Form CMS-10429 (Home Health Agencies) Survey of Access to Home Health S

Home Health Study Contract - Home Health Agency 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 better understanding your
perspective on providing home health services to Medicare beneficiaries. We are particularly interested
in understanding potential access problems experienced by specific types of beneficiaries and how
access might be affected by the current payment system.
Please complete this survey if you are the administrator of this home health agency. If you are not,
please pass this survey on 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 agency can be identified by the Medicare program.
After you read each question, mark the response that best represents your experience, using the
categories listed.

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 faceto-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.
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 C4-26-05, Baltimore, Maryland 21244-1850.

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

Q1. Please rate the burden on your agency’s administrative 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 effects due to the face-to-face requirement.
Also, when answering the following questions, please think about the
Medicare fee-for-service referrals (not Medicare Advantage patients)
your agency has received in the past month.
Q3. Thinking about the past month, how many Medicare fee-for-service referrals for home health has
your agency received? (Please provide your best estimate for the most recent month or 30-day period.)
(Please provide estimate here.)

Q4. Thinking about this past month’s Medicare fee-for-service referrals, please indicate how many
referrals your agency was unable to admit? (Please provide your best estimate.)
(Please provide estimate here.)

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

Q5. In the past month, how important were each of the following factors in cases where you were
unable to admit Medicare fee-for-service patients referred to your agency?
Never an important factor

Always an important factor

1…….......…2……….…..3………….…….4……….…….5……………..6……..……7

------------------------------------------------------------------------------------------------
Issue related to home health agency
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 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
Patient/family/caregiver cannot be or is unwilling to be
trained
Family/caregiver is unable to provide necessary support
Language barriers/communication problems
Patient or family refused services
Other, specify

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Home Health Study Contract - Home Health Agency Survey
Questionnaire—3/29/2012
0938-NEW
Q6. If you are unable to start care for a Medicare fee-for-service patient, where is the patient most
likely to go for the needed care? (Please select one response.)
Another agency
Nursing home or skilled nursing facility
Hospital
Home, with no formal care
Not applicable (we are able to start care for all referrals)
Don’t know

Q7. In the past month, please estimate how many Medicare fee-for-service referrals you started care for,
but were unable to provide all the ordered services?
(Please provide estimate here.)

Q8. If you were unable to provide all ordered services for some patients, what was the most common
reason for this? (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)

Q9. Thinking about the past month, how many times did you find that your agency had to delay the start
of care for Medicare fee-for-service patients? (Please provide your best estimate.)
(Please provide estimate here.)

Q10. In the past month, typically how long was the start of care delayed?
Less than 24 hours

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Home Health Study Contract - Home Health Agency Survey
Questionnaire—3/29/2012
0938-NEW
24 to 48 hours
More than 48 hours

Q11. In the past month, how important were each of the following factors in causing delays in the start
of care for your Medicare fee-for-service patients?
Never an important factor

Always an important factor

1…….......…2……….…..3………….…….4……….…….5……………..6……..……7

------------------------------------------------------------------------------------------------
Issue related to home health agency
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 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 barriers/communication problems
Patient or family refused services
Other, specify

Q12. Suppose you have been asked to provide home health services for a patient with a chronic
condition such as poorly controlled diabetes, heart failure or COPD, and the patient has other
comorbidities. The patient is homebound, in need of skilled services, and has a caregiver.
For this hypothetical patient, please indicate to what extent the presence of any of the following factors
would impact the cost of caring for the patient relative to current reimbursement levels.
Please check the most appropriate response in each row based on your experience with similar patients.

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Home Health Study Contract - Home Health Agency Survey
Questionnaire—3/29/2012
0938-NEW
How does the cost of care compare to
the current reimbursement for the
hypothetical patient who also has or
requires…
State of mind:

Cost of care
within
reimbursement

Developmental and/or intellectual
disabilities
Mental illness
Dementia or severe cognitive
impairment
Other (please specify or explain)

State of body:
Morbid obesity
Severe ADL/IADL limitations
Substance/alcohol abuse
Dialysis dependence
Dependence on mechanical ventilator
Oxygen dependence
Incontinence
Bed/wheelchair bound
Other (please specify or explain)

Frequency / complexity of procedures:
Use of multiple or high risk
medications
IV Administration
Timing, frequency and/or duration of
services needed (e.g. daily
nursing/aide/therapy visits or multiple
therapy disciplines)
Complex wound treatments
Other (please specify or explain)

Non-medical factors:

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Cost of care
somewhat
higher than
reimbursement

Cost of care
much higher
than
reimbursement

Could not take
the patient
regardless of
reimbursement

Home Health Study Contract - Home Health Agency Survey
Questionnaire—3/29/2012
0938-NEW
History of non-adherence/noncompliance
Language barriers/communication
problems
Patient living conditions or local area
unsafe
Patient located in hard to reach area
Other (please specify or explain)

Q13. Please indicate for all the patients you serve – Medicare or otherwise - what percentage are
covered by each of the following payer categories. Your best guess 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)

Q14. In your opinion, the current availability of home health care for Medicare fee-for-service
beneficiaries in your local area is…
Excellent
Good
Fair
Poor
Varies within our service area

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Home Health Study Contract - Home Health Agency 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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