CMS-10475 Hospice Experience Survey - Nursing Home Version

Attachment B

Hospice Experience Survey – Nursing Home Version (65 items)
Please answer the questions in this survey about the care this patient received from this hospice:

[NAME OF HOSPICE LABEL GOES HERE]

All of the questions in the survey will ask about experience with this hospice.

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 XXX-XXXX. 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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Hospice Experience of Care Survey – Nursing Home Version

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SURVEY INSTRUCTIONS
•

Please give this survey to the person in your household who knows the most about the
hospice care received by the person listed on the survey cover letter.

•
•

Answer all the questions by checking the box to the left of your answer.
You are sometimes told to skip over some questions in this survey. When this happens
you will see an arrow with a note that tells you what question to answer next, like this:
Yes

If Yes, go to Question 1.

No

THE HOSPICE PATIENT
1. How are you related to the person listed on the survey cover letter?
My spouse or partner
My parent
My mother-in-law or father-in-law
My grandparent
My aunt or uncle
My sister or brother
My child
My friend
Other:
Please print: __________________
2.

For this survey, the phrase “family member” refers to the person listed on the survey cover
letter. Did your family member receive care from the hospice listed on the survey cover
letter?
Yes
No

If No, please stop and return the survey in the envelope provided.

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3. What was the last location in which your family member received care from this hospice?
Home
Assisted living facility
Nursing home
Hospital
Hospice facility / hospice house
Other

YOUR ROLE
4. While your family member was in hospice care, how often did you take part in or oversee
care for him or her?
Never

If Never, please stop and return the survey in the envelope provided.

Sometimes
Usually
Always
5. Was your family member’s hospice care your first experience with hospice services for a
close friend or family member?
Yes
No

STARTING HOSPICE CARE
For this survey, the hospice team includes all the nurses, doctors, social workers, chaplains and
other people who provided hospice care to your family member. Please do not include hospice
volunteers.

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6. Did the hospice team explain the kinds of care and services they could give you and your
family member?
Yes, definitely
Yes, somewhat
No

7. Did your family member begin getting hospice care too early, at the right time, or too late?
Too early
At the right time
Too late

YOUR FAMILY MEMBER’S HOSPICE CARE
As you answer the rest of the questions in this survey, please think only about your family
member’s experience with this hospice in the last location in which he or she received hospice
care.
8. While your family member was in hospice care, did you need to contact the hospice team
during evenings, weekends, or holidays for questions or help with your family member’s
care?
Yes
No

If No, please go to Question 10.

9. How often did you get the help you needed from the hospice team during evenings,
weekends, or holidays?
Never
Sometimes
Usually
Always

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10. While your family member was in hospice care, how often did the nursing home staff and
hospice team work well together to care for your family member?
Never
Sometimes
Usually
Always
11. Personal care needs include bathing, dressing, eating meals and changing bedding. While
your family member was in hospice care, how often did your family member get as much
help with personal care as he or she needed?
Never
Sometimes
Usually
Always
12. While your family member was in hospice care, were your family member’s personal care
needs ever not taken care of because the nursing home staff expected the hospice team to
take care of those needs?
Yes
No
13. While your family member was in hospice care, when you or your family member asked for
help from the hospice team, how often did you get help as soon as you needed it?
Never
Sometimes
Usually
Always
14. While your family member was in hospice care, did the hospice team give you and your
family member enough privacy?
Yes, definitely
Yes, somewhat
No

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15. While your family member was in hospice care, how often did you have a hard time speaking
with or understanding members of the hospice team because you spoke different languages?
Never
Sometimes
Usually
Always
16. While your family member was in hospice care, did the hospice team seem informed and upto-date about your family member’s condition and care?
Yes, definitely
Yes, somewhat
No
17. While your family member was in hospice care, how often did the hospice team explain
things in a way that was easy to understand?
Never
Sometimes
Usually
Always
18. While your family member was in hospice care, how often did the hospice team keep you
informed about your family member’s condition?
Never
Sometimes
Usually
Always
19. While your family member was in hospice care, how often did anyone from the hospice team
give you confusing or contradictory information about your family member’s condition or
care?
Never
Sometimes
Usually
Always
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20. While your family member was in hospice care, how often was the information you were
given about your family member by the nursing home staff different from the information
you were given by the hospice team?
Never
Sometimes
Usually
Always
21. While your family member was in hospice care, how often did the hospice team respect your
needs and preferences?
Never
Sometimes
Usually
Always
22. While your family member was in hospice care, how often did the hospice team spend
enough time with your family member?
Never
Sometimes
Usually
Always
23. While your family member was in hospice care, how often did the hospice team treat your
family member with dignity and respect?
Never
Sometimes
Usually
Always

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24. While your family member was in hospice care, how often did you feel that the hospice team
really cared about your family member?
Never
Sometimes
Usually
Always
25. While your family member was in hospice care, did you talk with the hospice team about any
problems with your family member’s hospice care?
Yes
No

If No, please go to Question 28.

26. How often did the hospice team listen carefully to you when you talked about problems with
your family member’s hospice care?
Never
Sometimes
Usually
Always
27. How often were problems with your family member’s hospice care resolved as soon as you
needed?
Never
Sometimes
Usually
Always
28. While your family member was in hospice care, did he or she have any pain?
Yes
No

If No, please go to Question 30.

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29. Did your family member get as much help with pain as he or she needed?
Yes, definitely
Yes, somewhat
No

30. While your family member was in hospice care, did he or she receive any pain medicine?
Yes
No

If No, please go to Question 33.

31. Did you get the information you needed from the hospice team about your family member’s
pain medicine?
Yes, definitely
Yes, somewhat
No
32. Side effects of pain medicine include things like sleepiness. Did any member of the
hospice team discuss side effects of pain medicine with you or your family member?
Yes, definitely
Yes, somewhat
No
33. While your family member was in hospice care, did your family member ever have trouble
breathing or receive treatment for trouble breathing?
Yes
No

If No, please go to Question 36.

34. How often did your family member get the help he or she needed for trouble breathing?
Never
Sometimes
Usually
Always

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35. How often did you get the information you needed from the hospice team about your family
member’s trouble breathing?
Never
Sometimes
Usually
Always
36. While your family member was in hospice care, did your family member ever have trouble
with constipation?
Yes
No

If No, please go to Question 38.

37. How often did your family member get the help he or she needed for trouble with
constipation?
Never
Sometimes
Usually
Always
38. While your family member was in hospice care, did he or she show any feelings of anxiety
or sadness?
Yes
No
39. Did your family member need help with feelings of anxiety or sadness?
Yes
No

If No, please go to Question 41.

40. How often did your family member receive the help he or she needed from the hospice team
for feelings of anxiety or sadness?
Never
Sometimes
Usually
Always

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41. While your family member was in hospice care, did any member of the hospice team discuss
your family member’s religious or spiritual beliefs?
Yes
No

If No, please go to Question 43.

42. How often did the hospice team treat your family member’s religious or spiritual beliefs with
respect?
Never
Sometimes
Usually
Always
43. Did the hospice team give you as much information as you wanted about what to expect
while your family member was dying?
Yes, definitely
Yes, somewhat
No

If No, please go to Question 45.

44. Was the information provided in a way that was easy to understand?
Yes, definitely
Yes, somewhat
No

YOUR OWN EXPERIENCE WITH HOSPICE
45. While your family member was in hospice care, how often did the hospice team listen
carefully to you?
Never
Sometimes
Usually
Always

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46. While your family member was in hospice care, how often did the hospice team spend
enough time with you?
Never
Sometimes
Usually
Always
47. While your family member was in hospice care, were your religious or spiritual beliefs
discussed with any member of the hospice team?
Yes
No

If No, please go to Question 50.

48. How often did the hospice team treat your religious or spiritual beliefs with respect?
Never
Sometimes
Usually
Always
49. Support for religious or spiritual beliefs includes talking, praying, quiet time, or other ways
of meeting your religious or spiritual needs. While your family member was in hospice care,
how much support for your religious and spiritual beliefs did you get from the hospice team?
Too little
Right amount
Too much
50. While your family member was in hospice care, how much emotional support did you get
from the hospice team?
Too little
Right amount
Too much

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51. In the weeks after your family member died, how much emotional support did you get from
the hospice team?
Too little
Right amount
Too much

OVERALL RATING OF HOSPICE CARE
Please answer the following questions about your family member’s care from the hospice named
on the cover letter. Do not include care from other hospices in your answers.
52. Using any number from 0 to 10, where 0 is the worst hospice care possible and 10 is the best
hospice care possible, what number would you use to rate your family member’s hospice
care?
0

Worst hospice care possible

1
2
3
4
5
6
7
8
9
10 Best hospice care possible
53. Would you recommend this hospice to your friends and family?
Definitely no
Probably no
Probably yes
Definitely yes

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54. In thinking about your experiences with hospice, was there anything that went especially well
or that you wish had gone differently for you and your family member? Please tell us about
those experiences.
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________

ABOUT YOUR FAMILY MEMBER
55. What is the highest grade or level of school that your family member completed?
8th grade or less
Some high school but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
Don’t know
56. Was your family member of Hispanic, Latino/a, or Spanish origin or descent?
Yes
No

If No, please go to Question 58.

57. Which group best describes your family member?
Mexican, Mexican American, Chicano
Puerto Rican
Cuban
Another Hispanic, Latino/a, or Spanish Origin

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58. What was your family member’s race? Please mark one or more.
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

ABOUT YOU
59. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 84
85 or older
60. Are you male or female?
Male
Female

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61. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
Don’t know
62. Are you of Hispanic, Latino/a or Spanish origin or descent?
Yes
No

If No, please go to Question 64.

63. Which group best describes you?
Mexican, Mexican American, Chicano/a
Puerto Rican
Cuban
Another Hispanic, Latino/a, or Spanish Origin

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64. What is your race? Please mark one or more.
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

65. What language do you mainly speak at home?
English
Spanish
Chinese
Some other language:
Please print: ________________________

Thank you.
Please return the completed survey in the postage-paid envelope.

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