MEPS-HC Survey Instrument

OMB #: 0935-0108
PROVIDER LABEL

MEDICAL PROVIDER COMPONENT FOR REFERENCE YEAR 2005
CONTACT GUIDE FOR HOME CARE ORGANIZATIONS

IF PROVIDER IS A HOSPITAL, ASK: May I please speak to someone in the home health care
department? [GO TO INTRODUCTION ON NEXT PAGE]

OTHERWISE ASK:
May I please speak to the Business Manager or someone who is in charge of billing for the
organization? [IF ON SECOND CALL PERSON IS UNAVAILABLE, ASK TO SPEAK TO
SUPERVISOR IN THAT DEPARTMENT]
___

NOT AN ORGANIZATION. (GO TO INTRODUCTION ON NEXT PAGE.)

___

ORGANIZATION AND: (CHECK APPROPRIATE CATEGORY BELOW)
___

HAS BILLING STAFF. GO TO INTRODUCTION ON NEXT PAGE.

___

BILLING IS PERFORMED BY OUTSIDE BILLING SERVICE.
PERSON WHO DEALS WITH THE BILLING SERVICE.

___

DOES NOT BILL -- ALL SERVICES PROVIDED ON PREPAID OR A CAPITATED
BASIS. ASK TO SPEAK TO SOMEONE WHO DEALS WITH PATIENT RECORDS.
THEN START WITH INTRODUCTION ON NEXT PAGE.

___

NO BILLING STAFF AND IT IS NOT CLEAR WHO TO SPEAK TO. RECORD
INFORMATION BELOW, TERMINATE CALL, AND CONSULT WITH TASK
COORDINATOR.

ASK TO SPEAK TO

________________________________________________
________________________________________________

M:\7690\7690.19.04\2005 Deliveries\DEL #165 Data Collection Forms\HH Contact Guide.DOC - 12/9/2005 - 12:03 PM - cg

INTRODUCTION
Hello, my name is (YOUR NAME) and I am calling on behalf of the U.S. Public Health Service. This
is a nationwide study about how people in the United States use and pay for health care.
] person(s) in our survey identified (this organization/you)
[NUMBER FROM PATIENT LIST:
as having provided home care services during 2005 and signed an authorization form allowing you
to release information to us about the services they received. Right now, I just need to ask you a
few brief questions about (the organization/the services you provide). Then I can send a package of
materials that explains more about what we need.
(IF PROVIDER IS A HOSPITAL, BEGIN WITH H1a.)
H1.

First, let me verify that this is a home health care agency.

YES, HOME HEALTH CARE AGENCY ........................................
YES, HOME HEALTH CARE DEPT. IN HOSPITAL ......................
NO -- SOME OTHER KIND OF ORGANIZATION .......................
NO -- NOT AN ORGANIZATION ..................................................
H1a.

1 (BOX 2)
2 (BOX 2)
3
4 (BOX 1)

Does your organization include a home health care unit or department?
YES ................................................................................................ 1 (BOX 2)
NO ............................................................................................... 2

H1b.

Does your organization ever make arrangements for other organizations or individuals to
provide some kind of assistance to people in their homes?
YES ............................................................................................... 1 (H4)
NO ............................................................................................... 2 (H2)
BOX 1

FOR INDIVIDUAL PROVIDERS:
H1c.

During 2005, did you provide any kind of assistance to people in their homes?
YES ........................................................................................ 1
NO .......................................................................................... 2 [TERMINATE AND
CONSULT TASK
COORDINATOR]

H1d.

Were the services you provided exclusively to persons who needed in-home assistance for health
reasons?
EXPLAIN, IF NECESSARY: Health reasons can include either physical or mental health conditions.
YES ........................................................................................ 1 (H4)
NO .......................................................................................... 2 (BOX 3)

H2.

Does your organization provide any kind of assistance to people in their homes?
YES................................................................................................. 1
NO .................................................................................................. 2 [THANK RESPONDENT
AND END]

H2a.

Are your services provided exclusively to persons who need in-home assistance for health
reasons?
EXPLAIN, IF NECESSARY: Health reasons can include either physical or mental health
conditions.
YES ................................................................................................ 1 (BOX 2)
NO ................................................................................................ 2

1

H2b.

What kind of services does your organization provide to people in their homes?
CLEANING OR YARD WORK .......................................................
TRANSPORTATION ......................................................................
SHOPPING.....................................................................................
EMOTIONAL SUPPORT PERSON OR ONE-ON-ONE BUDDY...
SUPPORT GROUPS......................................................................
CHILD CARE..................................................................................
Other. (RECORD VERBATIM) ___________________________
_____________________________________________.............

1
2
3
4
5
6

(BOX 3)

7 [TERMINATE AND
CONSULT TASK
COORDINATOR]

BOX 2
H3.

INTERVIEWER: IS THIS A RUBBER-BAND CASE?
YES................................................................................................. 1
NO .................................................................................................. 2 (H4)
H3a.

I need to verify that the following organizations were associated with this organization during
2005. [REVIEW EACH PROVIDER WITH THE CONTACT PERSON AND COMPLETE A
SAMPLE PROBLEM FORM AS APPROPRIATE]

2

H4.

We need information about the in-home services provided to the persons in our study and about the
charges and payments for those services. Would you (or someone in your office) be able to provide
this information?
YES, RESPONDENT (OR SOMEONE ELSE IN OFFICE)
CAN PROVIDE INFORMATION ............................................ 1 (H5)
NO, NEED TO CONTACT BILLING SERVICE........................... 2 (H12)
NO, NEED TO CONTACT DIFFERENT DEPARTMENT ........... 3 (H14)
NO, ORGANIZATION ARRANGES FOR HOME HEALTH
CARE -- NEED TO CONTACT H.H. CARE ORGANIZATION
DIRECTLY .............................................................................. 4 (BOX 4, PAGE 10)
NO, THIS TYPE OF INFORMATION IS NOT AVAILABLE
(RECORD VERBATIM) _____________________________
________________________________________________
[TERMINATE AND
CONSULT TASK
COORDINATOR]

BOX 3
FOR ORGANIZATIONS OR INDIVIDUALS THAT DO NOT EXCLUSIVELY PROVIDE SERVICES FOR
HEALTH REASONS (SEE H2a):
H4a

We need information about the services provided to the persons in our study and about the charges
and payments for those services. Would you or someone in your office be able to provide this
information?
YES, OFFICE CAN PROVIDE INFORMATION ......................... 1 (NCH1)
NO, NEED TO CONTACT BILLING SERVICE........................... 2 (H12)
NO, THIS TYPE OF INFORMATION IS NOT AVAILABLE
(RECORD VERBATIM) ________________________________ TERMINATE AND
CONSULT TASK
COORDINATOR

H5.

We would like to send you a copy of the authorization form(s) and then call back to collect the
information. May I FAX the form(s) to you? (IF NOT: May I mail the form(s) to you?)
CAN PROVIDE INFORMATION BEFORE RECEIVING
AUTHORIZATION FORM(S)......................................................
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION ..........................................................................
MAIL AUTHOHRIZATION FORM(S) BEFORE COLLECTING
INFORMATION ..........................................................................
PREFERS MAILING RECORDS – FAX AUTHORIZATION
FORM(S) ....................................................................................
PREFERS MAILING RECORDS – MAIL AUTHORIZATION
FORM(S) ....................................................................................

3

1
2
3
4
5

H6.

OMITTED.

H7.

CODE ONE:
HOME CARE FORM(S) COMPLETE ............................................
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA ...........................................................................................
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA ...........................................................................................
RESPONDENT WILL MAIL RECORDS ........................................

H7a.

H8.

1
2 (H8)
3 (H9)
4 (H9)

Thank you very much for your time and help with this study. We will send you (the envelope
and) a copy of the authorization form(s) for your files. (H9)

We will FAX you a copy of the authorization form(s) today. What is your FAX number?
FAX NUMBER: (_______)_____________________________

H8a.

And what name and title should I put on the FAX cover page?
NAME:
_____________________________________
TITLE:
_____________________________________
DEPARTMENT: _____________________________________

H8b.

RESPONDENT NAME:
SAME AS NAME ON FAX COVER PAGE..................................... 1
DIFFERENT FROM NAME ON FAX COVER PAGE
(RECORD)______________________________________...... 2
GO TO H10.

4

H9.

Would you be the best person to receive the authorization form(s)?
YES................................................................................................. 1

(VERIFY NAME, TITLE,

NO .................................................................................................. 2

AND DEPARTMENT)
(OBTAIN NAME, TITLE,
AND DEPARTMENT)

H9a.

Let me also verify that I have the correct mailing address:
NAME:

__________________________________

TITLE:

__________________________________

DEPARTMENT:

__________________________________

PROVIDER NAME: __________________________________
ADDRESS:

H9b.

__________________________________
__________________________________

CITY:

__________ STATE: ______ ZIP: ______

TELEPHONE:

(______)_______________ EXT: _______

RESPONDENT NAME:
SAME AS NAME WHO WILL RECEIVE FORM(S) ....................... 1
DIFFERENT FROM NAME WHO WILL RECEIVE FORM(S)
(RECORD)_____________________________________....... 2

IF HOME CARE BOOKLETS COMPLETED,THANK RESPONDENT AND END CONTACT.
OTHERWISE, CONTINUE.

5

H10.

We will call you back shortly to collect the information.
What would be the best day and time to call?
DAY:___________ DATE:_________ R's TIME: __________ AM/PM
Thank you very much for your help. [END CONTACT AND RECORD FAX/MAIL DATE AND
APPOINTMENT ON CONTACT PERSON CALL RECORD.]

H11.

After you receive the authorization form(s), we hope you can mail the records to our office within two
weeks. Thank you very much for your time and your help with this study. [END CONTACT].

H12.

We will need to get in touch with the billing service to obtain some of the information we need. What
is the name of the billing service, their telephone number, and the name of a contact person?
PERSON'S NAME:

_________________________________

TITLE:

_________________________________

NAME OF SERVICE: _________________________________
TELEPHONE:

H13.

(______)_______________ EXT:______

I think we can probably get all the additional information we need from (BILLING SERVICE). We will
send you a copy of the authorization form(s) for your files. Let me verify that I have your correct
mailing address.
NAME:

__________________________________

TITLE:

__________________________________

DEPARTMENT:

__________________________________

PROVIDER NAME: __________________________________
ADDRESS:
CITY:

__________________________________
__________________________________
__________ STATE: ______ ZIP: ______

Thank you very much for your help. [END CONTACT AND CALL BILLING SERVICE
NAMED IN H12]

6

NEED TO CONTACT DIFFERENT DEPARTMENT: (HOSPITAL, CHAIN, ETC.)

H14.

Who could we contact to obtain this information?
NAME:

_____________________________________

TITLE:

_____________________________________

DEPARTMENT:

_____________________________________

ORGANIZATION NAME: _____________________________________
ADDRESS:

_____________________________________
_____________________________________

CITY:

__________ STATE: ______ ZIP: ________

TELEPHONE:

(______)_______________ EXT: _________

H14a. Thank you very much for your time and help with this study. [END CONTACT.]

7

CONTACT GUIDE FOR BILLING SERVICE

H15.

Hello, my name is (YOUR NAME). We are conducting the Medical Expenditure Panel Survey for the
US Public Health Service. The survey is about how people in the United States use and pay for
health care.
We were referred to you by (PROVIDER) for information about (NUMBER) of their clients. [READ
IF NECESSARY: We are collecting information about the home care services (this/these) person(s)
received from (PROVIDER) during 2005. We would like to send you copies of the authorization
form(s) we have from (this/these) person(s) and then call back to collect the information we need.
May I FAX the form(s) to you? (IF NOT: May I mail the form(s) to you?)]
IF ASKED FOR WHAT TYPE OF INFORMATION WE NEED: For each month of service, we need
information about diagnoses, services provided, charges and payments.
CAN PROVIDE INFORMATION BEFORE RECEIVING
AUTHORIZATION FORM(S)...................................................... 1
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION .......................................................................... 2 (H18)
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION .......................................................................... 3 (H18)

H16.

[COMPLETE HOME CARE BOOKLET(S) NOW. WHEN ALL FORM(S) HAVE BEEN COMPLETED,
GO TO H18.]

H17.

OMITTED

H18.

CODE ONE:
HOME CARE BOOKLET(S) COMPLETE ...................................... 1
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA .......................................................................................... 3 (H19)
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA .......................................................................................... 3 (H20)

H18a. Thank you very much for your time and help with this study. We will be sending you the
authorization form(s) (and envelope) today. (H20)

H19.

We will be faxing you the authorization form(s) today. What is your FAX number?
FAX NUMBER: (_______)_____________________________

H19a. And what name and title should I put on the fax cover page?
NAME:
_____________________________________
TITLE:
_____________________________________
DEPARTMENT: _____________________________________

H19b. RESPONDENT NAME:
SAME AS NAME ON FAX COVER PAGE..................................... 1
DIFFERENT FROM NAME ON FAX COVER PAGE
(RECORD)_____________________________________....... 2

8

H20.

Would you be the best person to receive the (authorization form(s)/envelope)?
YES................................................................................................. 1

(VERIFY NAME, TITLE,

NO .................................................................................................. 2

AND DEPARTMENT)
(OBTAIN NAME, TITLE,
AND DEPARTMENT)

H20a. Let me also verify that I have the correct mailing address.
NAME:

__________________________________

TITLE:

__________________________________

DEPARTMENT:

__________________________________

PROVIDER NAME: __________________________________
ADDRESS:

__________________________________
__________________________________

CITY:

__________ STATE: ______ ZIP: ______

TELEPHONE:

(______)_______________ EXT: _______

H20b. RESPONDENT NAME:
SAME AS NAME WHO WILL RECEIVE FORM(S) ....................... 1
DIFFERENT FROM NAME WHO WILL RECEIVE FORM(S)
(RECORD)_____________________________________....... 2

IF HOME CARE BOOKLETS COMPLETED, THANK RESPONDENT AND END CONTACT.
IF RESPONDENT WILL MAIL RECORDS, GO TO H22.
OTHERWISE, CONTINUE.

H21.

We will call you back shortly to collect the information.
What would be the best day and time to call?
DAY:___________ DATE:_________ R's TIME: __________ AM/PM
Thanks again. [END CONTACT]

H22.

After you receive the authorization form(s), we hope you can mail the records to our office within two
weeks. Thank you very much for your time and your help with this study. [END CONTACT]

9

FOR ORGANIZATIONS PROVIDING NON-HEALTH-CARE HOME CARE SERVICES:
NHC1. We would like to send you a copy of the authorization form(s) and then call back to collect the
information. May I FAX the form(s) to you? (IF NOT: May I mail the form(s) to you?)
CAN PROVIDE INFORMATION BEFORE RECEIVING
AUTHORIZATION FORM(S)......................................................
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION ..........................................................................
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION ..........................................................................
PREFERS MAILING RECORDS – FAX AUTHORIZATION
FORM(S) .....................................................................................
PREFERS MAILING RECORDS – MAIL AUTHORIZATION
FORM(S) .....................................................................................

1
2 (NHC4)
3 (NHC4)
4 (NHC4)
5 (NHC4)

NHC2. COMPLETE NON-HEALTH-CARE HOME CARE FORM(S) NOW. WHEN ALL FORM(S) HAVE
BEEN COMPLETED, GO TO NHC4.

NHC3. OMITTED

NHC4. CODE ONE:
NON-HEALTH-CARE HOME CARE FORM(S) COMPLETE ........
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA ...........................................................................................
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA ...........................................................................................
RESPONDENT WILL MAIL RECORDS ........................................

1
2 (NHC5)
3 (NHC6)
4 (NHC6)

NHC4a. Thank you very much for your time and help with this study. We will send you (the envelope
and) a copy of the authorization form(s) for your files. (NHC6)

NHC5. We will fax you a copy of the authorization form(s) today. What is your FAX number?
FAX NUMBER: (_______)_____________________________

NHC5a.What name and title should I put on the FAX cover page?
NAME:
_____________________________________
TITLE:
_____________________________________
DEPARTMENT: _____________________________________

NHC5b. RESPONDENT NAME:
SAME AS NAME ON FAX COVER PAGE..................................... 1
DIFFERENT FROM NAME ON FAX COVER PAGE
(RECORD)______________________________________...... 2
IF RESPONDENT NEEDS AN ENVELOPE FOR THE PRICE
LIST, CONTINUE. OTHERWISE, GO TO NHC7

10

NHC6. Would you be the best person to receive the (authorization form(s)/envelope)?
YES ................................................................................................ 1 (VERIFY NAME, TITLE,
AND DEPARTMENT)

NO ................................................................................................ 2 (OBTAIN NAME, TITLE,
AND DEPARTMENT)

NHC6a.Let me also verify that I have the correct mailing address:
NAME:

__________________________________

TITLE:

__________________________________

DEPARTMENT:

__________________________________

PROVIDER NAME: __________________________________
ADDRESS:

__________________________________
__________________________________

CITY:

__________ STATE: ______ ZIP: ______

TELEPHONE:

(______)_______________ EXT: _______

NHC6b. RESPONDENT NAME:
SAME AS NAME WHO WILL RECEIVE FORM(S) ....................... 1
DIFFERENT FROM NAME WHO WILL RECEIVE FORM(S)
(RECORD)_____________________________________....... 2

IF NON-HEALTH-CARE, HOME CARE FORM(S) COMPLETED, THANK
CORRESPONDENT AND END CONTACT.
IF RESPONDENT WILL MAIL RECORDS, GO TO NHC8.
OTHERWISE, CONTINUE.
NHC7. We will call you back shortly to collect the information.
What would be the best day and time to call?
DAY:___________ DATE:_________ R's TIME: __________ AM/PM
Thank you very much for your help. [END CONTACT AND RECORD FAX/MAIL DATE AND
APPOINTMENT ON CONTACT PERSON CALL RECORD.]

NHC8. After you receive the authorization form(s), we hope you can mail the records to our office within two
weeks. Thank you very much for your time and your help with this study. [END CONTACT]

11

BOX 4
ORGANIZATIONS WHO ARRANGE FOR HOME CARE
COMPLETE TABLE BELOW FOR EACH PATIENT ON LIST. IF SAME ORGANIZATION PROVIDED CARE
TO MORE THAN ONE PATIENT, ENTER ORGANIZATION NAME AND THEN “SEE ABOVE”.
H22.

Could you give me the name of each organization that provided home care to (PATIENT NAME). I
also need the name, title, and telephone number of a contact person at the organization.

PATIENT NAME:
______________________

ORGANIZATION NAME: __________________________________

______________________

CONTACT NAME: _______________________________________

______________________

TITLE: ________________________________________________
TELEPHONE: (____) ________________

EXT: _______________

PATIENT NAME:
______________________

ORGANIZATION NAME: __________________________________

______________________

CONTACT NAME: _______________________________________

______________________

TITLE: ________________________________________________
TELEPHONE: (____) ________________

EXT: _______________

PATIENT NAME:
______________________

ORGANIZATION NAME: __________________________________

______________________

CONTACT NAME: _______________________________________

______________________

TITLE: ________________________________________________
TELEPHONE: (____) ________________

EXT: _______________

PATIENT NAME:
______________________

ORGANIZATION NAME: __________________________________

______________________

CONTACT NAME: _______________________________________

______________________

TITLE: ________________________________________________
TELEPHONE: (____) ________________

EXT: _______________

PATIENT NAME:
______________________

ORGANIZATION NAME: __________________________________

______________________

CONTACT NAME: _______________________________________

______________________

TITLE: ________________________________________________
TELEPHONE: (____) ________________

TERMINATE INTERVIEW

12

EXT: _______________

FOLLOW-UP INTRODUCTION
HF1.

May I please speak to (RESPONDENT)?
Hello, my name is (YOUR NAME) and I am calling about the Medical Expenditure Panel Survey,
which we are conducting for the U.S. Public Health Service. Did you receive the authorization
form(s) we (Faxed/sent)?
YES ................................................................................................ 1 (HF6)
NO AND WAS FAXED ................................................................... 2
NO AND WAS MAILED .................................................................. 3

HF2.

Let me (FAX/send) the authorization form(s) to you ( again).
HAS FAX ........................................................................................ 1
DOES NOT HAVE FAX OR PREFERS MAIL ................................ 2 (HF4)

HF3.

I would like to verify your name and FAX number. I have (NAME AND FAX NUMBER FROM H8a).
Is that correct?
FAX NUMBER:
NAME:
TITLE:
DEPARTMENT:

(_______)_____________________________
_____________________________________
_____________________________________
_____________________________________

We will FAX the materials to you and call back shortly to collect the information. What would be the
best day and time to call you back?
DAY:___________ DATE:_________ R's TIME: __________ AM/PM
Thank you very much for your help. [END CONTACT AND RECORD FAX DATE AND
APPOINTMENT ON CONTACT PERSON CALL RECORD.]

HF4.

I would like to verify your name and address. I have (NAME AND ADDRESS FROM H9a). Is that
correct? [MAKE CORRECTIONS AS NECESSARY]
NAME:

__________________________________

TITLE:

__________________________________

DEPARTMENT:

__________________________________

PROVIDER NAME: __________________________________
ADDRESS:

__________________________________
__________________________________

CITY:

__________ STATE: ______ ZIP: ______

TELEPHONE:

(______)_______________ EXT: _______

13

HF5.

What would be the best day and time to call you back?
DAY:___________ DATE:_________ R's TIME: __________ AM/PM
Thank you very much for your help. [END CONTACT AND RECORD MAIL DATE AND
APPOINTMENT ON CONTACT PERSON CALL RECORD.]

HF6.

If it is convenient for you, we can just go ahead and complete the data form(s) together over the
phone right now. I’d be happy to hold on while you get the information you need from your records.
WILL COMPLETE BY PHONE NOW............................................. 1
WILL COMPLETE BY PHONE IN THE FUTURE .......................... 2 (HF8)
PREFERS MAILING RECORDS.................................................... 3 (HF9)

HF7.

COMPLETE FORM(S) NOW. (USE REGULAR HOME CARE FORM(S) OR NON-HEALTH-CARE
HOME CARE FORM(S) DEPENDING ON RESPONSE TO H2a.)
WHEN ALL FORM(S) HAVE BEEN COMPLETED, SAY: Thank you very much for your time and
your help with this study. [END CONTACT]

HF8.

What would be the best day and time to call you back?
DAY:___________ DATE:_________ R's TIME: __________ AM/PM
Thank you very much for your help.
CONTACT PERSON CALL RECORD.]

HF9.

[END CONTACT AND RECORD APPOINTMENT ON

OMITTED

HF10. We hope you can mail the records to our office within two weeks. Thank you very much for your
time and your help with this study. [END CONTACT]

14