CMS-10360 Screener_Informal Family Caregivers

Screener: Informal Family Caregivers
Target Population:
Group A – Care for someone who has had a hospital stay within the past 6 months
Group B – Care for someone who anticipates a hospital stay within the past 6 months

Recruitment Criteria:
All participants should regularly use the Internet (at least four times per week)
Exclude individuals who currently work or previously worked in the health care industry
or who have an immediate family member who is currently working in the health care
industry.
Exclude individuals who are current or former employees of the Social Security
Administration or the Department of Health and Human Services or one of its related
agencies (such as the Centers for Medicare & Medicaid Services, the Health Care
Financing Administration, the Agency for Healthcare Research and Quality, the Centers
for Disease Control, the Food and Drug Administration).
Exclude individuals who have participated in a health or health insurance related IDI or
focus group within the past year and/or who have participated in an IDI or focus group
within the past 6 months.
Recruitment Mix:
Recruit approximately 50% female and 50% male
Recruit a mix of race/ethnicity (Caucasian vs. Non-Caucasian)
Recruit a mix of ages, between 18 and 70.
Recruit a mix of education level (less than high school, high school graduate/GED, some
college, college graduate, post graduate). No more than 6 recruits of the 10 should have
education higher than a high-school diploma. (i.e. Some College/Associates, Bachelors, or
higher.)

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INTRODUCTION
Hello, my name is _____________ from ______________, a local research firm here in the
____________ area. We are working with L&M Policy Research on a project about health care.
If needed: If recruit asks about L&M Policy Research, please say the following: “L&M
Policy Research is a company with headquarters in Washington, D.C that conducts
research on many different healthcare issues.”
I’m calling today about a project that we are doing about the quality of certain hospital services
for the Centers for Medicare & Medicaid Services, the federal government agency that runs
Medicare. For this study we’d like your help figuring out the clearest way to tell people about
this hospital information. If you are interested in helping with the project and you meet its
requirements, we will invite you to come for an interview on [XX]. It would take about 90
minutes of your time, and we would pay you XX at the end of the interview. May I ask you a
few questions to see if you qualify to participate? If yes, continue to #1. If no, thank and end.
If needed: Since we need to include people who are a mix of different backgrounds and
experiences, there are some requirements that I have to check on for all of the people that
we bring in to participate. I need to ask you a few questions to see if you meet the
requirements for participating in the discussion.
1. Are you a primary caregiver to a family member who is elderly or disabled?
____ YES → Continue
____ NO → Thank and end call
2. Are you currently working or have you ever worked in the health care industry? (e.g.,
working for a hospital, nursing home, pharmacy, home health agency, medical office, clinic,
diagnostic imaging center, health plan, HMO, health insurance company, or pharmaceutical
company)
____ YES → Thank and end call
____ NO → Continue
____ NOT SURE → Thank and end call

3. Is an immediate family member currently working in the health care industry? (e.g.,
working for a hospital, nursing home, pharmacy, home health agency, medical office, clinic,
diagnostic imaging center, health plan, HMO, health insurance company, or pharmaceutical
company)

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____ YES → Thank and end call
____ NO → Continue
____ NOT SURE → Thank and end call

4. Are you currently or have you ever been employed by the Social Security
Administration or the Department of Health and Human Services or one of its related
agencies, such as the Centers for Medicare & Medicaid Services, the Health Care
Financing Administration, the Agency for Healthcare Research and Quality, the
Centers for Disease Control, or the Food and Drug Administration?
____ YES → Thank and end call
____ NO → Continue
5. Have you been paid to participate in an interview, focus group, or other group or
individual discussion in the past 6 months?
____ YES → Thank and end call
____ NO → Continue
____ NOT SURE → Thank and end call

6. Have you been paid to participate in a health or health insurance related interview,
focus group, or other group or individual discussion in the past year?
____ YES → Thank and end call
____ NO → Continue
____ NOT SURE → Thank and end call

7. Which category best describes your age? {Read list below.} {RECRUIT MIX}
____ 17 or under →Thank and end call
____ 18 to 49→ Continue
____ 50 to 70 → Continue
____ 71 or older → Thank and end call

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8. Have you visited Web sites on the Internet?
____ YES → Continue
____ NO → Thank and end call

9. How often do you use the Internet for things other than for checking e-mail (e.g., for
things such as checking news, online shopping, or searching for information)?
____ At least once per day → Continue
____ At least four times per week → Continue
____ About twice per week → Continue {RECRUIT NO MORE THAN 2}
____ About once per week → Thank and end call
____ Twice per month or less frequently → Thank and end call
10. If you were looking to make a major purchase (i.e. shopping for a car, a computer or
any other major purchase), which of the following sources would you use for
researching and comparing items before purchasing? {Read EVERY item and check ALL
that apply. All of the participants must indicate that they would use the Internet to search for
information.}
____ Friends and family → Continue
____ Trade magazines or literature (Car and Driver, Consumer Reports, etc.) → Continue
____ Internet (blue book, AAA) → {MUST indicate Internet as a choice to qualify}
____ Other → Continue

11. If you were looking for information to find a hospital for a planned health care service
or procedure for the person you care for, which of the following sources would you use?
{Read EVERY item and check ALL that apply.}
____ Friends and family → Continue
____ Magazines or other literature (US News & World Report, etc.) → Continue
____ Internet (hospital websites) → Continue
____ Other → Continue

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12. I am going to read a list of some different ways people help take care of family
members. Please tell me whether each applies to you. {Read EVERY item and check ALL
that apply. Must have item in blue to qualify.}
____ Taking my family member to doctor’s appointments → Continue
____ Talking with my family member’s doctor about their medical conditions or
treatment → Continue
____ Helping my family member select a doctor, clinic, or hospital → Continue, MUST
HAVE THIS TO QUALIFY
____ Managing my family member’s health insurance paperwork (e.g, reviewing plan
materials or medical bills for my family member) → Continue
____ Providing day-to-day care for my family member, such as providing meals or
assistance with bathing or toileting → Continue
13. Has the person you care for ever been admitted to a hospital?
____ Yes → Continue {Recruit for Group A}
____ No → Continue to 14

14. Does the person you care for anticipate being admitted to a hospital over the next 6
months?
____ Yes → Continue {Recruit for Group B}
____ NO → Thank and end call
I have a few more questions about your background. Again, this information will enable us
to make sure we have a broad mix of people participating in the interviews. If you feel
uncomfortable answering any of these questions, please let me know and we’ll go on to the
next question.
15. Gender. {Confirm if needed.}
____ MALE → Continue {RECRUIT ~50%}
____ FEMALE → Continue {RECRUIT ~50%}

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16. What is the last or highest grade that you finished in school? {Do not read options.}
{RECRUIT MIX BUT NO MORE THAN 6 PARTICIPANTS WITH “SOME COLLEGE” OR
ABOVE}
____ Less than high school degree → Continue
____ High school degree or GED→ Continue
____ Some college or two year degree →Continue
____ College graduate/4-year college degree → Continue
____ More than 4-year college degree →Continue
17. Are you of Hispanic or Latino origin or descent?
____ Yes, Hispanic or Latino → Continue
____ No, not Hispanic or Latino → Continue
18. What is your race? Are you… Read options.
____ White → Continue
____ Black or African American → Continue
____ Asian → Continue
____ Native Hawaiian or other Pacific Islander → Continue
____ Native American or Alaskan Indian or Alaskan Native → Continue
____ Other (Write response:_______________ ) → Continue
CONTINUE TO INVITATION BELOW
INVITATION:
Thank you for answering all of my questions. We would like to invite you to participate in the
study that will take place on _____________________________ located in
____________________. The interview will last about 90 minutes. As a thank you for your
participation, you will be paid $XX.

Are you willing to participate?

Yes____(CONTINUE)

[Schedule date and time]

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No____(THANK/END)

Now, let me just verify the spelling of your name and your address, so we can send you a
confirmation letter with directions. (RECORD RESPONDENT’S INFORMATION)

Name:_______________________________Telephone:________________________
Email:_______________________________________
Address:_______________________________________________________________
City, State:____________________________________________Zip:__________________

[IF EMAIL PROVIDED:] Would you rather receive a reminder by email or regular mail?
Email
Regular mail

As I mentioned during our conversation, you will be asked to read and discuss some materials
during the interview. So if you use reading glasses or assistive hearing devices, please remember
to bring them with you.
If you have any questions or find that you can’t attend, please call us right away at
___________________ so that we can find a replacement. Thank you for your time and for
agreeing to help.

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