Form CMS-10433 Appendix C_CCTP 1st Admin Participant Exp Survey

OMB No.: 0938-1167
Expiration Date: 06-30-2013

COMMUNITY-BASED CARE TRANSITIONS
PROGRAM (CCTP) PATIENT EXPERIENCE
SURVEY
FIRST ADMINISTRATION (WITHIN 4 DAYS AFTER HOSPITAL DISCHARGE)

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

Medicare Beneficiary ID (Health
Insurance Claim Number or HICN):

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Beneficiary Date of Birth:

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Medicare Hospital ID (CMS
Certification Number or CCN):

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CCTP CBO ID:

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Date Interview Completed: | | | / | | | / |
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Prepared by Mathematica Policy Research

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SURVEY INTRODUCTION:
INTERVIEWER/COACH: YOU MAY INTRODUCE THE SURVEY BY READING THE BULLETS, OR USE YOUR OWN
WORDS TO COVER THE FOLLOWING POINTS.
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This survey is part of Medicare's community-based care transitions program (also known as CCTP).

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The survey is about your most recent hospital stay.

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The information from all surveys combined will be used to improve care transitions after people have a
hospital stay.

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There are no right or wrong answers and you should answer honestly.

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The survey is voluntary (it is your choice to take the survey).

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Whether or not you chose to take the survey will not affect your health care coverage.

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Your answers will not be shared with your doctors but only with people on the study team.

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You may skip any question that you don't want to answer.

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The survey should take about 10 minutes.

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Could we begin now?

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YES 

CONTINUE WITH THE INTERVIEW

NO 

Thanks very much for your time. End interview.

(IF YES):
Thank you. To begin, these questions are about what happened during your most recent hospital stay.

1.

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

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3.

Yes
No

GO TO Q.4

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

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?

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MARK ONE ONLY

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Never
Sometimes
Usually
Always

Never
4.

Sometimes
Usually
Always

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?

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5.

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1

No

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?

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Yes

Yes
No

The next set of questions is about how prepared you felt when you left the hospital. Your answer choices are
Disagree Strongly, Disagree, Agree, and Agree Strongly. 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.
MARK ONE PER ROW

DISAGREE
STRONGLY

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 disagree or agree? [THEN ASK: Do
you disagree/agree strongly or just
disagree/agree?] ............................................

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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 disagree or agree?
[THEN ASK: Do you disagree/ agree
strongly or just disagree/agree?] ...................

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8. When I left the hospital, I clearly understood
the purpose for taking each of my
medications. Would you say you disagree or
agree? [THEN ASK: Do you disagree/agree
strongly or just disagree/ agree?] ..................

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DISAGREE

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AGREE

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3

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AGREE
STRONGLY

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DON’T KNOW/
DON’T
REMEMBER/
NOT
APPLICABLE

d

d

d

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The last set of questions is about how comfortable you feel taking care of your health. 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 Disagree Strongly, Disagree, Agree, and Agree Strongly.

9.

When all is said and done, I am the person who is responsible for taking care
of my health..........................................................................................................
10. Taking an active role in my own health care is the most important thing that
affects my health ..................................................................................................
11. I am confident I can help prevent or reduce problems associated with my
health ...................................................................................................................
12. I know what each of my prescribed medications do.............................................
13. I am confident that I can tell whether I need to go to the doctor or whether I
can take care of a health problem myself ............................................................
14. I am confident I can tell a doctor concerns I have even when he or she does
not ask..................................................................................................................
15. I am confident that I can follow through on medical treatments I may need to
do at home ...........................................................................................................
16. I understand my health problems and what causes them ....................................
17. I know what treatments are available for my health problems .............................
18. I have been able to maintain (keep up with) lifestyle changes, like eating right
or exercising .........................................................................................................
19. I know how to prevent problems with my health ..................................................
20. I am confident I can figure out solutions when new problems arise with my
health ...................................................................................................................
21. I am confident that I can maintain lifestyle changes, like eating right and
exercising, even during times of stress ................................................................

DISAGREE
STRONGLY

MARK ONE PER ROW
DISAGREE

AGREE

AGREE
STRONGLY

NA

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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 patient alone, with the patient
assisted by another person, or with someone else answering for the patient?

□ PATIENT ALONE
GO TO C
2 □ PATIENT WITH ASSISTANCE
3 □ SOMEONE ELSE ANSWERING FOR PATIENT
1

GO TO B

C. How much of the questionnaire do you think this patient understood?
1 □ MOST OR ALL
2 □ SOME
3

E.

□ NONE

B. Who assisted the patient or answered for them?
1 □ SPOUSE
2 □ ANOTHER RELATIVE
3 □ FRIEND
GO TO D
4 □ PAID CAREGIVER
5 □ SOMEONE ELSE (Specify)
D. Did you complete the interview in person or over the
phone?
1 □ IN PERSON
2 □ OVER THE PHONE

Is there any other information you think we should know about this interview?
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