CMS-P-0015A MCBS Facility Round 46 Use of Services Module

US. USE OF SERVICES

2006 Facility Interview
(Core Only)
US. USE OF SERVICES MODULE
(CORE ONLY)

BOX USO omitted.
FB37-FB45 omitted.
US1PRE
This series of questions is about the health care services that {SP} may have received between {REFERENCE
START DATE} and {REFERENCE END DATE} while {she/he} resided in {FACILITY/[READ FACILITY/UNITS
ABOVE]}. {The questions include any services that {she/he} received outside this facility, as well as care from any
providers who saw {her/him} here. The kinds of services I will be asking about include physician care, dental care,
mental health services, various kinds of therapies, and care from other kinds of health care providers. I will be
asking about the type of provider and the frequency or duration of the services. Please do not include care while
{she/he} was an overnight inpatient in an acute care hospital.}

CURRENT TIMELINE
PLACE NAME
{
}
{
}
{
}
ETC.

START DATE
{
}
{
}
{
}
ETC.

END DATE
{
}
{
}
{
}
ETC.

STAY TYPE
{
}
{
}
{
}
ETC.

USE ARROW KEYS. TO EXIT, PRESS ESCAPE.

US1
Between {REFERENCE START DATE} and {REFERENCE END DATE} while a resident in this {FACILITY/HOME},
did {she/he} see a medical doctor of any kind, outside the {FACILITY/HOME}, excluding mental health therapy
provided by a psychiatrist?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

1
0
-8
-7

(US2)
(US3)
(US3)
(US3)

US2
Between {REFERENCE START DATE} and {REFERENCE END DATE}, how many times did {she/he} see
doctors outside this facility?
_______________
NUMBER

US3
Between {REFERENCE START DATE} and {REFERENCE END DATE}, did {she/he} see a medical doctor of
any kind, here, in this {FACILITY/HOME}, excluding mental health therapy provided by a psychiatrist?
YES .............................................................................................
NO...............................................................................................
DK ...............................................................................................
RF ...............................................................................................

BOX US1 omitted.

1

1
0
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-7

(US5A)
(US6PRE)
(US3a)
(US6PRE)

US. USE OF SERVICES

2006 Facility Interview
(Core Only)

US3A
Please tell me the name and title of someone in {FACILITY/[READ FACILITY/UNITS ABOVE]} who could give
me that information.
RECORD RESPONDENT INFORMATION ON PAPER FROG.
Thank you for your time, those are all the questions I have for you. Right now I need to continue with [NAME
FROM FROG] to complete these questions.
PRESS ENTER TO CONTINUE.

US4 omitted.
US4A omitted.
US5 omitted.

US5A
Between {REFERENCE START DATE} and {REFERENCE END DATE}, how many times did {she/he} see any
doctor here?
(
)
NUMBER

US6PRE
The following questions are about services used both inside and outside this facility. We are only interested in
services {SP} received while residing in {FACILITY/[READ FAC/UNITS LISTED ABOVE]}.
PRESS ENTER TO CONTINUE.

US6
Between {REFERENCE START DATE} and {REFERENCE END DATE}, did {she/he} see a dentist, dental
surgeon, dental assistant, or any other professional for dental care?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................

1
0
-8
-7

(US7)
(US8)
(US8)
(US8)

US7
Between {REFERENCE START DATE} and {REFERENCE END DATE}, how many times did {she/he} see a dentist,
dental surgeon, dental assistant, or any other professional for dental care?
_______________ (US8)
NUMBER

US8
Between {REFERENCE START DATE} and {REFERENCE END DATE}, did {she/he} see a psychiatrist or any other
mental health care professional either inside or outside this facility?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................

2

1
0
-8
-7

(US9)
(US12)
(US12)
(US12)

US. USE OF SERVICES

2006 Facility Interview
(Core Only)

US9
What type of mental health specialist did {she/he} see?
PROBE: Any others?.
LICENSED CLINICAL SOCIAL WORKER
PSYCHIATRIC NURSE
PSYCHIATRIC SOCIAL WORKER
PSYCHIATRIST
PSYCHOLOGIST
OTHER (SPECIFY:____________________)

(US10)
(US10)
(US10)
(US10)
(US10)
(US10)

USE ARROW KEYS. TO SELECT OR DESELECT, PRESS ENTER. TO EXIT, PRESS ESC.

US10
Between {REFERENCE START DATE} and {REFERENCE END DATE}, how many sessions or visits did {she/he}
have?
_______________ (US11)

US11
Were these individual sessions, group sessions, or some of both?
INDIVIDUAL.................................................................................
GROUP........................................................................................
BOTH...........................................................................................

1
2
3

US12
Between {REFERENCE START DATE} and {REFERENCE END DATE}, did {she/he} see a therapist such as a
physical therapist, speech therapist, I.V. therapist, occupational therapist, or respiratory therapist?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................

1
0
-8
-7

(US13)
(US22A)
(US22A)
(US22A)

US13
Please look at this card and tell me about how often each week therapy was provided.
SHOW
CARD
US1

MORE THAN 5 TIMES A WEEK .................................................
LESS THAN ONCE A WEEK ......................................................
3 TO 5 TIMES A WEEK...............................................................
MORE THAN 5 TIMES A WEEK ................................................
ONE-TIME EVALUATION ...........................................................
DK ...............................................................................................

PRESS F1 FOR INFORMATION ON "ONE-TIME EVALUATION".

3

1
2
3
4
5
-8

(US14)
(US14)
(US14)
(US14)
(US22A)
(US14)

US. USE OF SERVICES

2006 Facility Interview
(Core Only)

US14
Now look at this card. Between {REFERENCE START DATE} and {REFERENCE END DATE}, over how long a
period was therapy provided?

SHOW
CARD
US2

LESS THAN 1 WEEK ..................................................................
1 TO 3 WEEKS............................................................................
4 TO 8 WEEKS............................................................................
MORE THAN 8 WEEKS BUT NOT THE WHOLE TIME .............
ABOUT THE WHOLE TIME ........................................................
DK ...............................................................................................
RF................................................................................................

4

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3
4
5
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-7

US. USE OF SERVICES

2006 Facility Interview
(Core Only)

US15-US22 omitted.

US22A
Between {REFERENCE START DATE} and {REFERENCE END DATE} was {SP} seen by a podiatrist (either inside
or outside this facility)?
YES..............................................................................................
NO ...............................................................................................

1
0

US23
Between {REFERENCE START DATE} and {REFERENCE END DATE}, did {she/he} receive educational or
habilitational services (either inside or outside this facility)?
PROBE: "Habilitational services" include training in daily living skills, self care, and so on, in a structured program.
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................

1
0
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-7

(US24)
(US29)
(US29)
(US29)

US24
Were those services educational, habilitational, or both?
EDUCATIONAL ..........................................................................
HABILITATIONAL ........................................................................
BOTH ...........................................................................................
DK ................................................................................................
RF ................................................................................................

1
2
3
-8
-7

(US25)
(US25)
(US25)
(US25)
(US29)

US25
Please look at this card and tell me, between {REFERENCE START DATE} and {REFERENCE END DATE},
over how long a period were these {educational} {habilitational}services provided?
SHOW
CARD
US4

LESS THAN 1 WEEK ..................................................................
1 TO 3 WEEKS............................................................................
4 TO 8 WEEKS............................................................................
MORE THAN 8 WEEKS BUT NOT THE WHOLE TIME .............
ABOUT THE WHOLE TIME ........................................................
DK ...............................................................................................
RF................................................................................................

US26 omitted.

BOX US2

If US24 = 3, go to US27; else go to US29.

5

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5
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US. USE OF SERVICES

2006 Facility Interview
(Core Only)

US27
Between {REFERENCE START DATE} and {REFERENCE END DATE}, over how long a period were these
habilitational services provided?

SHOW
CARD
US4

LESS THAN 1 WEEK...................................................................
1 TO 3 WEEKS ............................................................................
4 TO 8 WEEKS ............................................................................
MORE THAN 8 WEEKS BUT NOT THE WHOLE TIME .............
ABOUT THE WHOLE TIME ........................................................
DK ................................................................................................
RF ................................................................................................

1
2
3
4
5
-8
-7

US28 omitted.

US29
USE SHOW CARD US5 FOR PROMPTING AS NEEDED.
Between {REFERENCE START DATE} and {REFERENCE END DATE}, did {she/he} receive care from any other
licensed or certified health care provider (either inside or outside this facility)?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

1
0
-8
-7

(US30)
(US31PRE)
(US31PRE)
(US31PRE)

PRESS F1 FOR “ANY OTHER PROVIDER” CLARIFICATION.

US30
What kind of provider was that?
SELECT ALL THAT APPLY.
AUDIOLOGIST
DIETICIAN
LABORATORY TECHNICIAN
NURSE PRACTITIONER
OPHTHALMOLOGIST
OPTOMETRIST
PHYSICIANS ASSISTANT
RECREATIONAL THERAPIST
REGISTERED NURSE
SOCIAL WORKER
X-RAY TECHNICIAN
OTHER (SPECIFY:

)

US31PRE
The next few questions are about any visits {SP} may have made to a hospital emergency room, that is, from
{REFERENCE START DATE} through {REFERENCE END DATE}.
Please do not include visits to the emergency room that were immediately followed by inpatient hospital stays.
PRESS ENTER TO CONTINUE.

6

US. USE OF SERVICES

2006 Facility Interview
(Core Only)

US32
While {she/he} was in a nursing home, did {she/he} make any visits to a hospital emergency room between
{REFERENCE START DATE} and {REFERENCE END DATE}?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................

1
0
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-7

(US33)
(US37)
(US37)
(US37)

US33
{REF. START DATE} - {REF. END DATE}
On what date did the {first/next} ER visit occur?
MONTH (

) DAY (

) YEAR (

)

BOX US3 omitted.
US34 omitted.
US35 omitted.

US36
{REF. START DATE} - {REF. END DATE}
ER VISIT: {DATE FROM US33}
Other than what you have just told me, did {SP} have any other emergency room visits?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

1
0
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-7

(US33)
(US37)
(US37)
(US37)

US37
{Besides the {health care providers} {and} {emergency room} visits you have already told me about,} {D/d}id {she/he}
ever go to the hospital and return on the same day?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................

1
0
-8
-7

(US38)
(US40)
(US40)
(US40)

US38
How many times did this happen between {REFERENCE START DATE} and {REFERENCE END DATE}?
(

)
NUMBER

BOX US4 omitted.
US39 omitted.

7

US. USE OF SERVICES

2006 Facility Interview
(Core Only)

US40
Now I'd like to ask you about any kind of supplies, equipment, or other types of medical services {SP} received
other than the ones I've already mentioned. Please look at this first card and tell me what supplies or services
{SP} received between {REFERENCE DATE} and {END DATE}.
SELECT ALL THAT APPLY
SHOW
CARD
US6

DIABETIC EQUIPMENT OR SUPPLIES
EYE
GLASSES OR CONTACT LENSES
HEARING AID OR OTHER COMMUNICATION DEVICE
ORTHOPEDIC ITEMS
EQUIPMENT OR SUPPLIES FOR KIDNEY DIALYSIS
OSTOMY SUPPLIES
CLOTH DIAPERS
DISPOSABLE DIAPERS
AMBULANCE SERVICE
PROSTHESIS
OXYGEN
DON'T KNOW
NONE OF THE ABOVE

US41 omitted.

BOX US3

If DK selected in US40, go to US43. Else, continue.

8

US. USE OF SERVICES

2006 Facility Interview
(Core Only)

US42
Please look at this second card and tell me what medical devices or equipment {he/she} received between
{REFERENCE DATE} and {END DATE}.
SELECT ALL THAT APPLY
SHOW
CARD
US7

BEDSIDE COMMODE
BED PADS (CLOTH OR DISPOSABLE)
CATHETER AND CATHETER SUPPLIES
FEEDING SUPPLIES (INCLUDE PUMPS, SYRINGES, TUBES)
G TUBE AND SUPPLIES
GERI CHAIR
HOSPITAL BED
IV SUPPLIES
NEBULIZER
SPECIAL MATTRESS, CUSHIONS OR MATTRESS PADS
(INCLUDING EGG CRATE, AIR)
SUCTION MACHINE AND SUPPLIES
TED HOSE AND SUPPLIES
WHEELCHAIR/WALKER
SOME OTHER TYPE OF DEVICE OR EQUIPMENT
NONE OF THE ABOVE

9

US. USE OF SERVICES

2006 Facility Interview
(Core Only)

US43
Please tell me if {SP} received any of the following medical services? Did {he/she} receive. . .
YES = 1, NO = 0
Turning and positioning................................................................ ( )
Tubefeeding ................................................................................. ( )
Restraints..................................................................................... ( )
Injections...................................................................................... ( )

US44 omitted

US45
Now I'd like to ask about any other medically necessary items or provider services (SP) received that we haven't
talked about already.

Please look at this last card and tell me what other items or services {he/she} received between {REFERENCE
DATE} and {END DATE}?
SELECT ALL THAT APPLY
SHOW
CARD
US8

CATHETERIZATION AND IRRIGATION
APPLYING/CHANGING DRESSINGS INCLUDING BAND-AIDS
FEEDING (WITH SPOON, SYRINGE, PUMP, OR OTHER DEVICE)
SKIN TREATMENTS FOR PREVENTION,
TREATMENT OF SKIN ULCERS
APPLYING/MONITORING HOT PACKS
IV USE AND CARE
G TUBE USE AND CARE
PACEMAKER CHECK
SUCTIONING
INCONTINENCE
SOME OTHER KIND OF ITEM OR SERVICE
NONE OF THE ABOVE

US46
DID YOU ABSTRACT?
ALL .........................................................
MAJORITY..............................................
HALF ......................................................
SOME .....................................................
NONE .....................................................

1
2
3
4
5

(USEND)

US47
WHY DID YOU ABSTRACT?
NO KNOWLEDGEABLE RESPONDENT AVAILABLE ................
NO TIME/STAFF BURDEN TOO GREAT ...................................
REFUSAL--UNWILLING TO COOPERATE.................................
OTHER, (SPECIFY:
)........................

USEND
YOU HAVE COMPLETED THE USE SECTION FOR THIS SP.
PRESS ENTER TO RETURN TO NAVIGATION SCREEN.

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US. USE OF SERVICES

2006 Facility Interview
(Core Only)

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