CMS-10429 (Physician) Survey of Access to Home Health Services for

Home Health Study Contract---Physician Survey
Questionnaire—3/29/2012
0938-NEW
Survey of Access to Home Health Services
For Medicare Beneficiaries
Thank you for taking the time to fill out this questionnaire. We are interested in understanding your
perspective on referring Medicare beneficiaries for home health services and whether you see access
problems experienced by specific types of beneficiaries. The questions cover Medicare beneficiaries
who you may refer to home health care, either following a stay in an institution (e.g., hospital or nursing
home) or directly from the community.
We are interested in hearing from the individual in your practice who is primarily responsible for
identifying the home health agency and handling the arrangements for patients you refer. W e appreciate
your completing the questionnaire or passing it along to the appropriate person. If you have any
questions, please call the Study Manager, JANE DOE, at 1-800-XXX-XXXX.
Your responses will be completely confidential. Information will be reported only in grouped data so that
neither you nor your practice can be identified by the Medicare program.
After you read each question, mark the response that best represents your experience, using the
categories listed.

In the past 3 months, has the physician listed on the cover sheet referred 10 or more
Medicare fee-for-service patients to home health services? If you are uncertain as to which
patients are covered by Medicare fee-for-service, please focus on those likely to be 65 or
older or those who are severely disabled.
__ Yes
__ No [Please return the questionnaire in the enclosed envelope. We appreciate
your time.]
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 0938-NEW. The time required to complete this information collection is
estimated to average 15 minutes per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-2605, Baltimore, Maryland 21244-1850.

For physicians certifying Medicare home health services, under regulations
implemented in 2011, the certifying physician must document that he or she or
an allowed practitioner had a face-to-face encounter with the patient. The
next few questions focus on this Medicare home health face-to-face encounter
requirement. We have provided space at the end of the questionnaire for you
to offer additional comments about access to home health services.
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Home Health Study Contract---Physician Survey
Questionnaire—3/29/2012
0938-NEW

Q1. Please rate the burden on your practice’s administrative and/or clinical workload resulting from this
requirement.
Very significant
Somewhat significant
Not very significant
Don’t know
Q2. To what extent do you think the requirement has caused delays in access to home health care for
your Medicare fee-for-service patients?
Substantial increase in delays
Moderate increase in delays
Small increase in delays
No increase in delays

When answering the following questions, to the best of your ability, please
exclude any changes due to the face-to-face requirement.
Also, when answering the following questions, please think about the
Medicare fee-for-service patients (not Medicare Advantage patients) who have
been referred for home health care services in the past 3 months by the
individual physician listed on the cover sheet.

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Home Health Study Contract---Physician Survey
Questionnaire—3/29/2012
0938-NEW

Q3. Thinking about the past 3 months, how many Medicare fee-for-service patients have you referred for
home health services? (Please provide your best estimate.)
(Please provide estimate here.)

Q4. Thinking about the past 3 months, please indicate what percentage of your Medicare fee-for-service
patients you wanted to refer to home health care but for whom you were unable to find a placement?
(Please provide your best estimate.)
Rarely or never
For fewer than 5% of patients
For 6 to 10% of patients
For 11 to 20% of patients
For more than 20% of patients
Don’t know

Q5. In the past 3 months, how important do you think each of the following factors were in your being
unable to place your Medicare fee-for-service patients with a home health agency?
Never an important factor

Always an important factor

1……….....…2……………..3………….…….4……….…….5……………..6…….……7
------------------------------------------------------------------------------------------------
Issue related to home health agency

Rating of
Importance

Nursing staff with needed skill set not available
Therapy staff not available (e.g., PT, OT, ST)
Staff not experienced with medical condition(s)
Required equipment/supplies not available
Reimbursement not sufficient
Medical issue related to patient
Severity/complexity of patient’s medical condition
More than two 60 day periods (episodes) of care
expected
Two or more visits per day expected
Routine evening or weekend care expected
Patient does not qualify for Medicare home health
benefit (e.g., not homebound)
Non-medical issue related to patient
Patient living conditions or local area unsafe
Patient located in hard-to-reach area or travel
distance/time too great

3

Check if
Don’t Know

Home Health Study Contract---Physician Survey
Questionnaire—3/29/2012
0938-NEW
Patient/family/caregiver cannot be or is unwilling
to be trained
Family/caregiver is unable to provide necessary
support
Language barrier/communication problems
Patient or family refused services
Other, specify

_
_

Q6. In the past 3 months, if you have been unable to place a Medicare fee-for-service patient at the
first agency you tried, where was the patient most likely to go for the needed care? (Please select
one response)
Another agency  how many additional agencies do you usually need to contact?
1
2 or more

Nursing home or skilled nursing facility
Hospital
Home, with no formal care or with private pay care
Don’t know
Not applicable

Q7. In the past 3 months, how often did you need to contact more than one home health agency in order
to find a placement for one of your Medicare fee-for-service patients?
Rarely or never
For fewer than 5% of patients
For 6 to 10% of patients
For 11 to 20% of patients
For more than 20% of patients
Don’t know

Q8. In the past 3 months, in how many of your Medicare fee-for-service home health placements were
you aware the agency could not provide all services that you ordered? (Please provide your best
estimate.)
(Please provide estimate here.)

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Home Health Study Contract---Physician Survey
Questionnaire—3/29/2012
0938-NEW
Q9. In cases where an agency was not able to provide all the services that are ordered, what were the
most common service(s) the agencies were not able to provide? (Please check all that apply)
Specific type of staff not available (Please check all that apply):
nursing staff
therapy staff
social work staff
home health aide
Staff not available to travel to patient’s residence
Other (please specify)

Q10. Thinking about the past 3 months, how many times did you experience delays in finding a home
health agency willing and able to admit your Medicare fee-for-service patients? (Please provide your
best estimate.)
(Please provide estimate here.)

Q11. In the past 3 months, typically how long were these delays in placing a patient?
Less than 24 hours
24 to 48 hours
More than 48 hours

Q12. In the past 3 months, for your Medicare fee-for-service patients, how important do you think each
of the following factors were in causing delays in placing a patient with a home health agency services?
Never an important factor

Always an important factor

1……….....…2……………..3………….…….4……….…….5……………..6…….……7
------------------------------------------------------------------------------------------------
Issue related to home health agency

Rating of
Importance

Nursing staff with needed skill set not available
Therapy staff not available (e.g., PT, OT, ST)
Staff not experienced with medical condition(s)

5

Check if
Don’t Know

Home Health Study Contract---Physician Survey
Questionnaire—3/29/2012
0938-NEW
Required equipment/supplies not available
Reimbursement not sufficient
Medical issue related to patient
Severity/complexity of patient’s medical condition
More than two 60 day periods (episodes) of care
expected
Two or more visits per day expected
Routine evening or weekend care expected
Non-medical issue related to patient
Patient living conditions or local area unsafe
Patient located in hard-to-reach area or travel
distance/time too great
Patient/family/caregiver cannot be or is unwilling to be
trained
Family/caregiver is unable to provide necessary
support
Language barrier/communication problems
Patient or family refused services
Other, specify

_
_

Q13. How many physicians practice at this location?
One
2 to 5
5 to 10
More than 10
Q14. Please indicate for all the patients the physician listed on the cover sheet serves – Medicare or
otherwise - what percentage of the patients referred for home health services are covered by each of the
following payer categories. Your best estimate is fine (should sum to 100 percent).
% Medicare only (fee-for-service)
% Medicaid only
% Dually eligible for Medicare and Medicaid
% Privately insured (include Medicare Advantage)
% Other (self pay)

Q15. Please indicate your position at this practice.
Physician

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Home Health Study Contract---Physician Survey
Questionnaire—3/29/2012
0938-NEW
Office Manager/Medical Assistant
Nurse/PA/Clinical manager
Other, please specify

Q16. In your opinion, the current availability of home health care services to Medicare beneficiaries in
your local area is…
Excellent
Good
Fair
Poor
Varies within the local area where my patients live

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Home Health Study Contract---Physician Survey
Questionnaire—3/29/2012
0938-NEW

THANK YOU FOR COMPLETING THE SURVEY
We invite you to share any additional thoughts you have about the availability and adequacy of home
health care for Medicare patients in your local area.

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