CMS-10403 CCTP 2nd Admin

OMB No.: XXXX-XXXX

Expiration Date: XX-XX-XXXX

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

SECOND ADMINISTRATION (AT THE END OF THE CARE TRANSITION PROGRAM)

PILOT TEST Questionnaire

Based on March 12, 2012 draft

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 Interview Completed: | | | / | | | / | | | | |

Month Day Year

OR

If interview was not completed, reason why:

1 □ No patient activation intervention

2 □ Death of patient

3 □ Patient in hospital or skilled nursing facility

4 □ Unable to locate / unable to reach the patient

5 □ Patient moved

6 □ Other reason (specify)

S URVEY INTRODUCTION: Start Time | | | : | | | (Please enter ) AM / PM (Please circle)

You may recall that we did a survey at the beginning of our CCTP program, just after you left the hospital. We’d like to do another, shorter survey today. As always, please be aware that your decision to participate in the survey will not in any way affect your health care coverage. Also, your responses will not be directly shared with your doctors, only with the people on the study team. 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. Could we begin the survey 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, let’s begin.

For all of these questions, your answer choices are Strongly Agree, Agree, Disagree, and Strongly Disagree.

	MARK ONE PER ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE	NOT APPLICABLE
1. When all is said and done, I am the person who is responsible for managing my health condition	1 □	2 □	3 □	4 □	n □
2. 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 □
3. 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 □
4. I know what each of my prescribed medications do	1 □	2 □	3 □	4 □	n □
5. 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 □
6. 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 □
7. I am confident that I can follow through on medical treatments I need to do at home	1 □	2 □	3 □	4 □	n □
8. I understand the nature and causes of my health condition(s)	1 □	2 □	3 □	4 □	n □
9. I know the different medical treatment options available for my health condition	1 □	2 □	3 □	4 □	n □
10. I have been able to maintain the lifestyle changes for my health that I have made	1 □	2 □	3 □	4 □	n □
11. I know how to prevent further problems with my health condition	1 □	2 □	3 □	4 □	n □
12. I am confident I can figure out solutions when new situations or problems arise with my health condition	1 □	2 □	3 □	4 □	n □
13. 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: End Time | | | : | | | AM / PM

A. Did you complete the interview with the patient alone, with the patient assisted by another person, or with someone else answering for the patient? 1 □ PATIENT ALONE GO TO C 2 □ PATIENT WITH ASSISTANCE 3 □ SOMEONE ELSE ANSWERING FOR PATIENT	B. Who assisted the patient 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. How much of the questionnaire do you think this patient understood? 1 □ MOST OR ALL 2 □ SOME 3 □ NONE
E. Is there any other information you think we should know about this interview?

Prepared by Mathematica Policy Research