Form CMS-10403 CCTP - 1st Administration

OMB No.: XXXX-XXXX

Expiration Date: XX-XX-XXXX

COMMUNITY-BASED CARE TRANSITIONS PROGRAM (CCTP) PARTICIPANT EXPERIENCE SURVEY

FIRST ADMINISTRATION (WITHIN 4 DAYS AFTER HOSPITAL DISCHARGE)

Draft Questionnaire

September 27, 2011

INFORMATION TO BE PRE-FILLED BY THE CBOs FROM THE LIST BILLS

Medicare Beneficiary ID (Health Insurance Claim Number or HICN):	| | | |-| | |-| | | | |-| | | |
Beneficiary Date of Birth:	| | | / | | | / | | | | | Month Day Year
Medicare Hospital ID (CMS Certification Number or CCN):	| | | | | | |
CCTP CBO ID:

Date of Interview: | | | / | | | / | | | | |

Month Day Year

SURVEY INTRODUCTION:

As part of the Medicare community-based care transitions program (also known as CCTP), we are asking participants in the CCTP to complete a brief survey about their most recent hospital stay. The purpose of the survey is to help improve the transitional care of people who have recently had a hospital stay. Your decision to participate will not affect your health care coverage or your participation in this program. The survey is voluntary, and you may skip any question that you don’t want to answer. Also, your responses will not be directly shared with your doctors, only with people on the study team. The survey should take about 10 minutes to complete. Could we begin now?

1 □ YES CONTINUE WITH THE INTERVIEW

0 □ NO Thanks very much for your time. END INTERVIEW (SAVE FOR DATA ENTRY)

(IF YES):

Thank you. To begin, these questions are about your most recent hospital stay. For most participants, this is when they began receiving transitional care services under the community-based care transitions program (CCTP).

1 . During this hospital stay, were you given any medicine that you had not taken before?

1 □ Yes

0 □ No GO TO Q.4

2. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Would you say never, sometimes, usually, or always?

MARK ONE ONLY

1 □ Never

2 □ Sometimes

3 □ Usually

4 □ Always

3. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? Would you say never, sometimes, usually, or always?

MARK ONE ONLY

1 □ Never

2 □ Sometimes

3 □ Usually

4 □ Always

4. During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

1 □ Yes

0 □ No

5. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

1 □ Yes

0 □ No

For the rest of the questions, your answer choices are Strongly Agree, Agree, Disagree, and Strongly Disagree. Let’s start with the first question.

INTERVIEWER: DO NOT INTRODUCE THE OPTION TO PROVIDE A “DON’T KNOW/DON’T REMEMBER/NOT APPLICABLE” RESPONSE; OFFER IT ONLY IF IT BECOMES CLEAR THAT THE FOUR OTHER RESPONSES DO NOT PERTAIN.

	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE	DON’T KNOW/ DON’T REMEMBER/ NOT APPLICABLE
6. The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital. Would you say you agree or disagree? [Then ask: Do you strongly agree/ disagree or just agree/disagree?]	1 □	2 □	3 □	4 □	d □
7. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. Would you say you agree or disagree? [Then ask: Do you strongly agree/ disagree or just agree/disagree?]	1 □	2 □	3 □	4 □	d □
8. When I left the hospital, I clearly understood the purpose for taking each of my medications. Would you say you agree or disagree? [Then ask: Do you strongly agree/disagree or just agree/ disagree?]	1 □	2 □	3 □	4 □	d □

The last series of questions, which I will ask next, will help us get a better understanding of how comfortable you feel managing your health so that we can help target the activities that are provided. I want to assure you that there are NO right or wrong answers, and neither of us is being graded on how you answer, so I encourage you to be completely honest when you answer.

As with the earlier questions, your answer choices are Strongly Agree, Agree, Disagree, and Strongly Disagree.

	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE	NOT APPLICABLE
9. When all is said and done, I am the person who is responsible for managing my health condition	1 □	2 □	3 □	4 □	n □
10. Taking an active role in my own health care is the most important factor in determining my health and ability to function	1 □	2 □	3 □	4 □	n □
11. I am confident that I can take actions that will help prevent or minimize some symptoms or problems associated with my health condition	1 □	2 □	3 □	4 □	n □
12. I know what each of my prescribed medications do.	1 □	2 □	3 □	4 □	n □
13. I am confident that I can tell when I need to go get medical care and when I can handle a health problem myself	1 □	2 □	3 □	4 □	n □
14. I am confident I can tell my health care provider concerns I have even when he or she does not ask	1 □	2 □	3 □	4 □	n □
15. I am confident that I can follow through on medical treatments I need to do at home	1 □	2 □	3 □	4 □	n □
16. I understand the nature and causes of my health condition(s)	1 □	2 □	3 □	4 □	n □
17. I know the different medical treatment options available for my health condition	1 □	2 □	3 □	4 □	n □
18. I have been able to maintain the lifestyle changes for my health that I have made	1 □	2 □	3 □	4 □	n □
19. I know how to prevent further problems with my health condition	1 □	2 □	3 □	4 □	n □
20. I am confident I can figure out solutions when new situations or problems arise with my health condition	1 □	2 □	3 □	4 □	n □
21. I am confident that I can maintain lifestyle changes like diet and exercise even during times of stress	1 □	2 □	3 □	4 □	n □

That is the end of our questions. Thank you very much for participating in the survey!

Interviewer/Coach, please answer the following questions:

A. Did you complete the interview with the participant alone, with the participant assisted by another person, or with someone else answering for the participant? 1 □ PARTICIPANT ALONE GO TO C 2 □ PARTICIPANT WITH ASSISTANCE 3 □ SOMEONE ELSE ANSWERING FOR PARTICIPANT	B. Who assisted the participant or answered for them? 1 □ SPOUSE 2 □ ANOTHER RELATIVE 3 □ FRIEND 4 □ PAID CAREGIVER 5 □ SOMEONE ELSE (Specify)
C. Did you complete the interview in person or over the phone? 1 □ IN PERSON 2 □ OVER THE PHONE	D. Is this participant receiving patient activation intervention? 1 □ Yes 0 □ No

Prepared by Mathematica Policy Research