Form CMS-10483 Medical Home Survey

OMB No. ####-####

Medical Home
Survey
Sponsored by
The U.S. Department of Health and Human Services

CAHPS

®

Consumer Assessment
of Healthcare Providers and Systems

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
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control number for this information collection is 0938-XXXX. The time required to complete
this information collection is estimated to average 20 minutes per response, including the time
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21244-1850.

Your Care From This Provider in the
Last 12 Months

Survey Instructions
Answer each question by marking 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 Q1.
No

These questions ask about your own health
care. Do not include care you got when you
stayed overnight in a hospital. Do not include
the times you went for dental care visits.
4.

Your Provider
1.

In the last 12 months, how many times did
you visit this provider to get care for
yourself?
None → If None, go to Q44.
1 time
2
3
4
5 to 9
10 or more times

Our records show that you got care from
the clinic named below in the last 12
months. [Name of provider].
Is that right?
1
2

Yes
No → If No, go to Q44.

The questions in this survey will refer to the
provider you saw on your most recent visit to
this clinic as “this provider.” Please think of that
person as you answer the survey.

5.

In the last 12 months, did you phone this
provider’s office to get an appointment for
an illness, injury or condition that needed
care right away?
1

2.

Is this the provider you usually see if you
need a check-up, want advice about a health
problem, or get sick or hurt?
1
2

3.

2

6.

Yes
No

How long have you been going to this
provider?
1
2
3
4
5

In the last 12 months, when you phoned this
provider’s office to get an appointment for
care you needed right away, how often
did you get an appointment as soon as you
needed?
1
2

Less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 3 years
At least 3 years but less than 5 years
5 years or more

3
4

1

Yes
No → If No, go to Q8.

Never
Sometimes
Usually
Always

7.

In the last 12 months, how many days did
you usually have to wait for an appointment
when you needed care right away?

12. In the last 12 months, how often were you
able to get the care you needed from this
provider’s office during evenings,
weekends, or holidays?

Same day
1 day
2 to 3 days
4 to 7 days
More than 7 days
8.

2
3
4

2

1

Yes
No → If No, go to Q10.

2

2
3
4

1

Never
Sometimes
Usually
Always

2
3
4

2

1
2

Yes
No

2

Yes
No → If No, go to Q17.

16. In the last 12 months, when you phoned this
provider’s office after regular office hours,
how often did you get an answer to your
medical question as soon as you needed?

11. In the last 12 months, did you need care for
yourself during evenings, weekends, or
holidays?
1

Never
Sometimes
Usually
Always

15. In the last 12 months, did you phone this
provider’s office with a medical question
after regular office hours?

10. Did this provider’s office give you
information about what to do if you needed
care during evenings, weekends, or
holidays?
1

Yes
No → If No, go to Q15.

14. In the last 12 months, when you phoned this
provider’s office during regular office
hours, how often did you get an answer to
your medical question that same day?

In the last 12 months, when you made an
appointment for a check-up or routine
care with this provider, how often did you
get an appointment as soon as you needed?
1

Never
Sometimes
Usually
Always

13. In the last 12 months, did you phone this
provider’s office with a medical question
during regular office hours?

In the last 12 months, did you make any
appointments for a check-up or routine
care with this provider?
1

9.

1

1

Yes
No → If No, go to Q13.

2
3
4

2

Never
Sometimes
Usually
Always

17. Some offices remind patients between visits
about tests, treatment or appointments. In
the last 12 months, did you get any
reminders from this provider’s office
between visits?
1
2

21. In the last 12 months, did you talk with this
provider about any health questions or
concerns?
1
2

Yes
No

22. In the last 12 months, how often did this
provider give you easy to understand
information about these health questions or
concerns?

18. Wait time includes time spent in the waiting
room and exam room. In the last 12
months, how often did you see this provider
within 15 minutes of your appointment
time?

1
2
3

1
2
3
4

Never
Sometimes
Usually
Always

4

1
2
3

2
3
4

Never
Sometimes
Usually
Always

4

2
3
4

Never
Sometimes
Usually
Always

24. In the last 12 months, how often did this
provider show respect for what you had to
say?

20. In the last 12 months, how often did this
provider listen carefully to you?
1

Never
Sometimes
Usually
Always

23. In the last 12 months, how often did this
provider seem to know the important
information about your medical history?

19. In the last 12 months, how often did this
provider explain things in a way that was
easy to understand?
1

Yes
No → If No, go to Q23.

1
2

Never
Sometimes
Usually
Always

3
4

3

Never
Sometimes
Usually
Always

30. When you talked about starting or stopping
a prescription medicine, how much did this
provider talk about the reasons you might
not want to take a medicine?

25. In the last 12 months, how often did this
provider spend enough time with you?
1
2
3
4

Never
Sometimes
Usually
Always

1
2
3
4

26. In the last 12 months, did this provider
order a blood test, x-ray, or other test for
you?
1
2

31. When you talked about starting or stopping
a prescription medicine, did this provider
ask you what you thought was best for you?

Yes
No → If No, go to Q28.

1
2

27. In the last 12 months, when this provider
ordered a blood test, x-ray, or other test for
you, how often did someone from this
provider’s office follow up to give you
those results?
1
2
3
4

2

Never
Sometimes
Usually
Always

0 Worst provider possible
1
2
3
4
5
6
7
8
9
10 Best provider possible

Yes
No → If No, go to Q32.

29. When you talked about starting or stopping
a prescription medicine, how much did this
provider talk about the reasons you might
want to take a medicine?
1
2
3
4

Yes
No

32. Using any number from 0 to 10, where 0 is
the worst provider possible and 10 is the
best provider possible, what number would
you use to rate this provider?

28. In the last 12 months, did you and this
provider talk about starting or stopping a
prescription medicine?
1

Not at all
A little
Some
A lot

33. Specialists are doctors like surgeons, heart
doctors, allergy doctors, skin doctors, and
other doctors who specialize in one area of
health care. In the last 12 months, did you
see a specialist for a particular health
problem?

Not at all
A little
Some
A lot

1
2

4

Yes
No → If No, go to Q35.

38. In the last 12 months, did you and anyone
in this provider’s office talk at each visit
about all the prescription medicines you
were taking?

34. In the last 12 months, how often did the
provider named in Question 1 seem
informed and up-to-date about the care you
got from specialists?
1
2
3
4

1

Never
Sometimes
Usually
Always

2

39. In the last 12 months, did anyone in this
provider’s office ask you if there was a
period of time when you felt sad, empty, or
depressed?

Please answer these questions about the
provider named in Question 1 of this survey.

1
2

35. In the last 12 months, did anyone in this
provider’s office talk with you about
specific goals for your health?
1
2

2

1
2

1
2

2

Yes
No

41. In the last 12 months, did you and anyone
in this provider’s office talk about a
personal problem, family problem, alcohol
use, drug use, or a mental or emotional
illness?

Yes
No

37. In the last 12 months, did you take any
prescription medicine?
1

Yes
No

40. In the last 12 months, did you and anyone
in this provider’s office talk about things in
your life that worry you or cause you
stress?

Yes
No

36. In the last 12 months, did anyone in this
provider’s office ask you if there are things
that make it hard for you to take care of
your health?
1

Yes
No

Yes
No → If No, go to Q39.

5

Yes
No

Clerks and Receptionists at This
Provider’s Office

About You
44. In general, how would you rate your overall
health?

42. In the last 12 months, how often were clerks
and receptionists at this provider’s office as
helpful as you thought they should be?
1
2
3
4

1
2

Never
Sometimes
Usually
Always

3
4
5

45. In general, how would you rate your overall
mental or emotional health?

43. In the last 12 months, how often did clerks
and receptionists at this provider’s office
treat you with courtesy and respect?
1
2
3
4

Excellent
Very good
Good
Fair
Poor

1
2

Never
Sometimes
Usually
Always

3
4
5

Excellent
Very good
Good
Fair
Poor

46. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
47. Are you male or female?
1
2

6

Male
Female

51. Did someone help you complete this
survey?

48. What is the highest grade or level of school
that you have completed?
1
2

3
4
5
6

1

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

2

52. How did that person help you? Mark one or
more.

49. Are you of Hispanic or Latino origin or
descent?
1
2

1
2
3

Yes, Hispanic or Latino
No, not Hispanic or Latino

4

5

50. What is your race? Mark one or more.
1
2
3
4

5
6

Yes
No → Thank you.
Please return the completed
survey in the postage-paid
envelope.

Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way

Please print:

White
Black or African American
Asian
Native Hawaiian or Other Pacific
Islander
American Indian or Alaskan Native
Other

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

7