CAHPS Home Health Care Survey (CMS-10275)

CAHPS Home Health Care Survey

HomeHealthCAHPS_OMB_PartC

CAHPS Home Health Care Survey (CMS-10275)

OMB: 0938-1066

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The Home Health Care CAHPS Survey
Part C
Appendices, including the
Home Health Care Survey Questionnaires



TABLE OF CONTENTS

Section Page



APPENDIX A:

HOME HEALTH CARE CAHPS SURVEY QUESTIONNAIRE






CAHPS®

Home Health Care

Mail Survey Instrument









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 XXXX-XXXX. The time required to complete this information collection is estimated to average 12 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 estimate(s) or suggestions for improving this form, please write to: ATTN: PRA Clearance Officer, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Mail Stop C4-2605, Baltimore, Maryland 21244-1850.




Survey Instructions

  • Answer all the questions by checking the box to the left of your answer.

  • You are sometimes told to skip over 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:

Yes If yes, go to Question 1.

No

Your Home Health Care

  1. According to our records, you got care from the home health agency, [AGENCY NAME]. Is that right?

  1. Yes

  2. No If No, Please stop and return the survey in the envelope provided.

  1. As you answer the questions in this survey, think only about your experience with this agency.

    When you first started getting home health care from this agency, did someone from the agency tell you what care and services you would get?

  1. Yes

  2. No

  3. Do not remember

  1. When you first started getting home health care from this agency, did someone from the agency talk with you about how to set up your home so you can move around safely?

  1. Yes

  2. No

  3. Do not remember

  1. When you started getting home health care from this agency, did someone from the agency talk with you about all the prescription and over-the-counter medicines you were taking?

  1. Yes

  2. No

  3. Do not remember

  1. When you started getting home health care from this agency, did someone from the agency ask to see all the prescription and over-the-counter medicines you were taking?

  1. Yes

  2. No

  3. Do not remember

Your Care from Home Health Providers in the Last 2 Months

These next questions are about all the different staff from [AGENCY NAME] who gave you care in the last 2 months. Do not include care you got from staff from another home health care agency. Do not include care you got from family or friends.

  1. In the last 2 months of care, was one of your home health providers from this agency a nurse?

  1. Yes

  2. No

  1. In the last 2 months of care, was one of your home health providers from this agency a physical, occupational, or speech therapist?

  1. Yes

  2. No

  1. In the last 2 months of care, was one of your home health providers from this agency a home health or personal care aide?

  1. Yes

  2. No

  1. In the last 2 months of care, how often did home health providers from this agency seem informed and up-to-date about all the care or treatment you got at home?

  1. Never

  2. Sometimes

  3. Usually

  4. Always

  5. I only had one provider in the last 2 months of care

  1. In the last 2 months of care, did you and a home health provider from this agency talk about pain?

  1. Yes

  2. No

  1. In the last 2 months of care, did you take any new prescription medicine or change any of the medicines you were taking?

  1. Yes

  2. No If No, Go to Question 15.

  1. In the last 2 months of care, did home health providers from this agency talk with you about the purpose for taking your new or changed prescription medicines?

  1. Yes

  2. No

  3. I did not take any new prescription medicines or change any medicines

  1. In the last 2 months of care, did home health providers from this agency talk with you about when to take these medicines?

  1. Yes

  2. No

  3. I did not take any new prescription medicines or change any medicines

  1. In the last 2 months of care, did home health providers from this agency talk with you about the side effects of these medicines?

  1. Yes

  2. No

  3. I did not take any new prescription medicines or change any medicines

  1. In the last 2 months of care, how often did home health providers from this agency keep you informed about when they would arrive at your home?

  1. Never

  2. Sometimes

  3. Usually

  4. Always

  1. In the last 2 months of care, how often did home health providers from this agency treat you as gently as possible?

  1. Never

  2. Sometimes

  3. Usually

  4. Always

  1. In the last 2 months of care, how often did home health providers from this agency explain things in a way that was easy to understand?

  1. Never

  2. Sometimes

  3. Usually

  4. Always

  1. In the last 2 months of care, how often did home health providers from this agency listen carefully to you?

  1. Never

  2. Sometimes

  3. Usually

  4. Always

  1. In the last 2 months of care, how often did home health providers from this agency treat you with courtesy and respect?

  1. Never

  2. Sometimes

  3. Usually

  4. Always

  1. We want to know your rating of your care from this agency’s home health providers.

    Using any number from 0 to 10, where 0 is the worst home health care possible and 10 is the best home health care possible, what number would you use to rate your care from this agency’s home health providers?

0 0 Worst home health care possible

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10 Best home health care possible

Your Home Health Agency

The next questions are about the office of [AGENCY NAME].

  1. In the last 2 months of care, did you contact this agency’s office to get help or advice?

  1. Yes

  2. No If No, Go to Question 24.

  1. In the last 2 months of care, when you contacted this agency’s office did you get the help or advice you needed?

  1. Yes

  2. No If No, Go to Question 24.

  3. I did not contact this agency

  1. When you contacted this agency’s office, how long did it take for you to get the help or advice you needed?

  1. Same day

  2. 1 to 5 days

  3. 6 to 14 days

  4. More than 14 days

  5. I did not contact this agency

  1. In the last 2 months of care, did you have any problems with the care you got through this agency?

  1. Yes

  2. No

  1. Would you recommend this agency to your family or friends if they needed home health care?

  1. Definitely yes

  2. Probably yes

  3. Probably no

  4. Definitely no

About You

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

  1. Excellent

  2. Very good

  3. Good

  4. Fair

  5. Poor

  1. In general, how would you rate your overall mental or emotional health?

  1. Excellent

  2. Very good

  3. Good

  4. Fair

  5. Poor

  1. Do you live alone?

  1. Yes

  2. No

  1. 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 4-year college degree

  1. Are you Hispanic or Latino/Latina?

  1. Yes

  2. No

  1. What is your race? Please select one or more.

  1. American Indian or Alaska Native

  2. Asian

  3. Native Hawaiian or other Pacific Islander

  4. Black or African American

  5. White

  1. What language do you mainly speak at home?

  1. English

  2. Spanish

  3. Some other language:

    (Please print.)

  1. Did someone help you complete this survey?

  1. Yes

  2. No If No, Please return the completed survey in the postage-paid envelope.

  1. How did that person help you? Check all that apply.

  1. Read the questions to me

  2. Wrote down the answers I gave

  3. Answered the questions for me

  4. Translated the questions into my language

  5. Helped in some other way:

    (Please print.)

  6. No one helped me complete this survey


Thank you!

Please return the completed survey
in the postage-paid envelope.






APPENDIX B:

FEDERAL REGISTER NOTICE: HOME HEALTH CARE CAHPS SURVEY

As part of the Department of Health and Human Services (DHHS) Transparency Initiative on Quality Reporting, CMS plans to implement a process to measure and publicly report home health care patient experiences through the CAHPS (Consumer Assessment of Healthcare Providers and Systems) Home Health Care Survey. The Home Health Care CAHPS survey, as initially discussed in the May 4, 2007 Federal Register (72 Fed. Reg. 25356, 25452), is part of a family of CAHPS® surveys that ask patients about their health care experiences. The Home Health Care CAHPS survey, developed by the Agency for Healthcare Research and Quality (AHRQ), creates a standardized survey for home health patients to assess their home health care providers and the quality of their home health care. Prior to this survey, there was no national standard for collecting such information that would allow comparisons across all home health agencies.

AHRQ conducted a field test to determine the length and content of the Home Health Care CAHPS Survey. CMS has submitted the survey to the National Quality Forum (NQF) for consideration and approval in their consensus process. NQF endorsement represents the consensus opinion of many healthcare providers, consumer groups, professional organizations, purchasers, federal agencies, and research and quality organizations. The final survey will also be submitted to the Office of Management and Budget (OMB) for their approval under the Paperwork Reduction Act (PRA) process.

The survey captures topics such as patients’ interactions with the agency, access to care, interactions with home health staff, provider care and communication, and patient characteristics. The survey allows the patient to give an overall rating of the agency, and asks if the patient would recommend the agency to family and friends.

CMS is beginning plans for implementation of Home Health Care CAHPS Survey. Administration of the survey will be conducted by multiple, independent survey vendors working under contract with home health agencies to facilitate data collection and reporting. Recruitment and training of vendors who wish to be approved to collect Home Health Care CAHPS data will begin in 2009. Home health agencies interested in learning about the survey and/or voluntarily participating in the survey are encouraged to view the Home Health Care CAHPS website: http://www.homehealthCAHPS.org. Information about the project can also be obtained by sending an email to [email protected].

Home health agency participation in the Home Health Care CAHPS Survey is currently voluntary.

APPENDIX C:

MAY 7, 2007 FEDERAL REGISTER NOTICE: HOME HEALTH CARE CAHPS,
VOLUME 72, [[PAGE 25452]]

May 7, 2007 Federal Register Notice: Home Health CAHPS Home Health Care CAHPS, Volume 72, [[Page 25452]]



Speech-Language Pathology................... 121.22 x1.009 x1.05 123.11

x0.958614805 ...............

----------------------------------------------------------------------------------------------------------------

The estimated home health market basket update of 2.9 percent for CY 2008 is based on Global Insight, Inc, 4th

Qtr, 2006 forecast with historical data through 3rd Qtr, 2006.


Section 1895(b)(3)(B)(v)(III) of the Act further requires that the

``Secretary shall establish procedures for making data submitted under

subclause (II) available to the public.'' Additionally, the statute

requires that ``such procedures shall ensure that a home health agency

has the opportunity to review the data that is to be made public with

respect to the agency before such data being made public.'' To meet the

requirement for making such data public, we are proposing to continue

to use the Home Health Compare Web site whereby HHAs are listed

geographically.

Currently, the 10 existing quality measures are posted on the Home

Health Compare Web site. The Home Health Compare Web site will also

include the two proposed additional measures discussed earlier.

Consumers can search for all Medicare-approved home health providers

that serve their city or zip code and then find the agencies offering

the types of services they need as well as the proposed quality

measures. See http://www.medicare.gov/HHCompare/Home.asp. HHAs


currently have access (through the Home Health Compare contractor) to

their own agency's quality data (updated periodically) and we propose

to continue this process thus enabling each agency to know how it is

performing before public posting of data on the Home Health Compare Web

site.

Over the next year, we will be testing patient level process

measures for HHAs, as well as continuing to refine the current OASIS

tool in response to recommendations from a TEP conducted to review the

data elements that make up the OASIS tool. We expect to introduce these

complementary additional measures during CY 2008 to determine if they

should be incorporated into the statutory quality measure reporting

requirements. We hope to apply these measures to the CY 2010 reporting

period. Before usage in the HH PPS, we will test and refine these

measures to determine if they can more accurately reflect the level of

quality care being provided at HHAs without being overly burdensome

with the data collection instrument. To the extent that evidence-based

data are available on which to determine the appropriate measure

specifications, and adequate risk-adjustments are made, we anticipate

collecting and reporting these measures as part of each agency's home

health quality plan. We believe that future modifications to the

current OASIS tool, refinements to the possible responses as well as

adding new process measures will be made. In all cases, we anticipate

that any future quality measures should be evidence-based, clearly

linked to improved outcomes, and able to be reliably captured with the

least burden to the provider. We are also working on developing

measures of patient experience in the home health setting through the

development of the Home Health Consumer Assessment of Healthcare

Providers and Systems (CAHPS) Survey. We will be working with the

Agency for Healthcare Research and Quality (AHRQ) to field test this

instrument in summer/fall 2007. We anticipate implementing the Home

Health CAHPS Survey in late 2008 for potential application to the CY

2010 pay for reporting requirements.


III. Collection of Information Requirements


Under the Paperwork Reduction Act (PRA) of 1995, we are required to

provide 60-day notice in the Federal Register and solicit public

comment before a collection of information requirement is submitted to

the Office of Management and Budget (OMB) for review and approval. In

order to fairly evaluate whether an information collection should be

approved by OMB, section 3506(c)(2)(A) of the PRA of 1995 requires that

we solicit comment on the following issues:

The need for the information collection and its usefulness

in carrying out the proper functions of our agency.

The accuracy of our estimate of the information collection

burden.

The quality, utility, and clarity of the information to be

collected.

Recommendations to minimize the information collection

burden on the affected public, including automated collection

techniques.

Therefore, we are soliciting public comments on each of these

issues for the information collection requirements discussed below.

To implement the OASIS changes discussed in sections II.A.(2)(a),

II.A.(2)(b), and II.A.(2)(c) of this proposed rule, which are currently

approved in Sec. 484.55, Sec. 484.205, and Sec. 484.250, a few items

in the OASIS will need to be modified, deleted, or added. The

requirements and burden associated with the OASIS are currently

approved under OMB control number 0938-0760 with an expiration date of

August 31, 2007. We are soliciting public comment on each of the

proposed changes for the information collection requirements (ICRs) as

summarized and discussed below. For the purposes of soliciting public

review and comment, we have placed a current draft of the proposed

changes to the OASIS on the CMS Web site at: http://www.cms.hhs.gov/



APPENDIX D:

HOME HEALTH CARE CAHPS
MAIL SURVEY MODE EXPERIMENT COVER LETTERS


Home Health Care CAHPS Mail Survey Mode Experiment Cover Letter, First Mailing


NAME

ADDRESS

CITY, STATE ZIP


Dear NAME:


[Home Health Agency Name] is taking part in a national survey to provide the United States Department of Health and Human Services with information about the quality of health care delivered to people in their homes. Our records show that you recently received health care services in your home from [Agency Name]. You, along with a sample of other people who receive home health care, have been selected to take part in this important survey.


The enclosed questionnaire asks for your opinions about the home health care you received. Your help on this survey is important, as it will help us improve the quality of care provided by home health agencies. The survey results will also be used to help people make more informed decisions when choosing a home health care provider. We hope that you will take a few minutes to complete and return the questionnaire in the enclosed, postage-paid envelope.


If you need help reading or answering the questions, please ask a family member or friend to help you. It is important that your answers reflect your own opinions about the home health care you received, so please do not ask anyone from [Agency Name] for help when completing the survey.


Your participation in this survey is voluntary and will not affect any health care or benefits you receive. All information you give in this survey will be held in confidence and is protected by the Privacy Act. Your answers will not be linked to your name; they will be combined with answers from other people who take part in this survey and reported in summary form.


If you have any questions about the survey, please call Vanessa Thornburg toll-free at 1-XXX-XXXX. Thank you in advance for your participation.


Sincerely,




Name


CMS Privacy Officer

Enclosures [PRINT UNIQUE PATIENT ID NO. HERE.]

Home Health Care CAHPS Mail Survey Mode Experiment Cover Letter, Second Mailing



NAME

ADDRESS

CITY, STATE ZIP


Dear NAME:


Recently, we sent you a letter asking for your help on a survey to provide the United States Department of Health and Human Services with information about the quality of health care delivered to people in their homes. Your name was selected from a list of people who received home health care services through [Home Health Agency Name]. As of today, we have not yet received your completed questionnaire. If you have already returned the questionnaire, please accept our thanks.


The enclosed questionnaire asks for your opinions about the home health care you received. Your help on this survey is important, as it will help us improve the quality of care provided by home health care agencies. The survey results will also be used to help people make more informed decisions when choosing a home health care provider. If you have not completed the survey, please take a few moments to complete the questionnaire and return it in the enclosed postage-paid envelope.


If you need help reading or answering the questions, please ask a family member or friend to help you. It is important that your answers reflect your own opinions about the home health care you have received, so we ask that you do not get help from anyone from [Agency Name] when completing the survey.


Your participation in this survey is voluntary and will not affect any health care or benefits you receive. All information you give in this survey will be held in confidence and is protected by the Privacy Act. Your answers will not be linked to your name; they will be combined with answers from other people who take part in this survey and reported in summary form.


If you have any questions about the survey, please call Vanessa Thornburg toll-free at

1-XXX-XXX-XXXX. Thank you in advance for your participation.


Sincerely,


Name
CMS Privacy Officer


Enclosures [PRINT UNIQUE PATIENT ID NO. HERE.]

APPENDIX E:

TELEPHONE INTERVIEW SCRIPT FOR THE HOME HEALTH CARE CAHPS SURVEY: MODE EXPERIMENT



CAHPS®

Home Health Care Phone Survey Instrument



Home Health Care CAHPS Survey

Telephone Interview Procedures and Script


Overview

The Home Health Care CAHPS Survey Questionnaire uses certain conventions, which are described below, along with general telephone interview guidelines. The telephone interview script that follows the interviewing instructions and conventions explains the purpose of the survey and confirms required information about the sample patient.

General Interviewing Instructions and Conventions

  • Thoroughly familiarize yourself with the list of Frequently Asked Questions (FAQ) that sample patients will ask about the Home Health Care CAHPS Survey before you conduct interviews so that you are knowledgeable about the survey.

  • Ask every applicable question exactly as it is presented. Do not change the wording or condense any question when reading it.

  • Ask the questions in the exact order in which they are presented.

  • Read all questions including those that may appear to be sensitive to the respondent in the same manner with no hesitation or change in inflection.

  • When reading the question, emphasize all words or phrases that appear in bold or are underlined.

  • Words in the questionnaire that appear in ALL CAPITAL LETTERS are never to be read to the respondent. This includes both questions and response categories.

  • Ask every question specified, even when a respondent has seemingly provided the answer as part of the response to another question. Keep in mind that the answer received in the context of one question may not be the same answer that will be received when the other question is asked. If it becomes cumbersome to the respondent, remind him/her gently that you must ask all questions of all respondents in the same way.

  • If the answer to a question indicates that the respondent did not understand the intent of the question, repeat the question.

  • If the respondent is unable to hear well, you may attempt to set a call back on a different day at a different time, to see if this is better for the respondent. However, if the respondent still cannot hear, try to ask the sample member is there is someone else in the household who can answer the questions for him or her. Terminate work on the case if the sample member cannot hear well enough to hand the phone to a proxy respondent or provide you with information on how to contact a proxy respondent. For such cases, assign a final disposition code of ineligible: physically or mentally incapable to the case.

  • Read the questions slowly, at a pace that allows them to be readily understood. It is important to remember that the respondent has not heard these questions before and will not have had the exposure that you have had to the questionnaire.

  • Read transition statements just as they are presented. Transition statements are designed to inform the respondent of the nature of an upcoming question or a series of questions, to define a word, or to describe what is being asked for in the question. Do not create “transition statements” of your own, because these may unintentionally introduce bias into the interview.

  • Give the respondent plenty of time to recall past events.

  • Do not suggest answers to the respondent. Your job as an interviewer is to read the questions, make sure the respondent understands the questions, and then enter the responses. Do not assist the respondent in selecting responses.

  • At the end of the interview, tell the sample patient that the survey is completed and thank him or her for taking part in the survey.





Telephone Interview Script for the Home Health Care CAHPS Survey

Updated 3/20/09

INTRO1 Hello, may I please speak to [SAMPLED PATIENT’S NAME]?

<1> YES Go to INTRO 2

<2> NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]

<3> NO [REFUSAL] Go to TERMINATE Screen,

<4> MENTALLY/PHYSICALLY INCAPABLE [GO TO PROXY SCRIPT]


<M> MISSING/DK


IF ASKED WHO IS CALLING:

This is [INTERVIEWER NAME] calling from [ORGANIZATION]. I’d like to speak to [SAMPLE PATIENT’S NAME] about a study about health care.


INTRO2 Hello, this is [INTERVIEWER NAME] calling on behalf of [HOME HEALTH AGENCY]. [HOME HEALTH AGENCY] is participating in a survey about the care people receive from their home health agencies. This survey is part of a national effort to measure the quality of care from home health care agencies. The survey results will be used by people when choosing a home health care agency.


Your participation in this survey is completely voluntary and will not affect your health care or any benefits you receive. The interview will take about 12 minutes to complete. This call may be may monitored or recorded for quality improvement purposes.


NOTE: THE LENGTH OF THE INTERVIEW WILL DEPEND ON WHETHER THE HHA ADDS SUPPLEMENTAL QUESTIONS TO IS HOME HEALTH CARE CAHPS SURVEY.


Q1 According to our records, you got care from the home health agency, [HOME HEALTH AGENCY]. Is that right?

<1> YES [GO TO Q2_INTRO]

<2> NO [GO TO Q_INELIG]


<M> MISSING/DK


Q2_INTRO As you answer the questions in this survey, think only about your experience with this agency.


Q2 When you first started getting home health care from this agency, did someone from the agency tell you what care and services you would get?

<1> YES

<2> NO

<3> DO NOT REMEMBER


<M> MISSING/DK


Q3 When you first started getting home health care from this agency, did someone from the agency talk with you about how to set up your home so you can move around safely?

<1> YES

<2> NO

<3> DO NOT REMEMBER


<M> MISSING/DK


Q4 When you started getting home health care from this agency, did someone from the agency talk with you about all the prescription and over-the-counter medicines you were taking?

<1> YES

<2> NO

<3> DO NOT REMEMBER


<M> MISSING/DK


Q5 When you started getting home health care from this agency, did someone from the agency ask to see all the prescription over-the-counter medicines you were taking?

<1> YES

<2> NO

<3> DO NOT REMEMBER


<M> MISSING/DK


Q6_INTRO These next questions are about all the different staff from [HOME HEALTH AGENCY] who gave you care in the last 2 months. Do not include care you got from staff from another home health care agency. Do not include care you got from family or friends.


Q6 In the last 2 months of care, was one of your home health providers from this agency a nurse?

<1> YES

<2> NO


<M> MISSING/DK

Q7 In the last 2 months of care, was one of your home health providers from this agency a physical, occupational, or speech therapist?

<1> YES

<2> NO


<M> MISSING/DK


Q8 In the last 2 months of care, was one of your home health providers from this agency a home health or personal care aide?

<1> YES

<2> NO


<M> MISSING/DK


Q9 In the last 2 months of care, how often did home health providers from this agency seem informed and up-to-date about all the care or treatment you got at home? Would you say…

<1> Never,

<2> Sometimes,

<3> Usually,

<4> Always, or

<5> you only had one provider in the last 2 months of care?


<M> MISSING/DK


Q10 In the last 2 months of care, did you and a home health provider from this agency talk about pain?

<1> YES

<2> NO


<M> MISSING/DK


Q11 In the last 2 months of care, did you take any new prescription medicine or change any of the medicines you were taking?

<1> YES

<2> NO [GO TO Q15]


<M> MISSING/DK


Q12 In the last 2 months of care, did home health providers from this agency talk with you about the purpose for taking your new or changed prescription medicines?

<1> YES

<2> NO


<M> MISSING/DK


Q13 In the last 2 months of care, did home health providers from this agency talk with you about when to take these medicines?

<1> YES

<2> NO


<M> MISSING/DK


Q14 In the last 2 months of care, did home health providers from this agency talk with you about the side effects of these medicines?

<1> YES

<2> NO


<M> MISSING/DK


Q15 In the last 2 months of care, how often did home health providers from this agency keep you informed about when they would arrive at your home? Would you say…

<1> Never,

<2> Sometimes,

<3> Usually, or

<4> Always?


<M> MISSING/DK


Q16 In the last 2 months of care, how often did home health providers from this agency treat you as gently as possible? Would you say…

<1> Never,

<2> Sometimes,

<3> Usually, or

<4> Always?


<M> MISSING/DK


Q17 In the last 2 months of care, how often did home health providers from this agency explain things in a way that was easy to understand? Would you say…

<1> Never,

<2> Sometimes,

<3> Usually, or

<4> Always?


<M> MISSING/DK


Q18 In the last 2 months of care, how often did home health providers from this agency listen carefully to you? Would you say…

<1> Never,

<2> Sometimes,

<3> Usually, or

<4> Always?


<M> MISSING/DK


Q19 In the last 2 months of care, how often did home health providers from this agency treat you with courtesy and respect? Would you say…

<1> Never,

<2> Sometimes,

<3> Usually, or

<4> Always?


<M> MISSING/DK


Q20_INTRO We want to know your rating of your care from this agency’s home health providers.


Q20 Using any number from 0 to 10, where 0 is the worst home health care possible and 10 is the best home health care possible, what number would you use to rate your care from this agency’s home health providers?


READ RESPONSE CHOICES ONLY IF NECESSARY


<00> 0 Worst home health care possible

<01> 1

<02> 2

<03> 3

<04> 4

<05> 5

<06> 6

<07> 7

<08> 8

<09> 9

<10> 10 Best home health care possible


<M> MISSING/DK


Q21_INTRO The next questions are about the office of [HOME HEALTH AGENCY].


Q21 In the last 2 months of care, did you contact this agency’s office to get help or advice?

<1> YES

<2> NO [GO TO Q24]


<M> MISSING/DK


Q22 In the last 2 months of care, when you contacted this agency’s office did you get the help or advice you needed?

<1> YES

<2> NO [GO TO Q24]


<M> MISSING/DK


Q23 When you contacted this agency’s office, how long did it take for you to get the help or advice you needed? Would you say…

<1> Same day,

<2> 1 to 5 days,

<3> 6 to 14 days, or

<4> More than 14 days?


<M> MISSING/DK


Q24 In the last 2 months of care, did you have any problems with the care you got through this agency?

<1> YES

<2> NO


<M> MISSING/DK


Q25 Would you recommend this agency to your family or friends if they needed home health care? Would you say…

<1> Definitely yes,

<2> Probably yes,

<3> Probably no, or

<4> Definitely no?


<M> MISSING/DK


Q26 In general, how would you rate your overall health? Would you say that it is…

<1> Excellent,

<2> Very good,

<3> Good,

<4> Fair, or

<5> Poor?


<M> MISSING/DK


Q27 In general, how would you rate your overall mental or emotional health? Would you say that it is…

<1> Excellent,

<2> Very good,

<3> Good,

<4> Fair, or

<5> Poor?


<M> MISSING/DK


Q28 Do you live alone?

<1> YES

<2> NO


<M> MISSING/DK


Q29 What is the highest grade or level of school that you have completed? Would you say…

<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, or

<6> More than 4-year college degree?


<M> MISSING/DK


Q30 Are you Hispanic or Latino/Latina?

<1> YES

<2> NO


<M> MISSING/DK


Q31 What is your race? You may choose one or more of the following. Are you....

<1> American Indian or Alaska Native

<2> Asian

<3> Native Hawaiian or other Pacific Islander

<4> Black or African American

<5> White


<M> MISSING/DK


Q32 What language do you mainly speak at home? Would you say…

<1> English, [GO TO Q_END]

<2> Spanish, or [GO TO Q_END]

<3> Some other language? [GO TO 32A]


<M> MISSING/DK


Q32A What other language do you mainly speak at home? (ENTER RESPONSE BELOW).


{ALLOW UP TO 50 CHARACTERS}


<M> MISSING/DK


Q_END These are all the questions I have for you. Thank you for your time. Have a good (day/evening).



INELIGIBLE SCREEN:


Q_INELIG: Thank you for your time. Have a good (day/evening).



REFUSAL SCREEN:


Q_REF Thank you for your time. Have a good (day/evening).

File Typeapplication/msword
File TitleThe National Implementation of the Home Health Care CAHPS Survey
SubjectOMB Supporting Statement for Home Health Care CAHPS Survey
AuthorCenters for Medicare & Medicaid Services
Last Modified ByCMS
File Modified2009-04-10
File Created2009-04-01
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