CMS-10475 Hospice Experience Survey - Inpatient Version

Attachment C

Hospice Experience Survey – Inpatient Version (67 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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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. 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

11. 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
12. 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
13. 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
14. 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
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15. While your family member was in hospice care, did you speak to a doctor as often as you
needed?
Yes, definitely
Yes, somewhat
No

16. 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
17. 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
18. 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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19. While your family member was in hospice care, how often did the hospice team respect your
needs and preferences?
Never
Sometimes
Usually
Always
20. 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
21. 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
22.

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

23. 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 26.

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24. 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
25. How often were problems with your family member’s hospice care resolved as soon as you
needed?
Never
Sometimes
Usually
Always
26. While your family member was in hospice care, did he or she have any pain?
Yes
No

If No, please go to Question 28.

27. Did your family member get as much help with pain as he or she needed?
Yes, definitely
Yes, somewhat
No
28. While your family member was in hospice care, did he or she receive any pain medicine?
Yes
No

If No, please go to Question 31.

29. Did you get the information you needed from the hospice team about your family member’s
pain medicine?
Yes, definitely
Yes, somewhat
No
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30. 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
31. 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 34.

32. How often did your family member get the help he or she needed for trouble breathing?
Never
Sometimes
Usually
Always
33. How often did you get the information you needed from the hospice team about your family
member’s trouble breathing?
Never
Sometimes
Usually
Always
34. 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 36.

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

If No, please go to Question 39.

38. 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
39. 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 41.

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40. How often did the hospice team treat your family member’s religious or spiritual beliefs with
respect?
Never
Sometimes
Usually
Always
41. 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 43.

42. Was the information provided in a way that was easy to understand?
Yes, definitely
Yes, somewhat
No
43. Did the hospice team get in the way of you spending time with your family member while he
or she was dying?
Yes, definitely
Yes, somewhat
No

THE HOSPICE ENVIRONMENT
44. While your family member was in hospice care, were his or her room and bathroom kept
clean?
Yes, definitely
Yes, somewhat
No

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45. While your family member was in hospice care, was his or her room a comfortable place for
you to be together?
Yes, definitely
Yes, somewhat
No
46. While your family member was in hospice care, was your family member’s room a calm and
soothing place for him or her?
Yes, definitely
Yes, somewhat
No

YOUR OWN EXPERIENCE WITH HOSPICE
47. While your family member was in hospice care, how often did the hospice team listen
carefully to you?
Never
Sometimes
Usually
Always
48. While your family member was in hospice care, how often did the hospice team spend
enough time with you?
Never
Sometimes
Usually
Always
49. 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 52.
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50. How often did the hospice team treat your religious or spiritual beliefs with respect?
Never
Sometimes
Usually
Always
51. 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
52. 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

53. 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.

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54. 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
55. Would you recommend this hospice to your friends and family?
Definitely no
Probably no
Probably yes
Definitely yes
56. 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.
____________________________________
____________________________________
____________________________________
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____________________________________
____________________________________
____________________________________
____________________________________

ABOUT YOUR FAMILY MEMBER
57. 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
58. Was your family member of Hispanic, Latino and/or Spanish origin or descent?
Yes
No

If No, please go to Question 60.

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

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60. 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
61. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
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75 to 84
85 or older
62. Are you male or female?
Male
Female
63. 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
64. Are you of Hispanic, Latino/a, or Spanish origin or descent?
Yes
No

If No, please go to Question 66.

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

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66. 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
67. What language do you mainly speak at home?
English
Spanish
Chinese
Some other language:
Please print: ________________________

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

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