Form CMS-10427 PACE Survey

FOR-PROFIT PACE STUDY

PACE SURVEY

June 20, 2012

Sponsored by

Centers for Medicare & Medicaid Services

PRA Disclosure Statement

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-XXXX . The time required to complete this information collection is estimated to average 33 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.

INTRODUCTION AND SCREENER

1. Hello, my name is (INTERVIEWER’S FULL NAME). I am calling on behalf of the Medicare program. May I please speak to (SAMPLE MEMBER)?

SPEAKING TO SAMPLE MEMBER 1 SKIP TO I4

PERSON WHO ANSWERED WANTS TO KNOW WHAT THE CALL IS ABOUT 2 SKIP TO I2

SAMPLE MEMBER BUSY, UNAVAILABLE, NOT HOME, NOT FEELING WELL, OR TEMPORARILY OUT OF THE AREA 3 SKIP TO I5a

SAMPLE MEMBER CAN ONLY BE INTERVIEWED IN PERSON—SEND TO FIELD 4 SKIP TO I5a

WHEN SAMPLE MEMBER COMES TO THE PHONE 5 SKIP TO I3

SAMPLE MEMBER PHYSICALLY UNABLE TO RESPOND ON THE TELEPHONE 6 SKIP TO I7

SAMPLE MEMBER MENTALLY UNABLE TO RESPOND 7 SKIP TO I11

SAMPLE MEMBER HAS A SPEECH OR HEARING PROBLEM 8 SKIP TO I10

SAMPLE MEMBER IN A COMA 9 SKIP TO I10a

SAMPLE MEMBER DECEASED 10 SKIP TO I12

SAMPLE MEMBER IN THE HOSPITAL 11 SKIP TO I13

SAMPLE MEMBER IN A NURSING HOME 12 SKIP TO I16

SAMPLE MEMBER MOVED 13 SKIP TO I24

SAMPLE MEMBER ONLY SPEAKS SPANISH 14Ô SKIP TO SPANISH

VERSION

SAMPLE MEMBER DOES NOT SPEAK ENGLISH OR SPANISH 15 skip TO I10a

2. (SAMPLE MEMBER) should have received a letter explaining that we would be calling about the health care of Medicare beneficiaries who received care through (NAME OF PROGRAM). When is a good time to call (SAMPLE MEMBER)?

WHEN SAMPLE MEMBER COMES TO THE PHONE 1 skip TO I3

SAMPLE MEMBER BUSY, UNAVAILABLE, NOT HOME, NOT FEELING WELL, OR TEMPORARILY OUT OF THE AREA 2 skip TO I5a

SAMPLE MEMBER CAN ONLY BE INTERVIEWED IN PERSON—SEND TO FIELD 3 skip TO I5a

PERSON REFUSED FOR SAMPLE MEMBER 4 skip TO END

SAMPLE MEMBER PHYSICALLY UNABLE TO RESPOND ON THE TELEPHONE 5 skip TO I10

SAMPLE MEMBER MENTALLY UNABLE TO RESPOND 6 skip TO I11

SAMPLE MEMBER HAS A SPEECH OR HEARING IMPAIRMENT 7 skip TO I10

SAMPLE MEMBER IN A COMA 8 skip TO I11

SAMPLE MEMBER DECEASED 9 skip TO I12

SAMPLE MEMBER IN THE HOSPITAL 10 skip TO I13

SAMPLE MEMBER IN A NURSING HOME 11 skip TO I16

SAMPLE MEMBER MOVED 12 skip TO I24

SAMPLE MEMBER ONLY SPEAKS SPANISH 13Ô SKIP TO SPANISH

VERSION

SAMPLE MEMBER DOES NOT SPEAK ENGLISH OR SPANISH 14 SKIP TO I11

3. Hello, my name is (INTERVIEWER’S FULL NAME). I am calling on behalf of the Medicare program. CONTINUE TO I4.

INTERVIEWER: IF NECESSARY, USE DESIGNATED KEY SEQUENCE TO SWITCH FROM SAMPLE MEMBER TO PROXY AT ANY POINT DURING INTERVIEW.

4. You should have received a letter explaining that we are calling to conduct an interview about the health care of Medicare beneficiaries who received care through (NAME OF PROGRAM). The questions I will be asking are about your health and how you get along day-to-day. Your participation is voluntary and all of your answers will be held in strict confidence. The interview only takes about thirty minutes. I would like to begin the interview now.

BEGIN INTERVIEW 1 SKIP TO I31b

NOT A GOOD TIME 2 SKIP TO I5a

SAMPLE MEMBER CAN ONLY BE INTERVIEWED IN PERSON—SEND TO FIELD 3 SKIP TO I5a

DID NOT RECEIVE OR DOES NOT RECALL THE LETTER 4

5. The letter explained that we would be calling. I would like to begin the interview now.

BEGIN INTERVIEW 1 SKIP TO I31b

NOT A GOOD TIME 2

SAMPLE MEMBER CAN ONLY BE INTERVIEWED IN PERSON—SEND TO FIELD 3

DID NOT RECEIVE OR DOES NOT RECALL THE LETTER 4 SKIP TO I6

PROGRAMMER BOX I5a

CATI CHECK: APPOINTMENTS WILL BE SET NO SOONER THAN ONE WEEK FOLLOWING THE DATE OF THE TELEPHONE CONTACT.

5a. When would be a good time to (call/visit)?

DATE:

| | | / | | | / | | | | |

MONTH DAY YEAR

TIME:

| | | HOURS

| | | MINUTES

AM 1

PM 2

SKIP TO CALL BACK

6. In that case, let me send the letter to you again. To what address would you like the letter sent?

PROBE: Is there an apartment number?

STREET 1 APT #

STREET 2

STREET 3

CITY

STATE

ZIP

SKIP TO CALL BACK

7. (SAMPLE MEMBER) should have received a letter explaining that we are calling about the health care of Medicare beneficiaries who received care through (NAME OF PROGRAM). CONTINUE TO I8.

8. Will (SAMPLE MEMBER) be able to talk on the telephone if I call back next week?

YES 1

NO 0 SKIP TO I10

SAMPLE MEMBER CAN ONLY BE INTERVIEWED IN PERSON—SEND TO FIELD 3

NOT SURE d

9. When would be a good time to (call/visit) to see if (he/she) is up to it?

DATE:

| | | / | | | / | | | | |

MONTH DAY YEAR

TIME:

| | | HOURS

| | | MINUTES

AM 1

PM 2

SKIP TO CALL BACK

10. Would (SAMPLE MEMBER) be able to speak with someone in person?

YES 1 SKIP TO I15d

NO 0

DON’T KNOW d

PROGRAMMER BOX I10a

CATI CHECK: IF I2=5 OR 7, SKIP TO I11, ELSE ASK I10a

10a. (SAMPLE MEMBER) should have received a letter explaining that we are calling about the health care of Medicare beneficiaries who received care through (NAME OF PROGRAM). CONTINUE TO I11.

11. Perhaps there is someone who could answer the questions on behalf of (SAMPLE MEMBER). Is there a family member or friend who is knowledgeable about (his/her) health and the care (he/she) receives?

YES, SPEAKING TO PROXY, BEGIN INTERVIEW 1 SKIP TO I31

YES, BUT NOT A GOOD TIME OR PROXY NOT AVAILABLE 2 SKIP TO I15a

PROXY CAN ONLY BE INTERVIEWED IN PERSON—SEND TO FIELD 3 SKIP TO I15a

NO PROXY AVAILABLE 4 SKIP TO I35

PROXY REFUSAL r SKIP TO I35

12. I am very sorry to hear that (he/she) passed away. I am calling about a study we are conducting for the Medicare program concerning the health care of beneficiaries who received care through (NAME OF PROGRAM). A letter explaining why we are calling was recently sent to (SAMPLE MEMBER).

When did (SAMPLE MEMBER) pass away?

| | | / | | | / | | | | |

MONTH DAY YEAR

DON’T KNOW d

REFUSED r

12a. Thank you. Please accept my condolences.

SKIP TO I35

13. (SAMPLE MEMBER) should have received a letter explaining that we are calling about the health care of Medicare beneficiaries who received care through (NAME OF PROGRAM). Do you expect (SAMPLE MEMBER) to come home from the hospital within a day or two?

YES 1

NO 0 SKIP TO I15

DON’T KNOW d

REFUSED r

14. I would like to talk to (SAMPLE MEMBER) over the telephone about (his/her) health and how (he/she) gets along day-to-day. When would be a good time to call back?

MAKE APPOINTMENT 1

DATE:

| | | / | | | / | | | | |

MONTH DAY YEAR

TIME:

| | | HOURS

| | | MINUTES

AM 1

PM 2

SAMPLE MEMBER CAN ONLY BE INTERVIEWED IN PERSON—SEND TO FIELD 2 SKIP TO I15d

PATIENT WILL BE UNABLE TO RESPOND 3 SKIP TO I15

DON’T KNOW d

REFUSED r

SKIP TO CALL BACK

14a. When would be a good time to (call/visit)?

DATE:

| | | / | | | / | | | | |

MONTH DAY YEAR

TIME:

| | | HOURS

| | | MINUTES

AM 1

PM 2

SKIP TO CALL BACK

15. Perhaps there is someone who could answer the questions on behalf of (SAMPLE MEMBER). Is there a family member or friend who is knowledgeable about (his/her) health and the health care (he/she) receives?

YES, SPEAKING TO PROXY 1 SKIP TO I31

YES, BUT NOT A GOOD TIME OR PROXY NOT HOME 2

PROXY CAN ONLY BE INTERVIEWED IN PERSON—SEND TO FIELD 3

PROXY LIVES AT DIFFERENT ADDRESS 4

NO PROXY AVAILABLE 5 SKIP TO I35

PROXY REFUSAL r SKIP TO I35

15a. May I please have (your/his/her) name?

NAME (SPECIFY) 1

(STRING (NUM))

15b. And I’d like to get (your/his/her) address and telephone number so I can contact (you/him/her) at a more convenient time?

PROBE: Is there an apartment number?

SAME AS SAMPLE MEMBER 1

STREET 1 APT #

STREET 2

STREET 3

CITY

STATE

ZIP

PHONE: | | | | - | | | | - | | | | |

15c. How (are you/is [he/she]) related to (SAMPLE MEMBER)?

RELATIONSHIP (SPECIFY) 1

(STRING (NUM))

15c1. INTERVIEWER: IF RELATIONSHIP IS A PAID CAREGIVER, ASK I15c1. ELSE SKIP TO I15j. (Are you/Is [he/she]) hired through the PACE program?

YES 1 SKIP TO 15j

NO 0 SKIP TO 15j

NOT APPLICABLE n SKIP TO 15j

15d. Those are all the questions I have. Please tell me the name of a family member or friend who knows about your health and the health care you receive.

NAME (SPECIFY) 1

(STRING (NUM))

15e. And I’d like to get (his/her) address and telephone number so I can contact (him/her) at a later time.

PROBE: Is there an apartment number?

SAME AS SAMPLE MEMBER 1

STREET 1 APT #

STREET 2

STREET 3

CITY

STATE

ZIP

PHONE: | | | - | | | | - | | | | |

15f. How is (he/she) related to you?

RELATIONSHIP (SPECIFY) 1

(STRING (NUM))

15f1. INTERVIEWER: IF RELATIONSHIP IS A PAID CAREGIVER, ASK I15f1. ELSE SKIP TO I15j. (Are you/ is [he/she]) hired through the PACE program?

YES 1 SKIP TO 15j

NO 0 SKIP TO 15j

NOT APPLICABLE n SKIP TO 15j

15g. Those are all the questions I have. Please tell me the name of another family member or friend who knows about your health and the health care you receive.

NAME (SPECIFY) 1

(STRING (NUM))

15h. And I’d like to get (his/her) address and telephone number so I can contact (him/her) at a later time.

PROBE: Is there an apartment number?

SAME AS SAMPLE MEMBER 1

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

PHONE: | | | | - | | | | - | | | | |

15i. How is (he/she) related to you?

RELATIONSHIP (SPECIFY) 1

(STRING (NUM))

15i1. INTERVIEWER: IF RELATIONSHIP IS A PAID CAREGIVER, ASK I15i1. ELSE SKIP TO I15j. (Are you/is [he/she]) hired through the PACE program?

YES 1

NO 0

NOT APPLICABLE n

15j. When would be a good time to (call/visit)?

DATE:

| | | / | | | / | | | | |

MONTH DAY YEAR

TIME:

| | | HOURS

| | | MINUTES

AM 1

PM 2

DON’T KNOW d

REFUSED r

SKIP TO CALL BACK

16. I am calling about an interview we would like to conduct with (SAMPLE MEMBER) concerning the health care of Medicare beneficiaries who received care through (NAME OF PROGRAM). A letter explaining why we are calling was recently sent to (SAMPLE MEMBER).

Do you expect (him/her) to come home from the nursing home in the next few weeks?

YES 1 SKIP TO I17

NO 0

DON’T KNOW d

REFUSED r

16a. Will (SAMPLE MEMBER) be able to talk on the telephone if I call the nursing home?

YES 1 SKIP TO I28

SAMPLE MEMBER CAN ONLY BE INTERVIEWED IN PERSON—SEND TO FIELD 2 SKIP TO I28

SAMPLE MEMBER PHYSICALLY UNABLE TO RESPOND ON THE TELEPHONE 3

SAMPLE MEMBER MENTALLY UNABLE TO RESPOND 4 SKIP TO I18

SAMPLE MEMBER HAS A SPEECH OR HEARING IMPAIRMENT 5

SAMPLE MEMBER IN A COMA 6 SKIP TO I18

NO PHONE AVAILABLE 7

DON’T KNOW d SKIP TO I28

REFUSED r

16b. Would (SAMPLE MEMBER) be able to speak with someone in person?

YES 1 SKIP TO I28

NO 0 SKIP TO I18

DON’T KNOW d SKIP TO I28

REFUSED r SKIP TO I28

17. I would like to talk to (SAMPLE MEMBER) over the telephone about (his/her) health and how (he/she) gets along day-to-day. When would be a good time to call back?

MAKE AN APPOINTMENT 1 SKIP TO CALL BACK

SAMPLE MEMBER UNABLE TO RESPOND OVER THE TELEPHONE 2

SAMPLE MEMBER CAN ONLY BE INTERVIEWED IN PERSON—SEND TO FIELD 3 SKIP TO I22a

17a. Would (SAMPLE MEMBER) be able to speak with someone in person?

YES 1 SKIP TO I29a

NO 0

DON’T KNOW d

REFUSED r

18. Perhaps there is someone who could answer the questions on behalf of (SAMPLE MEMBER). Is there a family member or friend who is knowledgeable about (his/her) health and the care (he/she) receives?

YES, SPEAKING TO PROXY, BEGIN INTERVIEW 1 SKIP TO I31

YES, BUT NOT A GOOD TIME OR PROXY NOT AVAILABLE 2

PROXY CAN ONLY BE INTERVIEWED IN PERSON—SEND TO FIELD 3

PROXY LIVES AT DIFFERENT ADDRESS 4

NO PROXY AVAILABLE 5 SKIP TO END

PROXY REFUSAL r SKIP TO END

19. May I please have (your/his/her) name?

NAME (SPECIFY) 1

(STRING (NUM))

20. May I please have (your/his/her) telephone number?

| | | | - | | | | - | | | | |

21. And (your/his/her) address?

PROBE: Is there an apartment number?

STREET 1 APT #

STREET 2

STREET 3

CITY

STATE

ZIP

22. How (are you/is [he/she]) related to (SAMPLE MEMBER)?

RELATIONSHIP (SPECIFY) 1

(STRING (NUM))

22a1. INTERVIEWER: IF RELATIONSHIP IS A PAID CAREGIVER, ASK I22a1. ELSE SKIP TO I22a. (Are you/is [he/she]) hired through the PACE program?

YES 1

NO 0

NOT APPLICABLE n

22a. When would be a good time to (call/visit)?

DATE:

| | | / | | | / | | | | |

MONTH DAY YEAR

TIME:

| | | HOURS

| | | MINUTES

AM 1

PM 2

DON’T KNOW d

REFUSED r

23. Thank you very much for your time.

SKIP TO CALL BACK

24. (SAMPLE MEMBER) should have recently received a letter explaining that we are calling about the health care of Medicare beneficiaries who received care through (NAME OF PROGRAM).

Do you know how we can reach (SAMPLE MEMBER)?

YES 1 SKIP TO I25

NO, SPECIAL SEARCH NEEDED 0 SKIP TO LOCATING

DON’T KNOW d SKIP TO LOCATING

REFUSED r SKIP TO LOCATING

25. May I please have (his/her) telephone number?

| | | | - | | | | - | | | | |

DON’T KNOW d SKIP TO LOCATING

REFUSED r SKIP TO LOCATING

26. May I please have (his/her) address?

PROBE: Is there an apartment number?

STREET 1 APT #

STREET 2

STREET 3

CITY

STATE

ZIP

DON’T KNOW d SKIP TO LOCATING

REFUSED r SKIP TO LOCATING

27. Thank you very much for your time.

SKIP TO CALL BACK

28. What is the name of the nursing home?

NURSING HOME NAME (SPECIFY)

(STRING (NUM))

DON’T KNOW d SKIP TO LOCATING

REFUSED r SKIP TO LOCATING

28a. And, what is the address and telephone number of the nursing home?

PROBE: In what town or city is it located?

STREET 1 APT #

STREET 2

STREET 3

CITY

STATE

ZIP

DON’T KNOW d SKIP TO LOCATING

REFUSED r SKIP TO LOCATING

29. What is the telephone number of the nursing home?

| | | | - | | | | - | | | | |

DON’T KNOW d SKIP TO LOCATING

REFUSED r SKIP TO LOCATING

29a. When would be a good time to (call/visit)?

DATE:

| | | / | | | / | | | | |

MONTH DAY YEAR

TIME:

| | | HOURS

| | | MINUTES

AM 1

PM 2

DON’T KNOW d

REFUSED r

30. Thank you very much for your time.

SKIP TO CALL BACK

31. When it comes to getting health and/or personal care through (NAME OF PROGRAM) do you make arrangements for (SAMPLE MEMBER)’s health and personal care help, do you help (SAMPLE MEMBER) make arrangements for health and personal care help, do you talk things over but (SAMPLE MEMBER) arranges for (his/her) own health and personal care help, or are you not involved in these arrangements?

MAKE ARRANGEMENTS FOR SM 1

HELP MAKE ARRANGEMENTS 2

DISCUSS HEALTH AND/OR PERSONAL CARE, BUT SM MAKES ARRANGEMENTS 3

NOT INVOLVED 4 NOT SUITABLE PROXY

31a. To clarify, you will be answering all questions in this interview on behalf of (NAME). While you may have your own opinions, try to answer all the questions as you think (NAME) would respond if (he/she) were answering for (himself/herself).

31b. What is your name?

NAME (SPECIFY) 1

(STRING (NUM))

31c. And how are you related to (NAME)?

SPOUSE/PARTNER 1 SKIP TO I31d

CHILD 2 SKIP TO I31d

PARENT 3 SKIP TO I31d

OTHER RELATIVE 4 SKIP TO I31d

FRIEND 5 SKIP TO I31d

PAID CAREGIVER 6

OTHER 7 SKIP TO I31d

DON’T KNOW d SKIP TO I31d

31c1. Are you hired through the PACE program?

YES 1

NO 0

31d. INTERVIEWER CODE WITHOUT ASKING: IS PROXY MALE OR FEMALE?

MALE 1

FEMALE 2

31e. (Do you/Does SAMPLE MEMBER) live . . .

In (your/his/her) own house, 1 SKIP TO I33

In (your/his/her) own apartment, 2 SKIP TO I32

In a relative’s or friend’s house or apartment, 3 SKIP TO I33

In a group home, 4 SKIP TO I33

In an assisted living facility, 5 SKIP TO I33

In a nursing home or other long term care facility, or 6 SKIP TO I34

Some other place? (SPECIFY) 7 SKIP TO I33

(STRING (NUM))

DON’T KNOW d SKIP TO I33

REFUSED r SKIP TO I33

CONVENT 8

32. Is (your/his/her) apartment in an assisted living facility?

PROBE: An assisted living facility combines housing, supportive services, personalized assistance and healthcare designed to meet someone’s needs on a daily basis.

YES 1

NO 0

DON’T KNOW d

REFUSED r

33. Which of the following best describes (your/SAMPLE MEMBER’s) current living situation?

Live by (yourself/himself/herself), 1

Live with (your/his/her) spouse regardless of others, 2

With children, relatives, or friends and not spouse, 3

Or, just with paid caregivers? 4

OTHER (SPECIFY) 5

(STRING (NUM))

LIVING WITH OTHER NUNS 6

DON’T KNOW d

REFUSED r

34. INTERVIEWER: CODE WITHOUT ASKING IF KNOWN: (Are you/Is SAMPLE MEMBER) male or female?

MALE 1

FEMALE 2

SKIP TO A1

35. Thank you very much for your time.

SKIP TO END

SECTION A – MEDICAL CARE

The first series of questions is about (your/SAMPLE MEMBER’s) use of health care services.

1a. (Have you/Has SAMPLE MEMBER) been admitted to a hospital for overnight or longer at any time since (MONTH AND DAY ONE YEAR AGO)?

YES 1

NO 0 SKIP TO A2

DON’T KNOW d SKIP TO A2

REFUSED r SKIP TO A2

1b. Thinking about the most recent time (you were/SAMPLE MEMBER was) in a hospital, when (were you/was SAMPLE MEMBER) admitted and when (were you/was SAMPLE MEMBER) discharged?

ADMITTED:

| | | / | | | / | | | | |

MONTH DAY YEAR

DISCHARGED:

| | | / | | | / | | | | |

MONTH DAY YEAR

STILL IN HOSPITAL 99 SKIP TO A2

DON’T KNOW d

REFUSED r

1c. About how long was the most recent hospital stay?

| | | number (NUMBER RANGE)

days 1

weeks 2

months 3

DON’T KNOW d

REFUSED r

2. (Have you/Has SAMPLE MEMBER) been in a nursing home for overnight or longer at any time since (MONTH AND DAY ONE YEAR AGO)?

YES 1

NO 0 SKIP TO A3

DON’T KNOW d SKIP TO A3

REFUSED r SKIP TO A3

2a. Thinking about the most recent time in a nursing home, when (were you/was SAMPLE MEMBER) admitted and when (were you/was SAMPLE MEMBER) discharged?

ADMITTED:

| | | / | | | / | | | | |

MONTH DAY YEAR

DISCHARGED:

| | | / | | | / | | | | |

MONTH DAY YEAR

STILL IN NURSING HOME 99 SKIP TO A3

DON’T KNOW d

REFUSED r

2b. About how long was the most recent nursing home stay?

| | | number

days 1

weeks 2

months 3

DON’T KNOW d

REFUSED r

19. In the past year, did (you/SAMPLE MEMBER) receive any therapy outside of the PACE center that was provided by a physical therapist, an occupational therapist or a speech and language therapist?

YES 1

NO 0 SKIP TO A21

DON’T KNOW d SKIP TO A21

REFUSED r SKIP TO A21

20. How satisfied have you been with the overall quality of the therapy (you have/he has/she has) received outside of the PACE center? Are you very satisfied, satisfied, unsatisfied, or very unsatisfied?

NOTE: IF PROXY, WE’RE INTERESTED IN THE PROXY’S SATISFACTION WITH THE THERAPY THAT THE SAMPLE MEMBER HAS RECEIVED.

VERY SATISFIED 1

SATISFIED 2

UNSATISFIED 3

VERY UNSATISFIED 4

DON’T KNOW d

REFUSED r

21. In the past month, did (you/SAMPLE MEMBER) visit the PACE center?

YES 1 SKIP TO A3

NO 0

DON’T KNOW d SKIP TO A3

REFUSED r SKIP TO A3

22. Could you please tell us why you did not visit the PACE center in the past month? Was it because you were hospitalized, you were ill at home, you did not want to interact with other people, you are newly enrolled in the PACE program, or was there another reason?

HOSPITALIZED 1 SKIP TO A3

ILL AT HOME 2 SKIP TO A3

DID NOT WANT TO INTERACT WITH OTHER PEOPLE 3 SKIP TO A3

NEWLY ENROLLED IN PACE PROGRAM 4 SKIP TO A3

ANOTHER REASON 5

DON’T KNOW d SKIP TO A3

REFUSED r SKIP TO A3

22a. What is this reason?

(STRING (NUM))

3. Please tell me how satisfied you have been with the overall quality of medical care (you have/he/she has) received from doctors at the PACE center. Are you very satisfied, satisfied, unsatisfied, or very unsatisfied?

NOTE: IF PROXY, WE’RE INTERESTED IN THE PROXY’S SATISFACTION WITH THE MEDICAL CARE THAT THE SAMPLE MEMBER HAS RECEIVED.

VERY SATISFIED 1

SATISFIED 2

UNSATISFIED 3

VERY UNSATISFIED 4

DON’T KNOW d

REFUSED r

23. In the past year, did (you/SAMPLE MEMBER) receive any therapy at the PACE center that was provided by a physical therapist, an occupational therapist or a speech and language therapist?

YES 1

NO 0 SKIP TO A4

DON’T KNOW d SKIP TO A4

REFUSED r SKIP TO A4

24. How satisfied have you been with the overall quality of the therapy (you have/he has/she has) received at the PACE center? Are you very satisfied, satisfied, unsatisfied, or very unsatisfied?

NOTE: IF PROXY, WE’RE INTERESTED IN THE PROXY’S SATISFACTION WITH THE THERAPY THAT THE SAMPLE MEMBER HAS RECEIVED.

VERY SATISFIED 1

SATISFIED 2

UNSATISFIED 3

VERY UNSATISFIED 4

DON’T KNOW d

REFUSED r

4. How satisfied have you been with the information given to (you/SAMPLE MEMBER) by doctors and other health care professionals at the PACE center about the treatment for (your/his/her) health conditions. Are you very satisfied, satisfied, unsatisfied, or very unsatisfied?

VERY SATISFIED 1

SATISFIED 2

UNSATISFIED 3

VERY UNSATISFIED 4

DON’T KNOW d

REFUSED r

4a. In the past year, have you taken any prescription medicines?

YES 1

NO 0 SKIP TO A5

DON’T KNOW d SKIP TO A5

REFUSED r SKIP TO A5

4b. How satisfied have you been with the help (you have/SAMPLE MEMBER has) received from doctors and other health care professionals at the PACE center to follow your doctors’ instructions for taking these prescription medicines? Are you very satisfied, satisfied, unsatisfied, or very unsatisfied?

VERY SATISFIED 1

SATISFIED 2

UNSATISFIED 3

VERY UNSATISFIED 4

DON’T KNOW d

REFUSED r

5. How satisfied have you been with the ability of your primary doctor at the PACE center to coordinate and organize your medical care with all of your healthcare providers? Are you very satisfied, satisfied, unsatisfied, or very unsatisfied?

VERY SATISFIED 1

SATISFIED 2

UNSATISFIED 3

VERY UNSATISFIED 4

DON’T KNOW d

REFUSED r

6. How satisfied have you been with the respect that doctors or other health care providers at the PACE center showed for what (you/he/she) had to say. Are you very satisfied, satisfied, unsatisfied, or very unsatisfied?

VERY SATISFIED 1

SATISFIED 2

UNSATISFIED 3

VERY UNSATISFIED 4

DON’T KNOW d

REFUSED r

7. Now, would you please tell me whether you agree or disagree with this statement about the health care services you receive at the PACE center. It takes a great deal of energy to get the health care services (I need/[SAMPLE MEMBER] needs). Would you strongly agree, agree, disagree or strongly disagree?

STRONGLY AGREE 1

AGREE 2

DISAGREE 3

STRONGLY DISAGREE 4

DON’T KNOW d

REFUSED r

8. These next questions are about the transportation services (you/SAMPLE MEMBER) may received from PACE to take (you/him/her) to or from the PACE center in the past year.

In the past year, did (you/SAMPLE MEMBER) receive help from the PACE center with transportation to take (you/him/her) to or from the PACE center?

YES 1

NO 0 SKIP TO A14

DON’T KNOW d SKIP TO A14

REFUSED r SKIP TO A14

9. In the past year, when you asked the PACE center for help with transportation to take (you/SAMPLE MEMBER) to or from the PACE center, how often did you get it? Would you say never, sometimes, usually, or always?

never 1

sometimes 2

usually 3

always 4

DON’T KNOW d

REFUSED r

10. How satisfied have you been with the overall quality of the transportation service (you have/he/she has) received to take you to or from the PACE center. Are you very satisfied, satisfied, unsatisfied, or very unsatisfied?

NOTE: IF PROXY, WE’RE INTERESTED IN THE PROXY’S SATISFACTION WITH THE TRANSPORTATION SERVICE THAT THE SAMPLE MEMBER HAS RECEIVED.

VERY SATISFIED 1

SATISFIED 2

UNSATISFIED 3

VERY UNSATISFIED 4

DON’T KNOW d

REFUSED r

11.-13. NO QUESTIONS THIS VERSION

14 These next questions are about medical care (you/SAMPLE MEMBER) may have received from specialist doctors outside of the PACE center. Specialists are doctors like surgeons, heart doctors, and other doctors that specialize in one area of health care.

In the past year, did (you/SAMPLE MEMBER) think (you/he/she) needed to see a specialist doctor, either inside or outside of the PACE center?

YES 1

NO 0 SKIP TO A19

DON’T KNOW d

REFUSED r

15. In the past year, not counting the times you needed care right away, how often did (you/SAMPLE MEMBER) get an appointment with the specialist doctor as soon as (you/he/she) thought (you/he/she) needed? Would you say never, sometimes, usually, or always?

never 1

sometimes 2

usually 3

always 4

DON’T KNOW d

REFUSED r

16. Now, would you please tell me whether you agree or disagree with this statement. The PACE program does not have enough of the specialists (I need/[SAMPLE MEMBER] needs). Would you strongly agree, agree, disagree or strongly disagree?

STRONGLY AGREE 1

AGREE 2

DISAGREE 3

STRONGLY DISAGREE 4

DON’T KNOW d

REFUSED r

17. In the past year, was there a time when (you/SAMPLE MEMBER) needed to but could not see a specialist doctor?

YES 1

NO 0

DON’T KNOW d

REFUSED r

18. How satisfied have you been with the overall quality of medical care (you have/he/she has) received from the specialist doctors outside of the PACE center? Are you very satisfied, satisfied, unsatisfied, or very unsatisfied?

NOTE: IF PROXY, WE’RE INTERESTED IN THE PROXY’S SATISFACTION WITH THE MEDICAL CARE THAT THE SAMPLE MEMBER HAS RECEIVED.

VERY SATISFIED 1

SATISFIED 2

UNSATISFIED 3

VERY UNSATISFIED 4

DON’T KNOW d

REFUSED r

SECTION b – current health problems

1. Now, we have some questions about (your/SAMPLE MEMBER’s) health and health conditions. Your answers to these questions will not affect (your/his/her) health insurance coverage in any way whatsoever.

In general, compared to other people (your/SAMPLE MEMBER’s) age, would (you/he/she) say that (your/his/her) health is . . .

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

DON’T KNOW d

REFUSED r

2. Compared to one year ago, how would (you/he/she) rate (your/his/her) health in general now? Would (you/he/she) say (your/his/her) health is . . .

Much better now than one year ago, 1

Somewhat better now than one year ago, 2

About the same as one year ago, 3

Worse than one year ago, or 4

Much worse than one year ago? 5

DON’T KNOW d

REFUSED r

3. Now I am going to read you a list of health conditions and illnesses. Please tell me if a doctor or health professional has ever told (you/SAMPLE MEMBER) that (you/SAMPLE MEMBER) had . . .

	YES	NO	DON’T KNOW	REFUSED
a. Arthritis?	1	0	d	r
b. Hip fracture?	1	0	d	r
c. Bed sores or leg ulcers?	1	0	d	r
d. Alzheimer’s disease or dementia?	1	0	d	r
e. A mental or psychiatric disorder other than Alzheimer’s disease or dementia?	1	0	d	r
f. Diabetes or sugar diabetes?	1	0	d	r
g. Strokes?	1	0	d	r
h. Parkinson’s disease?	1	0	d	r
i. Impaired vision?	1	0	d	r
j. Special vision problems, such as Glaucoma, cataracts, or problems with (your/his/her) retina?	1	0	d	r
k. Hearing problems?	1	0	d	r
l. Angina or coronary heart disease?	1	0	d	r
m. Heart attacks or myocardial infarctions?	1	0	d	r
n. Emphysema, chronic bronchitis or chronic obstructive pulmonary disease (COPD)?	1	0	d	r
o. Cancer or malignancy (besides skin cancers that only grow on the skin)?	1	0	d	r
p. Kidney disease or failure?	1	0	d	r

4. (Have you/Has SAMPLE MEMBER) fallen in the past six months?

YES 1

NO 0 SKIP TO B5

DON’T KNOW d SKIP TO B5

REFUSED r SKIP TO B5

4a. (Have you/Has SAMPLE MEMBER) been injured in any of these falls?

PROBE: A fall is where you unintentionally end up on the floor, the ground or some other lower level. We’re not including incidents where you end up resting against a piece of furniture, a wall or some other structure.

YES 1

NO 0 SKIP TO B5

DON’T KNOW d SKIP TO B5

REFUSED r SKIP TO B5

5. INTERVIEWER: IS THIS INTERVIEW BEING CONDUCTED WITH A PROXY?

YES 1

NO 0 SKIP TO B13

6. Sometimes a person’s conditions and their medications can make them act a little different. Can you tell me how often (SAMPLE MEMBER) . . .

Wanders or strays or becomes lost in the community due to impaired judgment? Would you say never, less than once a week, or at least once a week?

PROBE: For example—a confused person leaves home unattended and is not able to find his or her way back.

NEVER 1

LESS THAN ONCE A WEEK 2

AT LEAST ONCE A WEEK 3

DON’T KNOW d

REFUSED r

7. READ IF NECESSARY: Can you tell me how often (SAMPLE MEMBER) . . .

Is verbally disruptive, that is yells, threatens, uses excessive profanity, or sexual references? Would you say never, less than once a week, or at least once a week?

NEVER 1

LESS THAN ONCE A WEEK 2

AT LEAST ONCE A WEEK 3

DON’T KNOW d

REFUSED r

8. READ IF NECESSARY: Can you tell me how often (SAMPLE MEMBER) . . .

Is physically aggressive or combative to self or others, for example, hits self, throws things, punches, or makes dangerous maneuvers with wheelchair or other objects? Would you say never, less than once a week, or at least once a week?

NEVER 1

LESS THAN ONCE A WEEK 2

AT LEAST ONCE A WEEK 3

DON’T KNOW d

REFUSED r

9. READ IF NECESSARY: Can you tell me how often (SAMPLE MEMBER) . . .

Has hallucinations, delirium, confusion, delusional, or paranoid behavior? Would you say never, less than once a week, or at least once a week?

NEVER 1

LESS THAN ONCE A WEEK 2

AT LEAST ONCE A WEEK 3

DON’T KNOW d

REFUSED r

10.-12. NO QUESTIONS THIS VERSION

13. (Have you/Has SAMPLE MEMBER) lost at least ten pounds over the past six months?

YES 1

NO 0 SKIP TO B15

DON’T KNOW d SKIP TO B15

REFUSED r SKIP TO B15

14. (Were you/Was SAMPLE MEMBER) trying to lose that weight?

YES 1

NO 0

DON’T KNOW d

REFUSED r

15. Now, let’s talk about pain. In the past week, how often has pain gotten in the way of (your/SAMPLE MEMBER’s) normal routine? Would (you/he/she) say all or most of the time, some of the time, only occasionally, or never?

PROBE: IF RESPONDENT STATES LEVEL OF PAIN HAS CHANGED IN PAST WEEK, READ: If the level of pain changed, please base your answer on the level of pain at the end of that week.

ALL OR MOST OF THE TIME 1

SOME OF THE TIME 2

ONLY OCCASIONALLY 3

NEVER 4

DON’T KNOW d

REFUSED r

15a. During the past week, how much bodily pain (have you/has SAMPLE MEMBER) had? Would you say no pain, very mild pain, mild pain, moderate pain, or severe pain?

PROBE: IF RESPONDENT STATES LEVEL OF PAIN HAS CHANGED IN PAST WEEK, READ: If the level of pain changed, please base your answer on the level of pain at the end of that week.

NO PAIN 1

VERY MILD PAIN 2

MILD PAIN 3

MODERATE PAIN 4

SEVERE PAIN 5

DON’T KNOW d

REFUSED r

16. Now, I have some questions about how (you’ve/SAMPLE MEMBER’s) been feeling. During the past month, (have you/has SAMPLE MEMBER) often felt down, depressed or hopeless?

YES 1

NO 0

DON’T KNOW d

REFUSED r

SAMPLE MEMBER CAN’T CONVEY 2

17. During the past month, (have you/has SAMPLE MEMBER) often experienced little interest or pleasure in doing things you usually enjoy?

YES 1

NO 0

DON’T KNOW d

REFUSED r

SAMPLE MEMBER CAN’T CONVEY 2

18. During the past month, (have you/has SAMPLE MEMBER) often worried at lot?

YES 1

NO 0

DON’T KNOW d

REFUSED r

SAMPLE MEMBER CAN’T CONVEY 2

19. During the past month, (have you/has SAMPLE MEMBER) often felt keyed up or on edge?

YES 1

NO 0

DON’T KNOW d

REFUSED r

SAMPLE MEMBER CAN’T CONVEY 2

20. Since September (FILL YEAR), (have you/has SAMPLE MEMBER) had the influenza vaccine or a flu shot?

YES 1 SKIP TO B22

NO 0

DON’T KNOW d SKIP TO B22

REFUSED r SKIP TO B22

21. Were you offered the influenza vaccine or flu shot, but refused it?

YES 1

NO 0

DON’T KNOW d

REFUSED r

22. (Have you/Has SAMPLE MEMBER) ever had a shot to prevent pneumonia?

YES 1

NO 0

DON’T KNOW d

REFUSED r

23. (Do you/Does SAMPLE MEMBER) have (your/his/her) hearing tested regularly?

PROBE: By regularly, we mean at least once every year.

YES 1

NO 0

NON-HEARING 2

DON’T KNOW d

REFUSED r

24. (Do you/Does SAMPLE MEMBER) have (your/his/her) eyesight tested regularly?

PROBE: By regularly, we mean at least once every year.

YES 1

NO 0

NON-SIGHTED 2

DON’T KNOW d

REFUSED r

SECTION C – DAILY ACTIVITIES AND CAREGIVERS

0. INTERVIEWER: DOES THE RESPONDENT SEEM FATIGUED, CONFUSED, OR IN NEED OF REINFORCEMENT?

YES 1 USE PROBES BELOW

NO 0 SKIP TO CA1

FATIGUE PROBES: 1. Are you feeling tired or can we continue?

2. Would you like to take a break? I can hold on.

3. Would you like to continue the interview at another time?

REINFORCEMENT PROBES: 1. You’re doing very well.

2. Your answers are very helpful.

3. You’re doing a great job.

0a. INTERVIEWER: DID YOU USE ANY FATIGUE OR REINFORCEMENT PROBES?

NO FATIGUE OR REINFORCEMENT PROBES GIVEN 1

FATIGUED AND WANTS TO BE CALLED BACK 2 SKIP TO CALLBACK

FATIGUED AND WANTS TO CONTINUE 3

FATIGUED AND WANTS PROXY TO CONTINUE 4

USED REINFORCEMENT PROBE, CONTINUE 5

ACTIVITIES OF DAILY LIVING

A. Eating

1. Next, I’m going to ask how (you are/SAMPLE MEMBER is) currently managing (your/his/her) personal care and whether (you carry/he/she carries) out (your/his/her) personal care by (yourself/himself/herself) or with someone’s help. During the past week, that is since last (FILL DATE), did any person help (you/SAMPLE MEMBER) eat?

YES 1 SKIP TO CA4

NO 0

DID NOT EAT AT ALL 2 SKIP TO CA7

DON’T KNOW d

REFUSED r

1a. Did someone usually stay nearby just in case (you/SAMPLE MEMBER) might need help?

YES 1

NO 0

DON’T KNOW d

REFUSED r

2. Did (you/SAMPLE MEMBER) use special utensils or special dishes to help (you/him/her) eat?

YES 1

NO 0

DON’T KNOW d

REFUSED r

3.

PROGRAMMER BOX CA3

CATI CHECK. IF CA2 = NO, d, or r, skip TO CA14, ELSE skip TO PROGRAMMER BOX CA8.

4. Did (you/SAMPLE MEMBER) also use special utensils or special dishes to help (you/him/her) eat?

YES 1 SKIP TO CA8

NO 0 SKIP TO CA8

DON’T KNOW d SKIP TO CA8

REFUSED r SKIP TO CA8

7. About how long (have you/has SAMPLE MEMBER) not been able to eat?

| | | number (NUMBER RANGE)

days 1 SKIP TO CB1

weeks 2 SKIP TO CB1

months 3 SKIP TO CB1

YEARS 4 SKIP TO CB1

entire life 99 SKIP TO CB1

DON’T KNOW d

REFUSED r

7a. Would you say it has been . . .

Less than 3 months, 1 SKIP TO CB1

3 to 6 months, 2 SKIP TO CB1

6 months to 1 year, 3 SKIP TO CB1

1 to 5 years, 4 SKIP TO CB1

5 years or more? 5 SKIP TO CB1

DON’T KNOW d SKIP TO CB1

REFUSED r SKIP TO CB1

PROGRAMMER BOX CA8

CATI CHECK. IF CA1 = YES, ASK CA8, ELSE SKIP TO CA14.

8. You said (you have had/SAMPLE MEMBER has had) help with eating. Was the person who helped you with this from the PACE program?

YES 1

NO, 0

DON’T KNOW d

9.-13. NO QUESTIONS THIS VERSION

SKIP TO CA15

14. (Do you/Does SAMPLE MEMBER) need help with eating?

YES 1

NO 0 SKIP TO CB1

DON’T KNOW d SKIP TO CB1

REFUSED r SKIP TO CB1

14a. (Have you/Has SAMPLE MEMBER) tried to get help with eating?

YES 1

NO 0 SKIP TO CB1

DON’T KNOW d SKIP TO CB1

REFUSED r SKIP TO CB1

15. Did (you/he/she) need more help with eating than (you/SAMPLE MEMBER) received?

YES 1

NO 0

DON’T KNOW d

REFUSED r

B. Getting Around Indoors

1. During the past week, that is since last (FILL DATE) did (you/SAMPLE) usually get around indoors by (yourself/himself/herself), did someone help (you/him/her), or did (you/he/she) not get around indoors at all?

BY SELF 1

WITH HELP 2 SKIP TO CB4

DID NOT GET AROUND INDOORS AT ALL 3 SKIP TO CB7

DON’T KNOW d

REFUSED r

1a. Did someone usually stay nearby just in case (you/SAMPLE MEMBER) might need help?

YES 1

NO 0

DON’T KNOW d

REFUSED r

2. Did (you/SAMPLE MEMBER) use special equipment like a wheelchair, cane or other device to help (you/SAMPLE MEMBER) get around indoors?

YES 1

NO 0

DON’T KNOW d

REFUSED r

3.

PROGRAMMER BOX CB3

CATI CHECK. IF CB2 = NO, d, or r, SKIP TO CB14, ELSE SKIP TO PROGRAMMER BOX CB8.

4. Did (you/SAMPLE MEMBER) also use special equipment like a wheelchair, cane or other device to help (you/SAMPLE MEMBER) get around indoors?

YES 1 SKIP TO CB8

NO 0 SKIP TO CB8

DON’T KNOW d SKIP TO CB8

REFUSED r SKIP TO CB8

7. About how long (have you/has SAMPLE MEMBER) been unable to get around indoors?

| | | number

days 1 SKIP TO CC1

weeks 2 SKIP TO CC1

months 3 SKIP TO CC1

YEARS 4 SKIP TO CC1

entire life 99 SKIP TO CC1

DON’T KNOW d

REFUSED r

7a. Would you say it has been . . .

Less than 3 months, 1 SKIP TO CC1

3 to 6 months, 2 SKIP TO CC1

6 months to 1 year, 3 SKIP TO CC1

1 to 5 years, 4 SKIP TO CC1

5 years or more? 5 SKIP TO CC1

DON’T KNOW d SKIP TO CC1

REFUSED r SKIP TO CC1

PROGRAMMER BOX CB8

CATI CHECK. IF CB1 = WITH HELP, ASK CB8, ELSE SKIP TO CB14.

8. You said (you have had/SAMPLE MEMBER has had) help with getting around indoors. Was the person who helped you with this from the PACE program?

YES 1

NO, 0

DON’T KNOW d

REFUSED r

9-13. NO QUESTIONS THIS VERSION

SKIP TO CB15

14. (Do you/Does SAMPLE MEMBER) need help getting around indoors?

YES 1

NO 0 SKIP TO CC1

DON’T KNOW d SKIP TO CC1

REFUSED r SKIP TO CC1

14a. (Have you/Has SAMPLE MEMBER) tried to get help with getting around indoors?

YES 1

NO 0 SKIP TO CC1

DON’T KNOW d SKIP TO CC1

REFUSED r SKIP TO CC1

15. Did (you/PERSON) need more help with getting around indoors than (you/he/she) received?

YES 1

NO 0

DON’T KNOW d

REFUSED r

C. Dressing

1. The next questions are about dressing, that is, getting and putting on the clothes that (you wear/SAMPLE MEMBER wears) during the day. During the past week, that is since last (FILL DATE) did (you/SAMPLE MEMBER) usually get dressed by (yourself/himself/herself), did someone help (you/him/her), or did (you/he/she) not get dressed at all?

BY SELF 1

WITH HELP 2 SKIP TO CC4

DID NOT GET DRESSED AT ALL 3 SKIP TO CC7

DON’T KNOW d

REFUSED r

1a. Did someone usually stay nearby just in case (you/SAMPLE MEMBER) might need help?

YES 1

NO 0

DON’T KNOW d

REFUSED r

2. Did (you/SAMPLE MEMBER) wear special clothing or use special equipment to get dressed?

YES 1

NO 0

DON’T KNOW d

REFUSED r

3.

PROGRAMMER BOX cc4

CATI CHECK. IF Cc2 = NO, d, or r, SKIP TO Cc14, ELSE SKIP TO PROGRAMMER BOX CC8.

4. Did (you/SAMPLE MEMBER) also use special equipment to help (you/SAMPLE MEMBER) dress or wear special clothing?

YES 1 SKIP TO CC8

NO 0 SKIP TO CC8

DON’T KNOW d SKIP TO CC8

REFUSED r SKIP TO CC8

7. About how long (have you/has SAMPLE MEMBER) been unable to get dressed at all?

| | | number (NUMBER RANGE)

days 1 SKIP TO CD1

weeks 2 SKIP TO CD1

months 3 SKIP TO CD1

YEARS 4 SKIP TO CD1

entire life 99 SKIP TO CD1

DON’T KNOW d

REFUSED r

7a. Would you say it has been . . .

Less than 3 months, 1 SKIP TO CD1

3 to 6 months, 2 SKIP TO CD1

6 months to 1 year, 3 SKIP TO CD1

1 to 5 years, 4 SKIP TO CD1

5 years or more? 5 SKIP TO CD1

DON’T KNOW d SKIP TO CD1

REFUSED r SKIP TO CD1

PROGRAMMER BOX CC8

CATI CHECK. IF Cc1 = with help, ask cc8, ELSE SKIP TO Cc14.

8. You said (you have had/SAMPLE MEMBER has had) help with getting dressed. Was the person who helped you with this from the PACE program?

YES 1

NO, 0

DON’T KNOW d

REFUSED r

9.-13. NO QUESTIONS THIS VERSION

SKIP TO CC15

14. (Do you/Does SAMPLE MEMBER) need help with getting dressed?

YES 1

NO 0 SKIP TO CD1

DON’T KNOW d SKIP TO CD1

REFUSED r SKIP TO CD1

14a. (Have you/Has SAMPLE MEMBER) tried to get help with getting dressed?

YES 1

NO 0 SKIP TO CD1

DON’T KNOW d SKIP TO CD1

REFUSED r SKIP TO CD1

15. Did (you/SAMPLE MEMBER) need more help with getting dressed than (you/he/she) received?

YES 1

NO 0

DON’T KNOW d

REFUSED r

D. Bathing

1. During the past week, that is since last (FILL DATE), did (you/SAMPLE MEMBER) usually bathe (yourself/himself/herself), did someone help (you/him/her), or were (you/he/she) unable to bathe at all?

BY SELF 1

WITH HELP 2 SKIP TO CD4

BED BATH/UNABLE TO BATHE 3 SKIP TO CD7

DON’T KNOW d

REFUSED r

1a. Did someone usually stay nearby just in case (you/SAMPLE MEMBER) might need help?

YES 1

NO 0

DON’T KNOW d

REFUSED r

2. Did (you/SAMPLE MEMBER) use special equipment like a shower seat, tub stool or grab bar to help (you/SAMPLE MEMBER) bathe?

YES 1

NO 0

DON’T KNOW d

REFUSED r

3.

PROGRAMMER BOX d4

CATI CHECK. IF CD2 = NO, d, or r, SKIP TO CD14, ELSE SKIP TO PROGRAMMER BOX CD8.

4. Did (you/SAMPLE MEMBER) also use special equipment like a shower seat, tub stool, or grab bars to help (you/SAMPLE MEMBER) bathe?

YES 1 SKIP TO CD8

NO 0 SKIP TO CD8

DON’T KNOW d SKIP TO CD8

REFUSED r SKIP TO CD8

7. About how long (have you/has SAMPLE MEMBER) been unable to bathe?

| | | number (NUMBER RANGE)

days 1 SKIP TO CE1

weeks 2 SKIP TO CE1

months 3 SKIP TO CE1

YEARS 4 SKIP TO CE1

entire life 99 SKIP TO CE1

DON’T KNOW d

REFUSED r

7a. Would you say it has been . . .

Less than 3 months, 1 SKIP TO CE1

3 to 6 months, 2 SKIP TO CE1

6 months to 1 year, 3 SKIP TO CE1

1 to 5 years, 4 SKIP TO CE1

5 years or more? 5 SKIP TO CE1

DON’T KNOW d SKIP TO CE1

REFUSED r SKIP TO CE1

PROGRAMMER BOX CD8

CATI CHECK: IF CD1=WITHHELP, ASK CD8, ELSE SKIP TO CD14.

8. You said (you have had/SAMPLE MEMBER has had) help with bathing. Was the person who helped you with this from the PACE program?

YES 1

NO, 0

DON’T KNOW d

REFUSED r

9.-13. NO QUESTIONS THIS VERSION

SKIP TO CD16

14. (Do you/Does SAMPLE MEMBER) need help with getting bathed?

YES 1

NO 0 SKIP TO CE1

DON’T KNOW d SKIP TO CE1

REFUSED r SKIP TO CE1

15. (Have you/Has SAMPLE MEMBER) tried to get help with getting bathed?

YES 1

NO 0 SKIP TO CE1

DON’T KNOW d SKIP TO CE1

REFUSED r SKIP TO CE1

16. Did (you/SAMPLE MEMBER) need more help with getting bathed that (you/he/she) received?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E. Using the Toilet

1. During the past week, that is since last (FILL DATE), did (you/SAMPLE MEMBER) usually get to the bathroom or use the toilet by (yourself/himself/herself), have someone help (you/him/her), or did (you/he/she) not use the toilet at all?

BY SELF 1

WITH HELP 2 SKIP TO CE4

DID NOT USE THE TOILET AT ALL 3 SKIP TO CE8

DON’T KNOW d

REFUSED r

1a. Did someone usually stay nearby just in case (you/SAMPLE MEMBER) might need help to use the toilet?

YES 1

NO 0

DON’T KNOW d

REFUSED r

2. Did (you/SAMPLE MEMBER) use special equipment like a raised toilet, bedside commode, or grab bar to help (you/SAMPLE MEMBER) use the toilet?

YES 1

NO 0

DON’T KNOW d

REFUSED r

2a. Did (you/SAMPLE MEMBER) take care of (your/his/her) toilet needs by using any other special equipment like a bedpan or special underwear?

YES 1

NO 0

DON’T KNOW d

REFUSED r

3.

PROGRAMMER BOX CE4

CATI CHECK. IF CE2 and ce2A = NO, d, or r, SKIP TO Ce9

IF CE2 OR CE2a = YES, SKIP TO CE9

4. Did (you/SAMPLE MEMBER) also use special equipment like a raised toilet, bedside commode, or grab bar to help (you/SAMPLE MEMBER) use the toilet?

YES 1

NO 0

DON’T KNOW d

REFUSED r

5. Did (you/SAMPLE MEMBER) take care of (you/his/her) toilet needs by using any other special equipment like a bedpan or special underwear?

YES 1 SKIP TO CE9

NO 0 SKIP TO CE9

DON’T KNOW d SKIP TO CE9

REFUSED r SKIP TO CE9

8. About how long (have you/has SAMPLE MEMBER) been unable to use the toilet?

| | | number (NUMBER RANGE)

days 1 SKIP TO CE9

weeks 2 SKIP TO CE9

months 3 SKIP TO CE9

YEARS 4 SKIP TO CE9

entire life 99 SKIP TO CE9

DON’T KNOW d

REFUSED r

8a. Would you say it has been . . .

Less than 3 months, 1

3 to 6 months, 2

6 months to 1 year, 3

1 to 5 years, 4

5 years or more? 5

DON’T KNOW d

REFUSED r

9. Did (you/SAMPLE MEMBER) use a device such as a urinary catheter or colostomy bag?

YES 1

NO 0

DON’T KNOW d

REFUSED r

10. During the past week, that is since (FILL DATE), (have you/has SAMPLE MEMBER) sometimes had trouble controlling (your/his/her) bladder or bowels so that (you/he/she) accidentally wet or soiled (yourself/himself/herself) either day or night?

YES 1

NO 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX CE11

CATI CHECK. IF CE1 = WITH HELP, ask ce11, else skip to ce13.

11. You said (you have had/SAMPLE MEMBER has had) help with getting to the bathroom, or using the toilet, or help with special devices, or help dealing with bladder or bowel problems. Was the person who helped you with this from the PACE program?

YES 1

NO, 0

DON’T KNOW d

REFUSED r

SKIP TO CE15

13. (Do you/Does SAMPLE MEMBER) need help with toileting or using special devices, or help dealing with bladder or bowel problems?

YES 1

NO 0 SKIP TO CF1

DON’T KNOW d SKIP TO CF1

REFUSED r SKIP TO CF1

14. (Have you/Has SAMPLE MEMBER) tried to get help with using the toilet?

YES 1

NO 0 SKIP TO CF1

DON’T KNOW d SKIP TO CF1

REFUSED r SKIP TO CF1

15. Did (you/SAMPLE MEMBER) need more help with using the toilet than (you/he/she) received?

YES 1

NO 0

DON’T KNOW d

REFUSED r

F. Getting In or Out of Bed

1. During the past week, that is since (FILL DATE), did (you/SAMPLE MEMBER) usually get in or out of bed by (yourself/himself/herself), did someone help (you/him/her), or did (you/he/she) not get out of bed at all?

BY SELF 1

WITH HELP 2 SKIP TO CF4

DID NOT GET OUT OF BED AT ALL 3 SKIP TO CF7

DON’T KNOW d

REFUSED r

1a. Did someone usually stay nearby (you/SAMPLE MEMBER) just in case (you/he/she) might need help?

YES 1

NO 0

DON’T KNOW d

REFUSED r

2. Did (you/SAMPLE MEMBER) use special equipment like a wheelchair, railing, walker, cane, hospital bed, or mechanical lift to help (you/SAMPLE MEMBER) get in or out of bed?

YES 1

NO 0

DON’T KNOW d

REFUSED r

3.

PROGRAMMER BOX CF3

CATI CHECK. IF CF2 = no, d, or r, SKIP TO CF13, ELSE SKIP TO PROGRAMMER BOX CF8

4. Did (you/SAMPLE MEMBER) also use special equipment like a wheelchair, railing, walker, cane, hospital bed, or mechanical lift to help (you/SAMPLE MEMBER) get in or out of bed?

YES 1 SKIP TO CF8

NO 0 SKIP TO CF8

DON’T KNOW d SKIP TO CF8

REFUSED r SKIP TO CF8

7. About how long (have you/has SAMPLE MEMBER) been unable to get out of bed?

| | | number

DAYS 1 SKIP TO CG1

WEEKS 2 SKIP TO CG1

MONTHS 3 SKIP TO CG1

YEARS 4 SKIP TO CG1

ENTIRE LIFE 99 SKIP TO CG1

DON’T KNOW d

REFUSED r

7a. Would you say it has been . . .

Less than 3 months, 1 SKIP TO CG1

3 to 6 months, 2 SKIP TO CG1

6 months to 1 year, 3 SKIP TO CG1

1 to 5 years, or 4 SKIP TO CG1

5 years or more? 5 SKIP TO CG1

DON’T KNOW d SKIP TO CG1

REFUSED r SKIP TO CG1

PROGRAMMER BOX CF8

CATI CHECK: IF CF1 = WITH HELP, ASK CF8, ELSE SKIP TO CF13.

8. You said (you have had/SAMPLE MEMBER has had) help with getting in or out of bed. Was the person who helped you with this from the PACE program?

YES 1

NO, 0

DON’T KNOW d

REFUSED r

9.-12. NO QUESTIONS THIS VERSION

SKIP TO CF15

13. (Do you/Does SAMPLE MEMBER) need help getting in or out of bed?

YES 1

NO 0 SKIP TO D1

DON’T KNOW d SKIP TO D1

REFUSED r SKIP TO G1

14. (Have you/Has SAMPLE MEMBER) tried to get help getting in or out of bed?

YES 1

NO 0 SKIP TO D1

DON’T KNOW d SKIP TO D1

REFUSED r SKIP TO D1

15. Did (you/SAMPLE MEMBER) need more help getting out of bed that (you/he/she) received?

YES 1

NO 0

DON’T KNOW d

REFUSED r

SECTION D – attitudes and satisfaction

0. INTERVIEWER: DOES THE RESPONDENT SEEM FATIGUED, CONFUSED, OR IN NEED OF REINFORCEMENT?

YES 1 USE PROBES BELOW

NO 0 SKIP TO D1

FATIGUE PROBES: 1. Are you feeling tired or can we continue?

2. Would you like to take a break? I can hold on.

3. Would you like to continue the interview at another time?

REINFORCEMENT PROBES: 1. You’re doing very well.

2. Your answers are very helpful.

3. You’re doing a great job.

0a. INTERVIEWER: DID YOU USE ANY FATIGUE OR REINFORCEMENT PROBES?

NO FATIGUE OR REINFORCEMENT PROBES GIVEN 1

FATIGUED AND WANTS TO BE CALLED BACK 2 SKIP TO CALLBACK

FATIGUED AND WANTS TO CONTINUE 3

FATIGUED AND WANTS PROXY TO CONTINUE 4

USED REINFORCEMENT PROBE, CONTINUE 5

1. CATI: IF PACE CAREGIVER IS PROXY, SKIP TO E0.; IF CA8=CB8=CC8=CD8=CE11=CF8=0, SKIP TO E0. ELSE ASK D1: Now, we’re interested in how (you feel/SAMPLE MEMBER feels) about the care (you have/SAMPLE MEMBER has) received over the past two weeks from your PACE caregivers.

How satisfied have you been with the concern of these PACE caregivers for (you/SAMPLE MEMBER) as a person rather than just someone who needs to be taken care of. Are you very satisfied, satisfied, unsatisfied, or very unsatisfied?

PROBE: By caregivers, we mean the people at PACE that have helped (you/him/her) with personal care over the past two weeks. By personal care needs we mean things like eating, bathing, and dressing.

VERY SATISFIED 1

SATISFIED 2

UNSATISFIED 3

VERY UNSATISFIED 4

DON’T KNOW d

REFUSED r

2. How would you rate the reassurance and emotional support offered to (you/him/her) by (your/his/her) PACE caregivers. Would you say it was poor, fair, good, or very good?

PROBE: By caregivers, we mean the people at PACE that have helped (you/him/her) with personal care over the past two weeks. By personal care needs we mean things like eating, bathing, and dressing.

POOR 1

FAIR 2

GOOD 3

VERY GOOD 4

DON’T KNOW d

REFUSED r

3. Do (your/his/her) PACE caregivers pay attention to what (you have/SAMPLE MEMBER has) to say? Would you say all of the time, most of the time, some of the time, or none of the time?

PROBE: By caregivers, we mean the people at PACE that have helped (you/him/her) with personal care over the past two weeks. By personal care needs we mean things like eating, bathing, and dressing.

ALL OF THE TIME 1

MOST OF THE TIME 2

SOME OF THE TIME 3

NONE OF THE TIME 4

SAMPLE MEMBER NOT ABLE TO SPEAK n

DON’T KNOW d

REFUSED r

4. Now, please think about the help that (you/he/she) received from (your/his/her) PACE caregivers over the past two weeks. How often were (your/his/her) personal care needs taken care of as well as they should have been? Would you say always, usually, sometimes, or never?

PROBE: By caregivers, we mean the people at PACE that have helped (you/him/her) with personal care over the past two weeks. By personal care needs we mean things like eating, bathing, and dressing.

ALWAYS 1

USUALLY 2

SOMETIMES 3

NEVER 4

DON’T KNOW d

REFUSED r

5. How often did the PACE caregivers complete all the work they were supposed to? Would (you/he/she) say all of the time, most of the time, some of the time, or none of the time?

PROBE: By caregivers, we mean the people at PACE that have helped (you/him/her) with personal care over the past two weeks. By personal care needs we mean things like eating, bathing, and dressing.

ALL OF THE TIME 1

MOST OF THE TIME 2

SOME OF THE TIME 3

NONE OF THE TIME 4

DON’T KNOW d

REFUSED r

6. How often did (your/his/her) the PACE caregivers rush through their work? Would you say all of the time, most of the time, some of the time, or none of the time?

PROBE: By caregivers, we mean the people at PACE that have helped (you/him/her) with personal care over the past two weeks. By personal care needs we mean things like eating, bathing, and dressing.

ALL OF THE TIME 1

MOST OF THE TIME 2

SOME OF THE TIME 3

NONE OF THE TIME 4

DON’T KNOW d

REFUSED r

SECTION E – overall quality of life and demographics

INTERVIEWER: DOES THE RESPONDENT SEEM FATIGUED, CONFUSED, OR IN NEED OF REINFORCEMENT?

YES 1 USE PROBES BELOW

NO 0 SKIP TO E1

FATIGUE PROBES: 1. Are you feeling tired or can we continue?

2. Would you like to take a break? I can hold on.

3. Would you like to continue the interview at another time?

REINFORCEMENT PROBES: 1. You’re doing very well.

2. Your answers are very helpful.

3. You’re doing a great job.

0a. INTERVIEWER: DID YOU USE ANY FATIGUE OR REINFORCEMENT PROBES?

NO FATIGUE OR REINFORCEMENT PROBES GIVEN 1

FATIGUED AND WANTS TO BE CALLED BACK 2 SKIP TO CALLBACK

FATIGUED AND WANTS TO CONTINUE 3

FATIGUED AND WANTS PROXY TO CONTINUE 4

USED REINFORCEMENT PROBE, CONTINUE 5

1. Now, I’d like to ask you some questions to clarify (your/SAMPLE MEMBER’s) attitudes and feelings about (your/his/her) life. FOR PROXY: We’re interested in (SAMPLE MEMBER’s) attitudes and feelings, so please make your best estimate of how (SAMPLE MEMBER) feels.

In general, how satisfying is the way (you are/SAMPLE MEMBER is) spending (your/his/her) life these days? Would (you/SAMPLE MEMBER) call it—completely satisfying, pretty satisfying or not very satisfying?

COMPLETELY SATISFYING 1

PRETTY SATISFYING 2

NOT VERY SATISFYING 3

DON’T KNOW d

REFUSED r

SAMPLE MEMBER CAN’T CONVEY 4

2. Day to day, how much choice (do you/does SAMPLE MEMBER) have about what (you do/[he/she] does) and when (you do/[he/she] does) it? (Do you/Does [he/she]) have a great deal of choice, some choice, or not very much choice?

A GREAT DEAL OF CHOICE 1

SOME CHOICE 2

NOT VERY MUCH CHOICE 3

DON’T KNOW d

REFUSED r

PROGRAMMER BOX E3

CATI CHECK: IF I33 = 2 OR 3, SKIP TO E5.

3. The next question is about talking to family and friends who do not live with (you/SAMPLE MEMBER). During the past week, did someone regularly check on (you/him/her) by telephone or in person to make sure (you were/he was/she was) all right?

PROBE: Because this person was worried that (you/SAMPLE MEMBER) would become really sick and that no one would be able to help (you/him/her).

PROBE: Someone who does not live with (you/SAMPLE MEMBER) such as a family member, friend, social worker or home health aide.

YES 1

NO 0

NO, DOES NOT HAVE FAMILY OR FRIENDS 2

DON’T KNOW d

REFUSED r

4. How (do you/does SAMPLE MEMBER) feel about how often (you talk/[he/she] talks) to those family members and friends in person or over the phone? Would (you/he/she) say (you talk/[he/she] talks) to them as often as (you want/[he/she] wants), or (do you/does he/she) wish (you/he/she) could talk to them more?

AS OFTEN AS WANT 1

WISH COULD TALK TO THEM MORE 2

DON’T KNOW d

REFUSED r

SAMPLE MEMBER CAN’T PERFORM ACTIVITY 3

5. The next question is about regularly attending social, religious, or recreational programs at a place other than where (you live/SAMPLE MEMBER lives).

Would (you/he/she) say (you get/he gets/she gets) to attend such programs as often as (you want/[he/she] wants), or (do you/does [he/she]) wish (you/he/she) could attend more often?

AS OFTEN AS WANT 1

WISH COULD ATTEND MORE OFTEN 2

DON’T KNOW d

REFUSED r

DOES NOT GO OUTSIDE HOME 3

PROGRAMMER BOX E6

CATI CHECK: IF I33 = 2, SKIP TO E7.

6. Now, let’s change the topic. What is (your/SAMPLE MEMBER’s) present marital status? (Are you/Is he or she) . . .

Married, 1

Living with a partner, 2

Divorced, 3 SKIP TO E8

Separated, 4 SKIP TO E8

Widowed, or 5 SKIP TO E8

Never married? 6 SKIP TO E8

DON’T KNOW d SKIP TO E8

REFUSED r SKIP TO E8

7. Compared to others of the same age, how would (you/SAMPLE MEMBER) describe the overall health of (your/his/her) spouse/partner? Would (you/he/she) say it is . . .

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

DON’T KNOW d

REFUSED r

8. Now, let’s change the subject to the topic of patient preferences.

(Do you/Does SAMPLE MEMBER) have a signed Durable Power of Attorney for Health Care or a signed Living Will?

PROBE: A Durable Power of Attorney for Health Care names someone to make decisions about medical treatment if (you/SAMPLE MEMBER) cannot speak for (yourself/himself/herself).

PROBE: A Living Will provides directions for the kind of medical treatment (you/SAMPLE MEMBER) would want if (you/he/she) could not speak for (yourself/himself/herself).

BOTH 1

DURABLE POWER OF ATTORNEY 2

LIVING WILL 3

NONE 0

DON’T KNOW d

REFUSED r

9. These are my final questions. What is the highest grade or level of school that (you/SAMPLE MEMBER) completed?

LESS THAN HIGH SCHOOL OR NO GED 1

HIGH SCHOOL OR GED 2

BUSINESS OR TRADE SCHOOL 3

SOME COLLEGE 4

ASSOCIATE/2-YEAR COLLEGE DEGREE 5

COMPLETED B.A. OR B.S. 6

POST GRADUATE EDUCATION 7

OTHER (SPECIFY) 8

(STRING (NUM))

HOME SCHOOLED 9

UNGRADED OR SPECIAL EDUCATION 10

NO SCHOOLING 11

DON’T KNOW d

REFUSED r

10. (Do you/Does SAMPLE MEMBER) consider (yourself/himself/herself) to be of Hispanic or Latino origin, such as Mexican, Puerto Rican, Cuban, or other Spanish background?

YES 1

NO 0

DON’T KNOW d

REFUSED r

11. I’m going to read you a list of five race categories. Please choose one or more races that (you consider/SAMPLE MEMBER considers) (yourself/himself/herself) to be?

INTERVIEWER: READ ALL CATEGORIES. CODE UNLISTED, RESPONDENT-OFFERED CATEGORIES IN “OTHER.”

IF RESPONDS “HISPANIC” OR “LATINO,” PROBE: Would that be White Hispanic/Latino, African American Hispanic/Latino, or something else?

White 1

African American or Black 2

American Indian or Alaska Native 3

Asian 4

Native Hawaiian or Other Pacific Islander 5

OTHER (SPECIFY) 6

(STRING (NUM))

HISPANIC - SPECIFIED 7

DON’T KNOW d

REFUSED r

CATI CHECK: IF I33 = 1 OR 2, ASK E12, ELSE SKIP TO E13

13. We would like to know (your/SAMPLE MEMBER’s) approximate income so that we can determine if people with lower income have more problems getting the care they need. Please think about the total income (you/SAMPLE MEMBER) [and (your/his/her) spouse] received from all sources in (2011/2012). Would you please tell me if (your/their) total income for (2011/2012) was . . .

Less than $5,000, 1

At least $5,000 but less than $10,000, 2

At least $10,000 but less than $15,000, 3

At least $15,000 but less than $20,000, 4

At least $20,000 but less than $30,000, 5

At least $30,000 but less than $40,000, 6

At least $40,000 but less than $50,000, or 7

More than $50,000? 8

DON’T KNOW d

REFUSED r

16. Thank you for your assistance in this important study. Your responses will help us better describe the health care provided to older Americans.

17. Finally, I’d like to confirm that I have the correct telephone number. The telephone number that I have is (PHONE). Is that correct?

YES 1

NO, MAKE NECESSARY CORRECTION TO ADDRESS 0

SECTION F – interviewer observations

INTERVIEWER: COMPLETE THIS SECTION IMMEDIATELY FOLLOWING INTERVIEW.

1. IN YOUR OPINION, HOW ACCURATE WERE THE RESPONDENT’S ANSWERS?

VERY ACCURATE 1

SOME DOUBT 2

UNRELIABLE 3

2. HOW OFTEN DID THE RESPONDENT HAVE TROUBLE UNDERSTANDING THE QUESTIONS?

NEVER 1 SKIP TO F4

OCCASIONALLY 2

FREQUENTLY 3

MOST OF THE TIME 4

3. WHY DID RESPONDENT HAVE TROUBLE?

LANGUAGE PROBLEM 1

FATIGUE 2

OTHER (SPECIFY) 3

(STRING (NUM))

TROUBLE HEARING 4

DIDN’T UNDERSTAND QUESTIONS 5

PHRASING, REPETITIVE, REREAD 6

4. TO WHAT EXTENT DID THE RESPONDENT SEEM TIRED OR SLEEPY?

NOT AT ALL SLEEPY 1

SOMEWHAT SLEEPY 2

VERY SLEEPY 3

5. WHAT WAS THE RESPONDENT’S GENERAL ATTITUDE TOWARD BEING INTERVIEWED?

PLEASED 1

NEUTRAL 2

HOSTILE AT LEAST SOME OF THE TIME 3