CMS-10497 MHS Beneficiaries Protocol

Version – 06-10-14

Medicare Health Care Quality (MHCQ) Demonstration Evaluation
Guide for RTI Staff Conducting Focus Groups with Medicare Beneficiaries Participating
in the Meridian Care Journey Program
A) Introduce RTI staff, provide background on roles of RTI and CMS in the MHCQ
Demonstration Evaluation
Hello and thank you for agreeing to meet with us today. My name is [
] and I work with
RTI International, a nonprofit research organization. I would like to introduce [
], who
also represents RTI International.
We are working on a project funded by the Centers for Medicare and Medicaid Services
(CMS) to learn about your experiences in receiving services from the Meridian Health
System. Your experiences will help us understand how some of their programs work for
patients and their caregivers.
My role is to guide our discussion and to encourage everyone to share their experiences at
[name of the hospital].
Before we get started, I’d like to go over a few things.
B) Review focus group process and ground rules for participation
First and foremost, during our discussion today, please keep in mind that there are no right or
wrong views or answers. Everyone’s opinion is important, so don’t hesitate to speak up
regardless of whether you agree with what has been said. In fact, if you have a different idea
or feeling, we especially want to hear from you so we can better understand all the ways
people think or feel about a subject.
To make sure that we understand everything people say today, we are making an audio and
video recording of this discussion. We will also take notes. So we can hear everyone clearly,
we ask that only one person speak at a time. Even if you disagree with what someone says,
please allow that person to speak before you respond. It seems that every group has one or
two “quiet” people, and if you are one of those, I might call on you! You are free to say that
you’d rather “pass,” but I’m hoping to hear from everyone at some point during our
discussion.
Your participation in this discussion is voluntary. You can choose not to answer any
questions or end your participation and leave the room at any time. We will not share any of
your comments with your doctor, your insurance provider, or anyone else in such a way that
you can be identified. We will not list your name in any written notes or transcripts. We will
make sure that collected data is kept and handled in a private and secure way. We will not
put names in any reports. Our job is to ask questions and make sure we understand what
you’re saying. We also want to make sure that everyone has a chance to share their ideas.

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Our discussion will last about two hours. I’ll balance the amount of time we spend on each
question, since we have a lot to get through. We won’t be taking an official break, but if you
need a personal break, please feel free to take one. [DESCRIBE LOCATION OF
RESTROOMS AND REFRESHMENTS.]
C) Hand out the name badges and ask to write first name only. [CAN BE FILLED OUT BY
PARTICIPANTS AS THEY ARRIVE].
D) Review informed consent process, obtain the signature of each focus group participant
on an informed consent form. [CAN BE REVIEWED WITH PARTICIPANTS AS THEY
ARRIVE OR JUST AS THEY ENTER THE ROOM, DEPENDING ON WHICH OPTION
IS MORE PRACTICAL FOR THE PARTICULAR SET UP].
Do you have any questions about the consent form? If you are okay with this, please sign the
informed consent form and pass it to us.
COLLECT INFORMED CONSENT FORMS; IF A PARTICIPANT IS NOT
COMFORTABLE SIGNING THE FORM, HE/SHE CANNOT PARTICIPATE IN THE
DISCUSSION.
E) Introductions
To begin, let’s go around and introduce ourselves. Please tell us your first name and
something you like to do for fun or a hobby that you have. I’ll go first…
Beneficiary Experience with Care
The primary purpose of today’s discussion is to learn about the care that you receive from
your primary care doctor and the Meridian Care Journey team working with your doctor.
The Meridian Care Journey team may include nurses, social workers, or chaplains. They may
call you on the phone to check in or visit you at home. During the next two hours, I will be
referring to these people as your “Care Journey team.” When answering questions, please
think about the people on your Care Journey team and the services they provide.

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Do you have any questions so far, especially about what we mean by your “Care Journey
team?”
I want to discuss one other important issue before we get started. Many of us enjoy talking
about our own health. However, the focus is on your experience with primary care teams
and providers, so please limit comments about your health or medical condition to facts that
may have affected your experience. Please don’t be offended if I ask you to clarify how your
health or medical conditions shape your experience with your providers or if I move
discussion along to the next topic.
Do you have any questions?
[ANSWER.]
Good, let’s get started!
F) Focus group discussion questions:
Today’s discussion is about the program called “Meridian Care Journey” (MCJ) and your care
team from that program. You might be familiar with this program from your recent interactions
with your primary care doctor for the Care Journey team.
1) How did you learn about the MCJ program? [PROBES: Did you receive a letter telling
you about this program? What did the letter say?]
2) What helped you to decide to participate in the MCJ program? Who was involved in that
decision? What were the top three things that mattered to you most in deciding to
participate in this program?
3) Do the MCJ program staff seem to understand your own unique needs? Do they consider
your cultural beliefs and values when you discuss your condition or treatment options?
[PROBE: Do they understand challenges that you may have to making an appointment,
your home situation, or other things that are important to you that may impact your
healthcare or treatment?]
a. What could the program staff do to better understand your values, your
preferences for treatment, or your unique needs?
4) Have MCJ program staff invited you and/or your family to provide ways they could
improve your experience?
5) There are many ways that patients and doctors can work together to manage the patient’s
health or medical condition. For example, some patients always depend on their doctor to
know what is best for them, while others take a more active role in the decisions that
affect them. How much of a role do you take in your own care? [PROBE: Do you ask
questions, share your views about what you think is best for you? Do you rely on your

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doctor to remind you to see a specialist?] How often do you and your provider discuss
alternative treatments and therapies?
6) We now would like to ask some questions about advance care directives, or documents
that summarize your living will. These could include a statement of treatment
preferences, a power of attorney for health care form (also called a health care proxy), or
a physician orders for life sustaining treatment (POLST) form, or the 5 wishes. How did
you learn about the document(s)? How long have you had your treatment preferences
documented? Who on your care team helped you to develop the document(s)? What did
you like about the process of creating the document(s)? What did you not like about the
process or the document(s)? Why?
7) In what ways does the Care Journey team support you and your family in getting
involved in your own care? [PROBE: Do your providers talk to you about your condition
or treatment options in a way that is easy for you to understand? Does your provider
explain the pros and cons of different treatment options? Are they willing to answer your
questions?]
8) What does the Care Journey team do to help you take better care of yourself and your
medical condition? [PROBES: Review the medications that you take, screen for more
conditions, etc.] Do you like or dislike how they do things? Why?
9) Are you able to contact someone on your Care Journey team to answer your questions or
assist you when your doctor is not available?
Next, we want to talk about how you get care from someone outside of the Care Journey team.
For example, sometimes you may need to see a specialist– like a surgeon, heart doctor, allergy
doctor, psychiatrist, foot doctor, or others who specialize in specific types of care.
10) Which providers other than your primary care doctor do you see for care? Probe on each
provider and types of interactions that they have with them. [PROBES: What type of care
did you receive from each of these providers (surgery, counseling, X-rays, chemotherapy,
other medications, or other services?)
11) Does your Care Journey team play a role in getting you to a specialist? How do they
help? [PROBES: Do they make referrals? Do they make the appointment for you?]
a. How does this arrangement work out for you? What do you like or dislike about
it?
b. Does your primary care provider know the results of your visit with a specialist?
[PROBE: Do they refer to test or lab results or notes from the specialist?]
12) When you go to your primary care doctor for a medical visit, does your doctor know if
you’ve visited the emergency room, been hospitalized, or had a nursing home or
rehabilitation stay since your last office visit?

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a. Does your primary care provider know about new prescriptions or procedures that
were done?
b. How do you think they know?
c. Has this always been the case or have you noticed any changes in the past year or
so?
13) Has anyone from the Care Journey team assisted you as you were admitted or discharged
from the hospital?
a. How did they help you?
14) Have you worked with palliative care providers at Meridian Health System?
a. How did they help you?
We now would like to ask about your experiences with different Care Journey team members,
such as nurse practitioners, nurses, social workers, or chaplains and pastoral care counselors.
These people may contact you by phone, by email, or through a home visit.
15) Do you have nurses in the Care Journey program that call you every so often, visit you at
home, or that you can call when you have questions?
a. How were you introduced to the nurses?
b. When did the nurses start to work with you?
c. How do the nurses help you? [PROBE: Have the nurses helped you manage your
condition(s)? Have the nurses called you when you returned from the hospital?
Has the [nurse] care manager helped you schedule a medical visit with a doctor?]
d. How useful are the nurses?
e. How do the nurses communicate with you? [PROBES: In-person at your doctor’s
office? Over the phone?] How often do they contact you?
f. If you take medication, do the nurses help you understand your medication? If so,
how useful is this?
g. What did you like or not like about the nurses?
16) Do you work with a social worker through the Care Journey program?
[If yes…]
a.
b.
c.
d.
e.

How does the social worker help you?
What kinds of resources and support does the social worker discuss?
How does the social worker usually communicate with you?
Do you feel comfortable discussing issues and challenges with the social worker?
What did you like or not like about the social worker?

17) Have you worked with a pastoral care counselor or chaplain through the Care Journey
program?
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[If no…]
a. Have you heard about such service? [If yes] What were some of the reasons that
you were not interested to use this service?
b. Did the Care Journey team reach out to your personal chaplain/counselor?
[If yes…]
c. How does this person help you?
d. What did you like or not like about the counselor/chaplain?
18) Has anyone on the Care Journey team (like a nurse or social worker) told you about nonmedical services in your community? [PROBE: Such services man include Meals on
Wheels, housing options, social activities at the local seniors’ center]
a. Do you receive services from any of these community resources?
b. Has your primary care provider or someone else on your care team asked if you
use any of those community resources? Did they ask you about your experiences
with these resources?
19) Overall, what are some of the things that you like about the Care Journey program? What
are some of the things about the Care Journey program you do not like?
20) Would you recommend the Care Journey program to your friends? Why or why not?
21) If you could change or improve one thing about the Care Journey program, what would
it be?
22) If the Care Journey program ended today, what would it mean for you?
These are all of my questions. Is there anything else you would like to share with me in regard to
the Meridian Care Journey program that we haven’t already discussed?
[Distribute honoraria and forms to sign for receipt of honoraria.]

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