Community Needs Assessment After Hours Care Center Survey

Community Needs Assessment After Hours Care Center

Jones Memorial Hospital is exploring the possibility of opening an After Hours Care Center to serve patients that need non-emergent care in the evenings or on weekends. This is similar to an "Urgent Care Center". The proposal is to offer the service a few evenings a week and one day on the weekend. As part of this process, we are seeking the input from our community to determine the level of need there might be. Please take a few minutes to answer this short survey.

1. Home Zip Code

Home Zip Code 14895 Wellsville 14715 Bolivar 14739 Friendship 14806 Andover	14813 Belmont 14709 Angelica 14880 Scio 14897 Whitesville	14711 Belfast 14802 Alfred Other
Other (please specify)

2. Choose one:

Choose one: Male

Female

3. What is your age group?

What is your age group? 18-25

26-35

36-49

50-64

66-75

76+

4. How many people are in your household?

How many people are in your household? 1

5. Do you have a primary care provider that you see regularly?

Do you have a primary care provider that you see regularly? Yes

6. Have you used an After Hours or Urgent Care Center in the last 12 months?

Have you used an After Hours or Urgent Care Center in the last 12 months? Yes	No
If yes, which one:

7. If yes, what was the reason for your visit(s)? Please check all that apply.

If yes, what was the reason for your visit(s)? Please check all that apply. Asthma/Respiratory Blood Sugar/Insulin Burn Pain ER Follow-up	Cut/Stitches Cold/Cough/Flu Bite Medication Issue Strain/SPrain	Fever,Sore Throat, Ear Infection Gastroenteritis Infection
Other (please specify)

8. How important do you think an After Hours Care Center is for our community?

How important do you think an After Hours Care Center is for our community? Very Important

Important

Not Very Important

Not Needed At All

9. How likely would you be to use an After Hours Care Center in Wellsville?

How likely would you be to use an After Hours Care Center in Wellsville? Very Likely

Somewhat Likely

Not Likely

Would Not Use

10. Do you recall why you used the After Hours or Urgent Care Center?

Do you recall why you used the After Hours or Urgent Care Center? I do not have a primary care provider

My provider was out of town/closed

My provider could not accommodate me/No appointments available

I could not get out of work during provider office hours

11. Have you had an ER visit in the past 12 months for which you could have used an After Hours or Urgent Care Center?

Have you had an ER visit in the past 12 months for which you could have used an After Hours or Urgent Care Center? Yes

12. If yes,

If yes, Age of patient:
Reason for visit:

13. In your opinion, would the following staffing proposal meet your needs?
Two hours on three evenings during the week and four to six hours on Saturday

In your opinion, would the following staffing proposal meet your needs? Two hours on three evenings during the week and four to six hours on Saturday Yes	No
If no, please explain: