Attachment 6 - P4P_Survey_Final_061709

Page 1 of 10
OMB Control No.: _______
Expiration Date: _________
PRA Disclosure Statement
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 0938-new. The time
required to complete this information collection is estimated to average 30 minutes to complete the survey, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

06/17/2009

Page 2 of 10
OMB Control No.: _______
Expiration Date: _________
The Division of Health Care Policy and Research
and
Centers for Medicare & Medicaid Services
Home Health Pay for Performance Demonstration Evaluation Survey
The purpose of this survey is to gather information from home health agencies participating in the
Centers of Medicare & Medicaid Services (CMS) Home Health Pay for Performance (P4P)
Demonstration. The questions that follow focus on policy or practice changes in your agency that may
have occurred during the timeframe of the demonstration. These questions focus on information about
your agency that is generally not available via other data sources.
The "correct answers" are simply what occurred at your agency during Calendar Year (CY) 2008.
Based on pre-testing with experienced home health agency managers, we estimate that the survey will
take about 15 minutes to complete.

1. Enter the Name of Agency:
1a. [Optional] Email address of
Agency or person completing survey:
2. Enter Agency's CMS Certification
Number (formerly Provider Number):

___________________

3. Title of person completing form:

Senior Mgmt (CEO, DON, etc)

4. Which of the following describes the changes in the number of your staff (e.g.,
increase = the position was vacant or created and was filled, or additional staff
were hired; decrease = a position was filled, but is now vacant) during CY2008?
Indicate change for each -- if any.
Decreased
No
Increased
Job Category
Staffing
Change
Staffing
a. Senior Management (CEO, DON,
etc.)
b. QI / PI Coordinator
c. Clinical Supervisor Positions
d. Registered Nurse
e. Registered Nurse with speciality
license
(e.g., wound, psychiatric)
f. Licensed Practical Nurse
g. Respiratory Therapist
h. Physical Therapist

06/17/2009

Page 3 of 10
OMB Control No.: _______
Expiration Date: _________

i. Occupational Therapist
j. Medical Social Worker
k. Home Health Aide
l. Administrative/Support
m. Other (specify)
5. Which of the following describes the turnover in your staff (e.g., a staff member
left and was replaced by a new or another staff member in that position) during
CY2008? Indicate change for each -- if any.
Staff
No
Job Category
change
Turnover
occurred
a. Senior Management (CEO, DON, etc.)
b. QI / PI Coordinator
c. Clinical Supervisor Positions
d. Registered Nurse
e. Registered Nurse with speciality license,
(e.g., wound, psychiatric)
f. Licensed Practical Nurse
g. Respiratory Therapist
h. Physical Therapist
i. Occupational Therapist
j. Medical Social Worker
k. Home Health Aide
l. Administrative/Support
m. Other (specify)
6. Have you added any new positions/functions during CY2008 specifically
because of your participation in the demonstration?
Already
Added
Does Not
Job Function
Existed Position/Function
Exist
a. Quality improvement (QI) or
performance improvement (PI)
coordination
b. Documentation quality
assurance or OASIS accuracy
c. Staff Education
d. Outcome Analysis
e. Utilization Review
f. "Combination" position(s) that

06/17/2009

Page 4 of 10
OMB Control No.: _______
Expiration Date: _________
include two or
more of the "a-e" functions
g. Other (specify)
7. Which of the following outcome measures have you targeted with the help of
your Medicare Quality Improvement Organization (QIO)?
Did not
Pre &
Pre2008
work
During
Outcome Measure
2008
(only)
with
2008
QIO
a. Acute Care Hospitalization
b. Any Emergent Care
c. Improvement in Bathing
d. Improvement in Ambulation/Locomotion
e. Improvement in Transferring
f. Improvement in Status of Surgical
Wounds
g. Improvement in Management of Oral
Medications
h. Improvement in Pain Interfering with
Activity
i. Other measure(s)
8. What policy changes has your agency implemented during CY2008? Policies
related to... (Check all that apply)
a. Changes in care practices (e.g., "front-loaded visits)
b. Implementation of care pathways/standardized care plans
c. Decrease in time between referral and admission visit
d. Communication with patient (quantity and/or quality)
e. Communication with physician (quantity and/or quality)
f. Disease management programs
g. Telehealth programs
h. Falls prevention programs
i. Patient infection control programs
j. New clinical specialties programs (specify):
k. Change in on-call staff for non-business hours
l. Expanded business hours
m. Changes in productivity requirements for staff
n. Changes in staff hiring requirements
o. Other (specify):

06/17/2009

Page 5 of 10
OMB Control No.: _______
Expiration Date: _________
9. What activities directed toward agency employees or contract staff and intended
to increase quality of care has your agency implemented during CY2008? (Check
all that apply)
a. New staff education programs and/or changes in requirements for number
of educational hours
b. Performance improvement programs
c. Mentoring programs
d. Additional clinical team meetings
e. Additional record review activities
f. New staff competencies
g. Change in staff evaluation criteria
h. Employee incentives for performance improvement
i. Changes in staff management practices of nursing or therapy staff (e.g.,
increased oversite, etc.)
j. Changes in home health aide supervisory practices
k. Additional clinical resources for field staff (e.g., consultation; new
specialty care staff; web access to best practices, etc.)
l. Other (specify):
10. What technological innovations designed to improve the quality of patient care
has your agency implemented during CY2008? (Check all that apply)
a. Telemonitoring equipment
b. Electronic medical records
c. Electronic information exchange with referral sources (e.g., hospital)
d. Electronic information exchange with physicians
e. Secure electronic messaging systems for agency care team members
f. New infusion devices
g. New respiratory equipment (e.g., ventilators, etc.)
h. Physiologic monitoring equipment (e.g., blood glucose monitors,
prothrombin monitors, etc.)
i. Inflatable mattresses or similar equipment to reduce incidence of pressure
ulcers
j. Special dressings or therapies for wound care
k. Medication reminder systems
l. Medication dispensing systems
m. Implementation of medication checking/reconciliation software
n. Personal emergency response systems
o. Electronic access to policies, procedures, best practices, etc.
p. Other (specify):
11. What care practice changes designed to improve the specific clinical outcomes

06/17/2009

Page 6 of 10
OMB Control No.: _______
Expiration Date: _________
has your agency implemented during CY2008? (Check all that apply)
a. Changes in visit patterns (e.g., front-loading; increased number visits for
specific diagnoses)
b. Introduction of telemonitoring
c. Changes in visit mix (e.g., increase use of PT, etc.)
d. Introduction of disease management programs
e. Introduction and/or increased use of clinical pathways
f. Changes in patient teaching plans
g. Increased communication with MD
h. Inclusion on POC of specific parameters for when to call physician (e.g.,
call MD for BS>150)
i. Increased care team communication (e.g., team meetings, etc.)
j. Implementation of screening assessments (e.g., falls risk)
k. Implementation of falls prevention programs
l. Enhanced wound care protocols
m. Increased efforts to improve vaccination rates (e.g., flu and
pneumococcus)
n. Use of medication reminder or dispensing systems
p. Other (specify):
12. Identify any corporate initiatives that have been implemented during CY2008?
(Indicate change for each -- if any)
NA, Not Part of Chain
Corporate Initiative Focus

No
Change

Modified
Existing
Program

Implemented
New Program

a. Reducing potentially avoidable
hospitalizations
b. Reducing potentially avoidable
emergency care
c. Improving rehabilitation outcomes
d. Pressure ulcer treatment
e. Use of technology to support patient
care
f. Staff training
g. Participation in QIO quality
initiatives
h. Performance incentive program
(monetary)
i. Enhanced corporate communications
j. Other (specify)

06/17/2009

Page 7 of 10
OMB Control No.: _______
Expiration Date: _________
13. Identify any impact on your agency that occurred during CY2008 that may
have been the
result of local/regional issues or situations. (indicate impact for each - if any)
No
Negative Both Positive
Type of Local/Regional Change
Impact Impact
+/Impact
a. # of community hospitals
(or hospital beds)
b. # of skilled nursing facilities
(or SNF beds)
c. # of urgent/emergency care
facilities
d. # of home health agencies
e. Availability of nurses locally
f. Availability of physical
therapists locally
g. Availability of occupational
therapists locally
h. Availability of home health
aids locally
i. Increase in population locally
j. Natural disaster,
(e.g., flood, fire, etc.)
k. State health care policy
(e.g., Medicaid funding)
l. Informal local health care practice
patterns
m. Change in available community
resources
(e.g., Assisted living facilities,
adult day care, transportation programs,
meal programs, respite care providers,
etc.)

14. What is your best estimate of the effects of activities related to the P4P
Demonstration will have on the cost of providing care to your patients?
Less than
Increase Increase Increase
Decrease Decrease Decrease
1%
by > 10% by 5 - 10% by 1 - 5%
by 1 - 5% by 5 - 10% by > 10%
change

06/17/2009

Page 8 of 10
OMB Control No.: _______
Expiration Date: _________

15. How much of an impact on your patients do you think your quality
improvement activities will have on the outcomes targeted in the P4P
Demonstration?
Probable impact of QI on outcomes
No
Modest
Substantial
Outcome Measure
Impact Improvement
Improvement
a. Acute Care Hospitalization
b. Any Emergent Care
c. Improvement in Bathing
d. Improvement in Ambulation Locomotion
e. Improvement in Transferring
f. Improvement in Status of
Surgical Wounds
g. Improvement in Management of
Oral
Medications
16. What effect do you think the demonstration will have on the following?
Very Slightly
No Slightly Very
Effect on ...
Negative Negative Impact Positive Positive
a. My agency's patient outcomes
b. Quality of care at my agency
c. Quality of care statewide
d. Access to care for Medicare
beneficiaries
e. Cost of providing home health
care
f. Financial solvency of my agency
g. Financial solvency of home
health agencies
statewide
h. Profitability of my agency
i. Profitability of home health
agencies
statewide
17a. Rate each of the following groups/individuals as demonstrating Low/No, Moderate, or High levels
of Commitment the P4P demonstration (Mark "NA" if position/function does not exist)
Commitment to the P4P
Demonstration
N/A
Groups/Individuals
Low/No
Moderate
High

06/17/2009

Page 9 of 10
OMB Control No.: _______
Expiration Date: _________
a. Administrator/Owner/CEO
b. Senior Clinical (Physician, DON)
c. Clinical Managers/Supervisors
d. QI/PI Coordinator
e. RN's (case managers)
f. PT's, OT's, Social Workers, etc.
g. Administrative Staff
17b. Rate each of the following groups/individuals as demonstrating Low/No, Moderate, or High
levels of Readiness for the P4P demonstration (Mark "NA" if position/function does not exist)
Readiness for the P4P Demonstration
N/A
Groups/Individuals
Low/No
Moderate
High
a. Administrator/Owner/CEO
b. Senior Clinical (Physician, DON)
c. Clinical Managers/Supervisors
d. QI/PI Coordinator
e. RN's (case managers)
f. PT's, OT's, Social Workers, etc.
g. Administrative Staff
17c. Rate each of the following groups/individuals as demonstrating Low/No, Moderate, or High levels
of Willingness to Sustain the P4P demonstration (Mark "NA" if position/function does not exist)
Willingness to Sustain Beyond the
Demonstration
N/A
Groups/Individuals
Low/No
Moderate
High
a. Administrator/Owner/CEO
b. Senior Clinical (Physician, DON)
c. Clinical Managers/Supervisors
d. QI/PI Coordinator
e. RN's (case managers)
f. PT's, OT's, Social Workers, etc.
g. Administrative Staff
18. Please rate the feedback on your agency's performance provided to you by the
demonstration implementation contractor (Abt Associates).
Disagree Disagree
Agree
Agree
N/A
Strongly Somewhat Somewhat Strongly
a. The information is useful to
my agency for quality
improvement purposes.
b. The information is presented

06/17/2009

Page 10 of 10
OMB Control No.: _______
Expiration Date: _________
in a manner that is easy to
understand.
c. The information is delivered to
our agency in a timely manner.
d. The reports are accurate and
complete.
19. Please use the space below to provide any other comments on the
demonstration and any suggestions you have for implementation of hime
health pay for performance. Please limit your response to about 250 words.
(optional)

Words
remaining:
250

Please review all of your answers prior to submitting this information.
When ready to submit, please check the 'Yes' box below and then click the 'Submit' button.
Yes
No
Ready to Submit
Thank you very much for taking the time to provide your feedback on the P4P Demonstration. If you
would like to send additional comments via email, please forward these comments to
[email protected].

06/17/2009