Form CMS-10208 Assessing Degrees of Health Care Involvement Survey

Patient Activation Survey: Draft 1 7/27/2006

This survey asks about you, your health care and how you make health care decisions. Answer each question thinking about yourself. Please take the time to complete this survey. Your answers are very important to us.

Please return the survey with your answers in the enclosed postage-paid envelope.

• Answer all the questions by checking the box to the left of your answer, like this:

 Yes

• Be sure to read all the answer choices given before checking your answer.

• You are sometimes told not to answer some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this: [  If no, go to Question 3 ].

See the examples below:

1. Do you wear a hearing aid now?

 Yes

 No  If no, go to Question 3

2. How long have you been wearing a hearing aid?

 Less than one year

 1 to 3 years

 More than 3 years

 I don’t wear a hearing aid

3. In the last 6 months, did you have any headaches?

 Yes

 No

EXAMPLE

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is CMS 10208 The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimates(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, S1-14-21, Baltimore, Maryland 21244-1850.

PA. PATIENT ACTIVATION: MCBS Questions

. I have some questions about how you make health care decisions. Answers to questions like these will help Medicare better understand how people use medical services.

Please keep in mind that there are no right or wrong answers to these questions. Your opinions and experiences are important to us.

Self Care Self-Efficacy

1. How confident are you that you can identify when it is necessary for you to get medical care?

4 = very confident,

3 = confident,

2 = somewhat confident,

1 = not at all confident

2. How confident are you that you can identify when you are having side effects from your medications?

4 = very confident,

3 = confident,

2 = somewhat confident,

1 = not at all confident or not applicable

3. Doctors often give instructions about how you should care for yourself at home, like changing a bandage, taking medicines on schedule, or applying ice packs. How confident are you that you can follow instructions to care for yourself at home?

4 = very confident,

3 = confident,

2 = somewhat confident,

1 = not at all confident or not applicable

4. Doctors often give instructions about changing your habits or lifestyle, such as changing your diet, stopping smoking, or getting regular exercise. How confident are you that you can follow this kind of instruction to change your habits or lifestyle?

4 = very confident,

3 = confident,

2 = somewhat confident,

1 = not at all confident

Doctor Relationship and Communication

5. Do you always, usually, sometimes, or never, leave your doctor’s office feeling that all your concerns or questions have been fully answered?

4 = always,

3 = usually,

2 = sometimes,

1 = never

6. The following always, usually, sometimes, or never happens. My doctor listens to what I have to say about my symptoms and concerns.

4 = always,

3 = usually,

2 = sometimes,

1 = never

7. The following always, usually, sometimes, or never happens. My doctor explains things to me in terms that I can easily understand.

4 = always,

3 = usually,

2 = sometimes,

1 = never

8. The following always, usually, sometimes, or never happens. I can call my doctor’s office to get medical advice when I need it.

4 = always,

3 = usually,

2 = sometimes,

1 = never

Assertiveness with Doctor

9. How likely are you to change doctors if you are dissatisfied with the way you and your doctor communicate?

4 = very likely,

3 = likely,

2 = unlikely,

1 = very unlikely

10. How likely are you to tell your doctor when you disagree with him or her?

4 = very likely,

3 = likely,

2 = unlikely,

1 = very unlikely

11. Do you always, usually, sometimes, or never, talk with your doctor about your options if you need tests or follow-up care?

4 = very likely,

3 = likely,

2 = unlikely,

1 = very unlikely

Active and Shared Decision-Making

12. Do you always, usually, sometimes, or never, bring with you to your doctor visits a list of questions you want to cover?

4 = very likely,

3 = likely,

2 = unlikely,

1 = very unlikely

13. Do you always, usually, sometimes, or never, take a list of all your prescribed medicines to your doctor visits?

4 = always,

3 = usually,

2 = sometimes,

1 = never, or

0= I do not take prescription medicine

Health Information-Seeking

14. Do you always, usually, sometimes, or never, read about health conditions in newspapers, magazines, or on the Internet?

4 = always,

3 = usually,

2 = sometimes,

1 = never, or not applicable

15. Do you always, usually, sometimes, or never, read information about a new prescription, such as side effects and precautions?

4 = always,

3 = usually,

2 = sometimes,

1 = never,

0= I do not take prescription medicine

Patient Activation Measure (Judy Hibbard Questions)

16. Below are some statements that people sometimes make when they talk about their health. Please indicate how much you agree or disagree with each statement as it applies to you personally by circling your answer. Your answers should be what is true for you and not just what you think the doctor wants you to say.

If the statement does not apply to you, circle N/A.

When all is said and done, I am the person who is responsible for managing my health condition.	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
Taking an active role in my own health care is the most important factor in determining my health and ability to function.	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
I am confident that I can take actions that will help prevent or minimize some symptoms or problems associated with my health condition.	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
I know what each of my prescribed medications does.	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
I am confident that I can tell when I need to go get medical care and when I can handle a health problem myself.	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
I am confident I can tell a doctor concerns I have even when he or she does not ask.	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
I am confident that I can follow through on medical treatments I need to do at home.	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
I understand the nature and causes of my health condition(s).	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
I know the different medical treatment options available for my health condition.	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
I have been able to maintain the lifestyle changes for my health condition that I have made.	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
I know how to prevent further problems with my health condition.	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
I am confident I can figure out solutions when new situations or problems arise with my health condition.	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
I am confident that I can maintain lifestyle changes, like diet and exercise, even during	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A

Porter Novelli Index	Strongly disagree						Strongly agree
DOCRELY I rely on my doctor to tell me everything I need to know to manage my health		1	2		3	4		5
HI2HARD Most health issues are too complex for me to understand		1	2		3	4		5
TRYPREV I actively try to prevent diseases and illnesses		1	2		3	4		5
UPTODOC I leave it to my doctor to make the right decisions about my health.		1	2		3	4		5
HIIMP2M It is important to me to be informed about health issues		1	2		3	4		5
FORFAM I need to know about health issues so I can keep myself and my family healthy		1	2		3	4		5
HIDIFCL I have difficulty understanding a lot of the health information that I read		1	2		3	4		5
WKWDOCS My doctor(s) and I work together to manage my health		1	2		3	4		5
TALK2DO When I read or hear something that’s relevant to my health care, I bring it up with my doctor		1	2		3	4		5
KNOWRIS I try to understand my personal health risks times of stress.		1	2		3	4		5

Beliefs About Decision-Making

Self-Efficacy

For each of the following, how confident are you in your ability to make a good choice?

18. Choosing a healthy diet

4 = very confident,

3 = confident,

2 = somewhat confident,

1 = not at all confident

19. Choosing a doctor

4 = very confident,

3 = confident,

2 = somewhat confident,

1 = not at all confident

20. Choosing a Medicare drug plan

4 = very confident,

3 = confident,

2 = somewhat confident,

1 = not at all confident

Outcome Expectancies

For each of the following, how likely is it that making a good choice will have a positive effect on the quality of the healthcare you receive?

21. Choosing a healthy diet

4 = not at all likely ,

3 = somewhat likely,

2 = likely,

1 = very likely

22. Choosing a doctor

4 = not at all likely ,

3 = somewhat likely,

2 = likely,

1 = very likely

23. Choosing a Medicare drug plan

4 = not at all likely ,

3 = somewhat likely,

2 = likely,

1 = very likely

Value Items

24. How important is eating a healthy diet

4 = not at all important ,

3 = somewhat important,

2 = important,

1 = very important

25. How important is choosing a doctor

4 = not at all important ,

3 = somewhat important,

2 = important,

1 = very important

26. How important is choosing a Medicare drug plan

4= not at all important ,

3 = somewhat important,

2 = important,

1 = very important

Perceived knowledge

27. How much do you feel you know about eating a healthy diet?

4 = very knowledgeable,

3 = somewhat knowledgeable,

2 = a little knowledgeable, ,

1 = not at all knowledgeable,

28. How much do you feel you know about choosing a doctor ?

4 = very knowledgeable,

3 = somewhat knowledgeable,

2 = a little knowledgeable, ,

1 = not at all knowledgeable,

29. How much do you feel you know about Medicare drug plans?

4 = very knowledgeable,

3 = somewhat knowledgeable,

2 = a little knowledgeable, ,

1 = not at all knowledgeable,

Health Behaviors

30. In the past six months, have you tried to eat healthy food?

4 = always,

3 = usually,

2 = sometimes,

1 = never,

31. In the past six months, have you tried to find a new doctor or specialist?

4 = always,

3 = usually,

2 = sometimes,

1 = never,

32. In the past six months, have you tried to review the Medicare drug plans available to you?

4 = always,

3 = usually,

2 = sometimes,

1 = never,

0= I do not have a Medicare drug plan.

Decision-Making Process

33. With how many family or friends do you typically talk when you want or need to make a health care decision for yourself, such as choosing a health plan, doctor, hospital, or nursing home?

0

1

2

3

4

5

> 5

34. With which one person among your family and friends are you typically most likely to talk when you want or need to make a health care decision for yourself, such as choosing a health plan, doctor, hospital, or nursing home?

Spouse

Boyfriend/girlfriend/fiancé/fiancée

Close/longtime friend

Daughter

Daughter-in-law

Son

Son-in-law

Sister

Brother

Neighbor

35. How do you typically involve your family or friends in making a health care decision for yourself, such as choosing a health plan, doctor, hospital, or nursing home?

Once I have the information I need, I make my decision without talking to family or friends.

Once I have the information I need, I talk to family or friends, but then make my own decision.

Family or friends help me make my decision.

Family or friends make the decision for me.

CAHPS Chronic Care Questions.

36. Has a doctor ever told you that you had heart disease?

 Yes

 No

37. Has a doctor ever told you that you had cancer?

 Yes

 No

38. Has a doctor ever told you that you had a stroke?

 Yes

 No

39. .Has a doctor ever told you that you had COPD—chronic obstructive pulmonary disease?

 Yes

 No

40. Has a doctor ever told you that you had diabetes?

 Yes

 No

(VA Version SF-12 Questions)

41. . In general, how would you rate your overall health?

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

The next two questions are about activities you might do during a typical day.

35. Does your health now limit you in doing moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? If so, how much?

¹Yes, limited a lot

²Yes, limited a little

³No, not limited at all

. 36. Does your health now limit you in climbing several flights of stairs? If so, how much?

1. ¹Yes, limited a lot

2. ²Yes, limited a little

³No, not limited at all

The next two questions ask about your physical health and your daily activities during the past four weeks.

37. During the past 4 weeks, have you accomplished less than you would like as a result of your physical health?

3. ¹No, none of the time

4. ²Yes, a little of the time

5. ³Yes, some of the time

6. ⁴Yes, most of the time

7. ⁵Yes, all of the time

38. During the past 4 weeks, were you limited in the kind of work or other regular daily activities you did as a result of your physical health?

¹No, none of the time

²Yes, a little of the time

³Yes, some of the time

⁴Yes, most of the time

⁵Yes, all of the time

The next two questions ask about problems with your work or other regular daily activities as a result of any emotional problems, such as feeling depressed or anxious.

40 During the past 4 weeks, have you accomplished less than you would like as a result of any emotional problems, such as feeling depressed or anxious?

¹No, none of the time

²Yes, a little of the time

³Yes, some of the time

⁴Yes, most of the time

⁵Yes, all of the time

.41 During the past 4 weeks, did you do work or other regular daily activities less carefully than usual as a result of any emotional problems, such as feeling depressed or anxious?

¹No, none of the time

²Yes, a little of the time

³Yes, some of the time

⁴Yes, most of the time

⁵Yes, all of the time

. 42 During the past 4 weeks, how much did pain interfere with your normal work, including both work outside the home and housework?

1Not at all

2A little bit

3Moderately

4Quite a bit

5Extremely

The next three questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

.43 How much of the time, during the past 4 weeks, have you felt calm and peaceful?

1All of the time

2Most of the time

3A good bit of the time

4Some of the time

5A little of the time

6None of the time

. 44 How much of the time, during the past 4 weeks, did you have a lot of energy?

1All of the time

2Most of the time

3A good bit of the time

4Some of the time

5A little of the time

6None of the time

. 45 How much of the time, during the past 4 weeks, have you felt downhearted and blue?

1All of the time

2Most of the time

3A good bit of the time

4Some of the time

5A little of the time

6None of the time

. 46 During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

1All of the time

2Most of the time

3A good bit of the time

4Some of the time

5A little of the time

6None of the time

Demographics (from MCBS Survey)

47 Are you male or female?

1 Male

2 Female

48 Are you of Hispanic or Latino origin or descent?

1 Yes, Hispanic or Latino

2 No, not Hispanic or Latino

49 How would you describe your race? Please mark one or more.

a American Indian or Alaskan Native

b Asian

c Black or African American

d Native Hawaiian or Other Pacific Islander

e White

f Another race

50 What is your current marital status?

1 Married

2 Divorced

3 Separated

4 Widowed

5 Never married

51 What is the highest grade or level of school that you have completed?

1 8th grade or less

2 Some high school, but did not graduate

3 High school graduate or GED

4 Some college or 2 year degree

5 4 year college graduate

6 More than a 4 year college degree

53 What is your age?

¹ 18 to 24

² 25 to 34

³ 35 to 44

⁴ 45 to 54

⁵ 55 to 64

⁶ 65 to 74

⁷ 75 to 80

 81 to 84

 85 or older

54. Which of the following categories best represents the combined income for all family members in your household for the past 12 months?

01 Less than $5,000

02 $5,000–$9,999

03 $10,000–$19,999

04 $20,000–$29,999

05 $30,000–$39,999

06 $40,000–$49,999

07 $50,000–$79,999

08 $80,000–$99,999

09 $100,000 or more

10 Don’t know

55. The Medicare Program is trying to learn more about the health care or services provided to people with Medicare. May we contact you again about the health care services that you received?

8. Y es

N o

Please write your daytime telephone number below.

Area Code

THANK YOU FOR COMPLETING THIS SURVEY.

Please return your completed survey in the postage paid envelope to:

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