listing actions planned, such as reading educational material and using community services, to help your patients and their families better manage dementia care? (Circle your answer)

  1.   Yes, for all patients (even if only one patient referred).
  2. Yes, but only for some patients.
  3.   Never (SKIP to question 4).

2. Have you ever reviewed or discussed this treatment plan with patients or family caregivers? (Circle your answer)

  1.   Yes.
  2. No.

3. How helpful is this treatment plan as a way for you to discuss dementia care with patients and family caregivers in the office? (Circle)

  1.   Very helpful.
  2. Somewhat helpful.
  3.   Not at all helpful.

4. Have you had any telephone contact with the ASCP Service Coordinator since referring your patients and their family caregivers to her? (Circle)

  1.   Yes.
  2. No (SKIP to question 7).

5. How helpful has this telephone contact been in helping you discuss dementia care with your patients and their family caregivers in the office? (Circle)

  1.   Very helpful.
  2. Somewhat helpful.
  3.   Not at all helpful.

6. Would you like to have more, less, or about the same contact with the ASCP Service Coordinator after you refer a patient and family caregiver to her? (Circle)

  1.   More contact.
  2. About the same amount of contact.
  3.   Less contact.

7. Has your involvement in the ASCP increased your awareness of the kinds of help available to our patients with dementia and their families? (Circle)

  1.   Yes.
  2. No.

8. Compared to before your involvement in the ASCP, how confident are you now in your ability to discuss dementia care with your patients and families? (Circle)

  1.   More confident than before.
  2. About the same level of confidence as before.
  3.   Less confident than before.

9. Do you plan to refer more patients and family caregivers to the ASCP in the future? (Circle)

  1.   Yes.
  2. No.

10.  In general, how satisfied are you with the ASCP? (Circle)

  1.   Very satisfied.
  2. Satisfied.
  3.   Dissatisfied.
  4. Very dissatisfied.

11.  What recommendations would you make to improve the ASCP? Please use the space below.

 

Thank you. Please fax this completed form to

Page last reviewed March 2013
Internet Citation: Appendix D. Clinical-Community Relationships Measures Instruments (continued): Clinical-Community Relationships Measures (CCRM) Atlas. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/resources/clinical-community-relationships-measures-atlas/ccrm-atlasapd4.html