Crosswalk

Revisions to Attachment B, Key Informant Interview Questions: MEPD Project Director (PD) Interview Questions
Issue
#
1.

Section
All

Question
#
All

Action to be
performed
Separate
protocols by key
informant group

2.

I. Introduction

Add as follows:

3.

II. Role and
Responsibility

1.

Add as follows:

4.

III. Program
Design

2. - 5.

Move entire
section

Changes to the Protocol

Reason for the Change

For the 60-day Federal Register notice, all interview
questions were presented in a single table with
separate columns for each key informant group. The
questions have now been divided into separate
protocols for each key informant group.
Thank you for agreeing to speak with us. As you
know, Mathematica Policy Research is evaluating the
Medicaid Emergency Psychiatric Demonstration for
the Centers for Medicare & Medicaid Services (CMS)
through its Center for Medicare and Medicaid
Innovation (CMMI). The evaluation will determine
whether and to what extent using Medicaid funding to
provide care for adults in private institutions for
mental disease (IMDs) impacts service use, quality of
care, and Medicaid costs.
We are speaking with you to learn about changes in
the state’s role in administering the demonstration and
associated costs, evolving contextual factors affecting
psychiatric emergency and inpatient care in the state,
and implementation facilitators and challenges.
We will be taking notes during the interview and
would like to audiotape our discussion to ensure that
we have captured your comments accurately. The
audio recording will not be shared with anyone outside
of the project team and will be destroyed at the
conclusion of the study. Is this okay with you?
Do you have any questions before we get started?
Has your role and responsibilities changed since we
last spoke on [insert date of fall 2012 interview]?

Revised to allow for ease of
administration.

Questions in Program Design section were moved
from the end of the interview guide to the beginning.

Added to provide background
information and for conversational
flow and rapport-building.

Needed to ensure informant role and
responsibilities are current and
correct.
Revised to facilitate conversational
flow.

Changes to MEPD PD Interview Questions (continued)
Issue
#
5.
6.

Section

Question
#

IV. Access to
Inpatient
Psychiatric Care
IV. Access to
6.
Inpatient
Psychiatric Care

Action to be
performed
Add as follows:

Changes to the Protocol

Reason for the Change

Next, I’d like to talk about access to care.

Added to introduce transition to a
different discussion topic.

Revise as
follows:

Replace: How does access to inpatient psychiatric care
for Medicaid beneficiaries experiencing a psychiatric
emergency compare to access for those beneficiaries
before the demonstration? (Probe: Has it increased or
decreased? Why?)
With: How does access to inpatient psychiatric care
for Medicaid beneficiaries experiencing a psychiatric
emergency compare to access for those beneficiaries
before the demonstration? (PROBE: Has access to
inpatient psychiatric care increased or decreased? Why
or why not?
Replace: Have there been any changes in patient
enrollment estimates since we spoke last [insert date]?
If so, what accounts for this change?
With: Have there been any changes in patient
enrollment estimates since we last spoke on [insert
date of fall 2012 interview]?
If there has been a change in patient enrollment, what
accounts for this change?
I’d like to shift the discussion to boarding in ERs and
general hospital scatter beds.

Revised for clarity.

7.

7. – 8.
IV. Access to
Inpatient
Psychiatric Care

Revise as
follows:

8.

V. Boarding
Time in ER and
General
Hospital Scatter
Beds
V. Boarding
Time in ER and
General
Hospital Scatter
Beds

Add as follows:

9.

9.

Move question
up from last
section of the
interview, and
revise as
follows:

Replace: Can you discuss the extent of emergency
room boarding and shortage of inpatient beds in the
state?
With: Can you discuss the extent of emergency room
boarding in the state?

Revised for clarity.

Added to introduce transition to a
different discussion topic.

Moved to an earlier section to
facilitate flow of conversation.
Revised to clarify and simplify the
compound question; shortage of
inpatient beds is now discussed
separately in question 32.

2

Changes to MEPD PD Interview Questions (continued)
Issue Section
#
10. V. Boarding
Time in ER and
General
Hospital Scatter
Beds
11.

V. Boarding
Time in ER and
General
Hospital Scatter
Beds

12.

VI. Referral and
Admission

Question
#
10.

11. – 14.

Action to be
performed
Move question
up from last
section of the
interview, and
revise as
follows:
Revise as
follows:

Add as follows:

Changes to the Protocol

Reason for the Change

Replace: Can you discuss the extent of general
hospital psychiatric boarding and shortage of inpatient
beds in the state?
With: Can you discuss the extent of psychiatric
boarding in general hospital scatter beds in the state?

Moved to an earlier section to
facilitate flow of conversation.
Revised to clarify and simplify the
compound question; shortage of
inpatient beds is now discussed
separately in question 32.
Separated the main question
and follow-up question into
different questions for ERs and
GHs to clarify the compound
question.

Replace: How does psychiatric boarding time in
ERs and GH scatter beds for patients with
psychiatric emergencies compare to boarding
times for psychiatric emergencies before the
demonstration? (Probe: Has it increased or
decreased? Why?
Is this different for Medicaid beneficiaries?
With: How does psychiatric boarding time in
ERs for patients with psychiatric emergencies
compare to boarding times for psychiatric
emergencies before the demonstration?
(PROBE: Has boarding time increased or
decreased? Why?)
Is this different for Medicaid beneficiaries?
How does psychiatric boarding time in GH
scatter beds for patients with psychiatric
emergencies compare to boarding times for
psychiatric emergencies before the
demonstration? (PROBE: Has boarding time
increased or decreased? Why?)
Is this different for Medicaid beneficiaries?
Next, I’d like to talk about referral and
admission, stabilization, and discharge planning.

Added to introduce transition to
different discussion topics.

3

Changes to MEPD PD Interview Questions (continued)
Issue Section
#
13. VIII. Length of
Stay

14.

IX. Discharge
Planning

15.

XI. Context

Question
#
20.

Action to be
performed
Revise as
follows:

21.

Revise as
follows:

Add as follows:

Changes to the Protocol

Reason for the Change

Replace:
What is the average length of stay for patients enrolled
in the demonstration?
What is the average length of stay for patients not
participating in the demonstration? (e.g., Medicaid
beneficiaries with psychiatric emergencies who are
admitted to public IMDs, general hospitals, or
alternatives.)
With: How does the average length of stay for
patients enrolled in the demonstration compare to the
average length of stay for patients not participating in
the demonstration? (e.g., Medicaid beneficiaries with
psychiatric emergencies who are admitted to the
public IMDs, general hospitals, or alternatives.)
Replace:
How has the proportion of Medicaid beneficiaries with
psychiatric emergencies who are discharged from the
participating IMDs with a continuing care plan
changed as a result of the demonstration?
How has the quality of discharge planning changed
under the demonstration? (Probe: Has it improved,
worsened, or stayed the same?)
How are patients involved in discharge planning under
the demonstration? (Probe: How does this impact the
patient’s discharge experience?)
With: What kinds of changes, if any, have occurred
regarding post-discharge follow up procedures for
Medicaid beneficiaries as a result of the
demonstration?
Next, I’d like to talk about the context in which the
demonstration is operating.

Revised to reduce burden on
respondents. Specific data on length
of stay for patients enrolled in the
demonstration are already available
through existing CMS payment and
monitoring data; similar data for
nonparticipants may be difficult to
obtain across multiple types of
alternative facilities. The revised
question allows the informant to
answer in more general
impressionistic terms.
Revised to decrease the length of the
interview to lessen the burden on
respondent. The previous more
detailed questions will still be asked in
the IMD staff interview protocol, as
IMD personnel who are doing the
discharge planning will be able to
provide more specific information.

Added to introduce transition to a
different discussion topic.

4

Changes to MEPD PD Interview Questions (continued)
Issue Section
#
16. XI. Context

Question
#
32.

Action to be
performed
Revise as
follows:

17.

XII. Outcomes

Add as follows:

18.

XIII. Closing

Add as follows:

19.

XIII. Closing

Add as follows:

20.

XIII. Closing

Add as follows:

21.

XIII. Closing

Add as follows:

Changes to the Protocol

Reason for the Change

Replace: Can you discuss the extent of emergency
room boarding and shortage of inpatient beds in the
state? and Can you discuss the extent of general
hospital psychiatric boarding and shortage of inpatient
beds in the state?
With: Can you discuss the extent to which there is a
shortage of inpatient psychiatric beds in the state?
I’d like to conclude the interview by talking about
outcomes of the demonstration.
That completes the questions we have for you today.

Revised to clarify and simplify the
compound questions; extent of
emergency room and general hospital
psychiatric boarding are now
discussed separately in questions 9
and 10.

Is there anything we should have asked about but
didn’t?
Do you have anything you would like to tell us, or
questions you would like to ask us?
Thank you again for taking the time to speak with us.
We appreciate and value your input.

Added to introduce transition to
different discussion topics.
Added for conversation flow and
make informant aware that the
interview has ended.
Added for conversational flow and
rapport-building.
Added for conversational flow and
rapport-building.
Added to let informant know that we
appreciate their time.

5

Revisions to Attachment B, Key Informant Interview Questions: MEPD IMD Staff Member Interview Questions
Issue
#
1.

2.

Section

All

I. Introduction

Question
#
All

Action to be
performed
Separate
protocols by key
informant group
Add as follows:

Changes to the Protocol

Reason for the Change

For the 60-day Federal Register notice, all interview
questions were presented in a single table with
separate columns for each key informant group. The
questions have now been divided into separate
protocols for each key informant group.
Thank you for taking the time to speak with us. We are
from Mathematica Policy Research, an independent
research firm contracted by the Centers for Medicare
& Medicaid Services (CMS) through its Center for
Medicare and Medicaid Innovation (CMMI) to
evaluate the Medicaid Emergency Psychiatric
Demonstration. The three-year demonstration allows
eligible, private institutions for mental disease (IMDs)
in participating states to receive federal Medicaid
reimbursement for adults ages 18 to 64. The purpose
of the demonstration is to make inpatient care more
accessible to adult Medicaid beneficiaries with
psychiatric emergency medical conditions. The
evaluation will determine whether and to what extent
using Medicaid funding to provide care for adults in
private IMDs impacts service use, quality of care, and
Medicaid costs.
We are speaking with you to learn about how care is
provided in [insert name of IMD]. In particular; we are
interested in understanding how the referral and
admission, stabilization and discharge planning
processes differ for Medicaid beneficiaries as a result
of the demonstration.
We will be taking notes during the interview and
would like to audiotape our discussion to ensure that
we have captured your comments accurately. The
audio recording will not be shared with anyone outside
of the project team and will be destroyed at the
conclusion of the study. Is this okay with you?
Do you have any questions before we get started?

Revised to allow for ease of
administration.

Added to provided background
information and for conversational
flow and rapport-building.

6

Changes to MEPD IMD Staff Member Interview Questions (continued)
Issue
#
3.
4.
5.
6.
7.
8.
9.
10.

11.

Section
II. Role and
Responsibilities
II. Role and
Responsibilities
II. Role and
Responsibilities
II. Role and
Responsibilities

Question
#
1.

Action to be
performed
Add as follows:

Changes to the Protocol

Reason for the Change

Add as follows:

Please describe your role and responsibilities at [insert
name of IMD].
How long have you been in this role?

3.

Add as follows:

How long have you worked at [insert name of IMD]?

4.

Add as follows:

Are you aware that [insert name of IMD] is
participating in the Medicaid Emergency Psychiatric
Demonstration?
Questions in Program Design section were moved
from the end of the interview guide to the beginning.
I would like to discuss access to care.

Needed to ensure informant role and
responsibility is current and correct.
Needed to ensure informant role and
responsibility is current and correct.
Needed to ensure informant role and
responsibility is current and correct.
Based on informant’s awareness of the
study, some questions in the protocol
may be skipped.
Revised to facilitate conversation
flow.
Added to introduce transition to a
different topic.

2.

III. Program
5. – 8.
Design
IV. Access to
Inpatient
Psychiatric Care
IV. Access to
9.
Inpatient
Psychiatric Care
IV. Access to
10.
Inpatient
Psychiatric Care

Move entire
section.
Add as follows:

IV. Access to
11.
Inpatient
Psychiatric Care

Revise as
follows:

Revise as
follows:
Revise as
follows:

Replace: (Probe: Has it increased or decreased? Why?) Revised for clarity.
With: PROBE: Has access to inpatient psychiatric care
increased or decreased? Why or why not?
Revised for clarity.
Replace: How has the mix of patients in your IMD
changed since implementing the demonstration?
With: How has the mix of patients in this hospital
changed since implementing the demonstration on
[insert date of implementation]?
Revised for clarity.
Replace: Are you noticing any trends in the
participation of a particular sub-group of populations
eligible for the demonstration (e.g., trends by age,
race, gender, Medicaid eligibility status)? If so, please
describe.
With: Are you noticing any trends in the participation
of a particular sub-group of populations eligible for the
demonstration (e.g., trends by age, race, gender,
Medicaid eligibility status)? If so, please describe
these trends.

7

Changes to MEPD IMD Staff Member Interview Questions (continued)
Issue
#
12.

Section
IV. Access to
Inpatient
Psychiatric Care

Question
#
12.

Action to be
performed
Revise as
follows:

13.

IV. Access to
13. – 14.
Inpatient
Psychiatric Care

Revise as
follows:

14.

V. Boarding
Time in ER

Add as follows:

15.

V. Boarding
Time in ER

16.

Revise as
follows:

16.

V. Boarding
Time in ER

17.

Revise as
follows:

17.

V. Boarding
Time in ER

18.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: Are you having challenges with
implementing patient eligibility criteria? If so, please
discuss these.
With: Are you having challenges with implementing
patient eligibility criteria? If so, please describe these
challenges.
Replace: Have there been any changes in patient
enrollment estimates since we spoke last [insert date]?
If so, what accounts for this change?
With: Have there been any changes in patient
enrollment estimates since we last spoke on [insert
date]? If there has been a change in patient enrollment
estimates, what accounts for this change?
Now I’d like to talk about the amount of time patients
spend in the ER or intake department prior to
admission.
Replace: Does this IMD have an ER?
With: Does this hospital have an ER or a place where
someone comes (for example, an intake or assessment
department) because they are experiencing a
psychiatric emergency condition? Is so, please
describe. [Obtain during site visit planning.]
Replace: If so, before the demonstration, did your
facility ever have to board Medicaid patients in the ER
while awaiting admission to a hospital for a
psychiatric emergency?
With: Before the demonstration, did this facility ever
have to board Medicaid patients in the ER or
intake/assessment department while awaiting
admission to a hospital for psychiatric emergency?
Replace: Has this changed since the demonstration
was implemented?
With: Has this changed since the demonstration was
implemented in [insert date of implementation]?

Revised for clarity.

Revised for clarity.

Added to introduce transition to a
different topic.
Revised for clarity. We learned during
the pilot test that some IMDs may not
have ERs, per se, but do have intake
units where people who are
experiencing psychiatric emergencies
can come.
Revised for clarity.

Revised for clarity.

8

Changes to MEPD IMD Staff Member Interview Questions (continued)
Issue
#
18.

Section
V. Boarding
Time in ER

Question
#
19.

Action to be
performed
Revise as
follows:

21.

Revise as
follows:

19.

V. Boarding
Time in ER

20.

VI. Referral and
Admission
VI. Referral and 26.
Admission

21.

22.

VI. Referral and 22., 22a.
Admission

Add as follows:
Move question
down from first
one in this
section to the
last one in
section.
Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: If so, on average, how long does a patient
with a psychiatric emergency currently wait in the ER
once it has been decided that psychiatric
hospitalization is needed?
With: If this has changed since the demonstration, on
average how long does a patient with a psychiatric
emergency currently wait in the ER or
intake/assessment department once it has been decided
that psychiatric hospitalization is needed?
Replace: Has this changed since the demonstration
began in [start date of demonstration in state]?
(Probe: Has it increased or decreased? Why?)
With: Has this changed since the demonstration began
in [insert date of implementation]?
PROBE: Have wait times in the ER or
intake/assessment department increased or decreased
since the demonstration began? Why or why not?
I’d like to shift the discussion to referral and
admission to this hospital.
What are your primary methods for identifying
patients for the demonstration?

Revised for clarity.

Replace: What is the primary source of referral for
demonstration patients?
With: What is the primary source of referral for
patients to this hospital?
[Ask only if informant is aware of the
demonstration.] Is that the same referral source for
demonstration patients? If not, what is the primary
referral source for demonstration patients?

Revised for clarity.

Added to introduce transition to a
different topic.
Moved to last question asked in this
section to facilitate flow of
conversation.

Revised to make clearer for staff
members who are not aware of the
demonstration per se.

9

Changes to MEPD IMD Staff Member Interview Questions (continued)
Question
#
VI. Referral and 23., 23a.
Admission

Action to be
performed
Revise as
follows:

24.

VI. Referral and 25.
Admission

Revise as
follows:

25.

VII.
Stabilization
VII.
Stabilization

Add as follows:

Issue
#
23.

26.

27.

Section

VIII. Length of
Stay

30.

Revise as
follows:

33.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: What are other sources of referral for
demonstration patients?
With: What are other sources of referral for patients to
this hospital?
[Ask only if informant is aware of the
demonstration.] Are the other referral sources the
same for demonstration patients? If not, what are the
other sources of referral for demonstration patients?
Replace: How does the referral and admission process
under the demonstration differ from what you were
doing before the demonstration?
With: How does the referral process since the
demonstration began differ from what you were doing
before the demonstration?
Next, I would like to discuss procedures for stabilizing
patients.
Replace: What types of treatments do demonstration
patients receive while in this IMD?
With: What types of treatments do patients receive
while in this hospital? PROBE: What types of
therapies and modes are offered, for example,
psychotherapies (CBT, interpersonal therapy, and
behavioral therapy), psychoeducation and individual
and/or group psychotherapy, or other therapeutic
treatments?
Replace: What is the average length of stay for
patients not participating in the demonstration? (e.g.,
people with psychiatric emergencies with other
payment sources and people without psychiatric
emergencies)?
With: What is the average length of stay for patients in
this hospital?
PROBE: For example, people with psychiatric
emergencies with payment sources other than
Medicaid and people without psychiatric emergencies.

Revised to make clearer for staff
members who are not aware of the
demonstration per se.

Revised for clarity.

Added to introduce transition to a
different topic.
Revised for clarity.

Revised for clarity.

10

Changes to MEPD IMD Staff Member Interview Questions (continued)
Issue
#
28.
29.

30.

Section
IX. Discharge
Planning
IX. Discharge
Planning

IX. Discharge
Planning

Question
#

Action to be
performed
Add as follows:

35., 35a.

Add as follows:

46., 46a.,
47., 48.,
49.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Now I’d like to talk about discharge planning and
post-discharge care.
Could you please describe the hospital’s discharge
planning procedures?
[Ask only if informant is aware of the the
demonstration] Are the discharge planning procedures
the same for demonstration patients? If not, how do
they differ?

Added to introduce transition to a
different topic.
Added to aid conversational flow. If
later questions have already been
answered through this more general
question, they will not be asked.
Second portion of the question added
to clarify how discharge procedures
have or have not changed in
association with the demonstration.
Desired more detail regarding the
aftercare that is provided and any
changes that may have occurred due
to the demonstration.

Replace: How has the proportion of Medicaid
beneficiaries with psychiatric emergencies who are
discharged from the participating IMDs with a
continuing care plan changed as a result of the
demonstration?
With: What types of aftercare services are provided to
patients?
[Ask only if informant is aware of the
demonstration.] What types of aftercare services are
provided to demonstration patients?
Where do the majority of patients typically receive
aftercare services?
[Ask only if informant is aware of the
demonstration.] Where do the majority of
demonstration patients typically receive aftercare
services?
Could you please describe the post discharge follow
up procedures for Medicaid beneficiaries?
[Ask only if informant is aware of demonstration.]
What kinds of changes, if any, have occurred
regarding post-discharge follow up procedures for
Medicaid beneficiaries as a result of the
demonstration?

11

Changes to MEPD IMD Staff Member Interview Questions (continued)
Issue
#
31.

Section
IX. Discharge
Planning

Question
#
36.

Action to be
performed
Revise as
follows:

32.

IX. Discharge
Planning

37.

Revise as
follows:

33.

IX. Discharge
Planning

38.

Revise as
follows:

34.

IX. Discharge
Planning

40.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: How does the discharge planning process
under the demonstration differ from what you were
doing before the demonstration?
With: How does the discharge planning process differ
now from what you were doing prior to the
demonstration?
Replace: How has the quality of discharge planning
changed under the demonstration? (Probe: Has it
improved, worsened, or stayed the same?)
With: How has the quality of discharge planning
changed under the demonstration?
PROBE: Has the quality of discharge planning
improved, worsened, or stayed the same?
Replace: How are demonstration patients at your
hospital involved in discharge planning under the
demonstration? (Probe: How does this impact the
patient’s discharge experience?) Is this different than
how non-demonstration patients are involved in
discharge planning? If so, how?
With: How are patients at your hospital involved in
discharge planning?
PROBE: How does patient involvement (or lack of)
impact the patient’s discharge experience?
Replace: How has the amount of time staff spend
developing discharge plans under the demonstration
compare to time staff spent on discharge planning for
Medicaid beneficiaries before the demonstration?
(Probe: Is this helpful? If so, how?)
With: How does the amount of time staff spend
developing discharge plans now compare to the
amount of time staff spent on discharge planning for
Medicaid beneficiaries prior to the demonstration?

Revised for clarity.

Revised for clarity.

Revised to obtain more specifics about
how patient involvement affects
discharge planning.

Revised for clarity.

12

Changes to MEPD IMD Staff Member Interview Questions (continued)
Issue
#
35.

Section
IX. Discharge
Planning

36.

IX. Discharge
Planning

37.

X. Cost

Question
#
41., 43.,
44., 45.,
45a.

Action to be
performed
Revise as
follows:

42.

Revise as
follows:

Add as follows:

Changes to the Protocol

Reason for the Change

Replace: Under the demonstration, has the proportion
of Medicaid beneficiaries with psychiatric
emergencies discharged from your hospital to
community-based residences changed? (Probe: How?
To where are demonstration patients being discharged
most frequently?)
With: Under the demonstration, has the proportion of
Medicaid beneficiaries with psychiatric emergencies
discharged from your hospital to community-based
residences changed?
PROBE: How has the proportion discharged from
your hospital to community-based residences
changed? [Ask only if informant is aware of the
demonstration.]
To where is the majority of patients discharged?
PROBE: For example, home, group home or other
structured setting, jail, or patients are homeless.
To where is the majority of demonstration patients
discharged?
What proportion of patients are discharged outside of
the local area?
[Ask only if informant is aware of the
demonstration.] What proportion of demonstration
patients are discharged outside of the local area?
Replace: Under the demonstration, has the level of
detail included in discharge plans changed? (Probe:
How? What is included?)
With: Under the demonstration, has the level of detail
included in discharge plans changed?
PROBE: How has the level of included detail
changed? What is included?
I’d like to ask next a few questions about cost.

Revised to make clearer for staff
members who are not aware of the
demonstration per se and to get more
specific information about discharge
disposition.

Revised for clarity.

Added to introduce transition to a
different topic.

13

Changes to MEPD IMD Staff Member Interview Questions (continued)
Issue
#
38.

Section
X. Cost

Question
#
52.

Action to be
performed
Revise as
follows:

39.

XI. Context

Add as follows:

40.

XI. Context

53., 53a.

Revise as
follows:

41.

XI. Context

54., 54a.

Revise as
follows:

42.

XI. Context

55.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: What, if any, were the administrative costs to
the IMD to fully implement the demonstration (e.g, for
staffing or making changes to the physical
environment)?
With: What, if any, were the administrative costs to
the hospital to fully implement the demonstration (e.g.,
for staffing or making changes to the physical
environment)?
I’d like to talk about the availability of mental health
services.
Replace: What types of step-down and outpatient
services are available for demonstration patients?
With: What types of psychiatric step-down and
outpatient services are available for patients?
[Ask only if informant is aware of demonstration.]
What types of psychiatric step-down and outpatient
services are available for demonstration patients?
Replace: Are step-down and outpatient services
reimbursed by Medicaid? If not, how are these
services funded?
With: Are psychiatric step-down and outpatient
services reimbursed by Medicaid? If not, how are
these services funded?
Replace: Please describe the working relationship your
facility has with step-down or outpatient providers.
With: Please describe the working relationship your
facility has with psychiatric step-down or outpatient
providers.

Revised for clarity.

Added to introduce transition to a
different topic.
Revised to make clearer for staff
members who are not aware of the
demonstration per se.

Revised for clarity.

Revised for clarity.

14

Changes to MEPD IMD Staff Member Interview Questions (continued)

XI. Context

Question
#
56.

Action to be
performed
Revise as
follows:

44.

XI. Context

57.

Revise as
follows:

45.

XII. Outcomes

Add as follows:

46.

XIII. Closing

Add as follows:

XIII. Closing

Add as follows:

XIII. Closing

Add as follows:

XIII. Closing

Add as follows:

Issue
#
43.

Section

Changes to the Protocol

Reason for the Change

Replace: Have there been any changes in mental
health service delivery that could affect the
demonstration (e.g., closure of facilities, new IMDs
opening, changes in availability of community-based
services)?
With: Have there been any changes in mental health
service delivery that could affect the demonstration
(e.g., closure of facilities, new IMDs/hospitals
opening, changes in availability of community-based
services)?
Replace: Are you aware of any local-level initiatives
that may be changing the incidence of psychiatric
emergencies and access to services for patients
experiencing a psychiatric emergency?
With: Are you aware of any local-level events or
initiatives that may be changing the incidence of
psychiatric emergencies and access to services for
patients experiencing a psychiatric emergency?
I’d like to conclude by talking about outcomes of the
demonstration.
That completes the questions we have for you today.

Revised for clarity.

Is there anything we should have asked about but
didn’t?
Do you have anything you would like to tell us, or
questions you would like to ask us?
Thank you again for taking the time to speak with us.
We appreciate and value your input.

Revised for clarity.

Added to introduce transition to a
different topic.
Added for conversation flow and
make informant aware that the
interview is over.
Added for conversation flow and
rapport-building.
Added for conversation flow and
rapport-building.
Added to let informant know that we
appreciate their time.

15

Revisions to Attachment B, Key Informant Interview Questions: MEPD GH Staff Member Interview Questions
Issue
#
1.

2.

Section

All

I. Introduction

Question
#
All

Action to be
performed
Separate
protocols by key
informant group
Add as follows:

Changes to the Protocol

Reason for the Change

For the 60-day Federal Register notice, all interview
questions were presented in a single table with
separate columns for each key informant group. The
questions have now been divided into separate
protocols for each key informant group.
Thank you for taking the time to speak with us. We are
from Mathematica Policy Research, an independent
research firm contracted by the Centers for Medicare
& Medicaid Services (CMS) through its Center for
Medicare and Medicaid Innovation (CMMI) to
evaluate the Medicaid Emergency Psychiatric
Demonstration. The three-year demonstration allows
eligible, private institutions for mental disease (IMDs)
in participating states to receive federal Medicaid
reimbursement for adults ages 21 to 64. The purpose
of the demonstration is to make inpatient care more
accessible to adult Medicaid beneficiaries with
psychiatric emergency medical conditions. The
evaluation will determine whether and to what extent
using Medicaid funding to provide care for adults in
private IMDs impacts service use, quality of care, and
Medicaid costs.
We are speaking with you to learn about how care is
provided in [insert name of GH]. In particular, we are
interested in understanding how care is provided to
Medicaid beneficiaries experiencing a psychiatric
emergency and the process of referring these
individuals for inpatient psychiatric treatment.
We will be taking notes during the interview and
would like to audiotape our discussion to ensure that
we have captured your comments accurately. The
audio recording will not be shared with anyone outside
of the project team and will be destroyed at the
conclusion of the study. Is this okay with you?
Do you have any questions before we get started?

Revised to allow for ease of
administration.

Added to provide background
information and for conversational
flow and rapport-building.

16

Changes to MEPD GH Staff Member Interview Questions (continued)
Issue
#
3.

Section
II. Role and
Responsibilities

Question
#
1.

Action to be
performed
Add as follows:

Changes to the Protocol

Reason for the Change

Please describe your role and responsibilities at [insert
name of GH].

Needed to ensure informant role and
responsibilities are current and
correct.
Needed to ensure informant role and
responsibilities are current and
correct.
Needed to ensure informant role and
responsibilities are current and
correct.
Based on informant’s awareness of the
study, some questions in the protocol
may be skipped.
Added to obtain staff perceptions of
change since demonstration began.

4.

II. Role and
Responsibilities

2.

Add as follows:

How long have you been in this role?

5.

II. Role and
Responsibilities

3.

Add as follows:

How long have you worked at [insert name of GH]?

6.

II. Role and
Responsibilities

4.

Add as follows:

Are you aware of the state’s participation in the
Medicaid Emergency Psychiatric Demonstration?

7.

III. Program
Design

5.

Add as follows:

8.

IV. Access to
Care
V. Boarding
Time in ER
V. Boarding
Time in the ER

Have you seen any service improvements since [insert
name(s) of participating IMD(s)] began the
demonstration? PROBE: For example, changes in
procedures for identifying available inpatient beds, ER
diversion, use of peer supports in ER, use of mobile
crisis team.
Next, I would like to discuss access to care.

9.
10.
11.
12.
13.

Add as follows:
Add as follows:
9.

V. Boarding
10.
Time in the ER
VI. Referral and
Admission
VII.
13.
Stabilization

Add as follows:
Add as follows:
Add as follows:
Revise as
follows:

Now I’d like to talk about the amount of time patients
spend I the ER prior to admission.
Has this changed since [insert start date of
demonstration in state]?
If a change was observed, what factors do you think
account for the change?
I’d like to shift the discussion to referral and
admission to this hospital.
Replace: What type of treatment do patients
experiencing psychiatric emergencies receive while in
non-psychiatric units of this hospital?
With: Next, please tell me about the types of
treatments patients experiencing psychiatric
emergencies receive while in non-psychiatric units of
this hospital.

Added to introduce transition to a
different topic.
Added to introduce transition to a
different topic.
Added in order to obtain needed
information about change due to the
demo.
Added in order to obtain more
information.
Added to introduce transition to a
different topic.
Revised for conversation flow.

17

Changes to MEPD GH Staff Member Interview Questions (continued)
Issue
#
14.

Section
VII.
Stabilization

15.

VIII. Length of
Stay

16.

IX. Discharge
Planning
IX. Discharge
Planning

17.
18.

Question
#
17.

Action to be
performed
Revise as
follows:

19.

Revise as
follows:

Add as follows:
Delete as
follows:
25.

19.

IX. Discharge
Planning
X. Context

Add as follows:

20.

X. Context

28.

Revise as
follows:

21.

X. Context

31.

Revise as
follows:

22.

X. Context

Add as follows:

Delete as
follows:

Changes to the Protocol

Reason for the Change

Replace: Is there anything you would like done
differently?
With: Is there anything you would like to see done
differently in how patients with psychiatric
emergencies are stabilized on non-psychiatric units of
this hospital?
Replace: On average, how long do psychiatric
emergency patients stay in non-psychiatric units of
your hospital while awaiting admission to a
psychiatric unit or psychiatric hospital?
With: On average, how long do psychiatric emergency
patients stay in non-psychiatric units of this hospital
while awaiting admission to a psychiatric unit or
psychiatric hospital?
Now I’d like to talk about discharge planning and
post-discharge care.
Please describe the discharge process for psychiatric
patients admitted to non-psychiatric units of this
hospital.
What types of aftercare services are provided to
psychiatric patients?
I’d like to talk about the context in which the
demonstration is operating.
Replace: Have the sources of referral to the unit
changed?
With: Have the sources of referral to the unit changed
since the demonstration was implemented [insert date
of implementation]?
Replace: Has the average length of stay or discharge
planning process changed?
With: Has the average length of stay or discharge
planning process changed since implementing the
demonstration on [insert date of implementation]?
Is your hospital involved in other initiatives that could
influence emergency room boarding (e.g., quality
improvement initiatives)?

Revised for clarity.

Revised for clarity.

Added to introduce transition to a
different topic.
Deleted because was identical to the
question that followed it.
Added to obtain more detail about
services following discharge.
Added to introduce transition to a
different topic.
Revised for clarity.

Revised for clarity.

Deleted to decrease burden—not
critical for GH staff to answer. Still
asked in ER staff interview protocol.
18

Changes to MEPD GH Staff Member Interview Questions (continued)
Issue
#
23.

Section
XI. Closing

24.

Question
#

Action to be
performed
Add as follows:

Changes to the Protocol

Reason for the Change

That completes the questions we have for you today.

XI. Closing

Add as follows:

25.

XI. Closing

Add as follows:

26.

XI. Closing

Add as follows:

Is there anything we should have asked about but
didn’t?
Do you have anything you would like to tell us, or
questions you would like to ask us?
Thank you again for taking the time to speak with us.
We appreciate and value your input.

Added for conversation flow and
make informant aware that the
interview is over.
Added for conversation flow and
rapport-building.
Added for conversation flow and
rapport-building.
Added to let informant know that we
appreciate their time.

19

Revisions to Attachment B, Key Informant Interview Questions: MEPD ER Staff Member Interview Questions
Issue
#
1.

2.

Section

All

I. Introduction

Question
#
All

Action to be
performed
Separate
protocols by key
informant group
Add as follows:

Changes to the Protocol

Reason for the Change

For the 60-day Federal Register notice, all interview
questions were presented in a single table with
separate columns for each key informant group. The
questions have now been divided into separate
protocols for each key informant group.
Thank you for taking the time to speak with us. We are
from Mathematica Policy Research, an independent
research firm contracted by the Centers for Medicare
& Medicaid Services (CMS) through its Center for
Medicare and Medicaid Innovation (CMMI) to
evaluate the Medicaid Emergency Psychiatric
Demonstration. The three-year demonstration allows
eligible, private institutions for mental disease (IMDs)
in participating states to receive federal Medicaid
reimbursement for adults ages 21 to 64. The purpose
of the demonstration is to make inpatient care more
accessible to adult Medicaid beneficiaries with
psychiatric emergency medical conditions. The
evaluation will determine whether and to what extent
using Medicaid funding to provide care for adults in
private IMDs impacts service use, quality of care, and
Medicaid costs.
We are speaking with you to learn about how care is
provided in [insert name of ER] In particular; we are
interested in understanding how care is provided to
Medicaid beneficiaries experiencing a psychiatric
emergency and the process of referring these
individuals for inpatient psychiatric treatment.
We will be taking notes during the interview and
would like to audiotape our discussion to ensure that
we have captured your comments accurately. The
audio recording will not be shared with anyone outside
of the project team and will be destroyed at the
conclusion of the study. Is this okay with you?
Do you have any questions before we get started?

Revised to allow for ease of
administration.

Added to provide background
information and for conversational
flow and rapport-building.

20

Changes to MEPD ER Staff Member Interview Questions (continued)
Issue
#
3.

Section
II. Role and
Responsibilities

Question
#
1.

Action to be
performed
Add as follows:

Changes to the Protocol

Reason for the Change

Please describe your role and responsibilities at [insert
name of ER].

Needed to ensure informant role and
responsibilities are current and
correct.
Needed to ensure informant role and
responsibilities are current and
correct.
Needed to ensure informant role and
responsibilities are current and
correct.
Based on informant’s awareness of the
study, some questions in the protocol
may be skipped.
Revised to facilitate conversational
flow.
Revised for clarity.

4.

II. Role and
Responsibilities

2.

Add as follows:

How long have you been in this role?

5.

II. Role and
Responsibilities

3.

Add as follows:

How long have you worked at [insert name of ER]?

6.

II. Role and
Responsibilities

4.

Add as follows:

Are you aware of the state’s participation in the
Medicaid Emergency Psychiatric Demonstration?

7.

III. Program
Design
III. Program
Design

5.

Move section:

5.

Revise as
follows:

Question in Program Design section was moved from
the end of the interview guide to the beginning.
Replace: Have you seen any service improvements
since [name of participating IMDs] began the
demonstration?
With: Have you seen any service improvements since
[insert name(s) of participating IMD(s)] began the
demonstration?
PROBE: For example, changes in procedures for
identifying available inpatient beds, ER diversion, use
of peer supports in ER, use of mobile crisis teams.
Next, I would like to discuss access to care.

8.

9.
10.

IV. Access to
Inpatient
Psychiatric Care
IV. Access to
7.
Inpatient
Psychiatric Care

Add as follows:
Revise as
follows:

Replace: Please describe your experience working
with individuals experiencing a psychiatric
emergency.
With: Please describe how you work with individuals
experiencing a psychiatric emergency.

Added to introduce transition to a
different topic.
Revised for clarity.

21

Changes to MEPD ER Staff Member Interview Questions (continued)
Issue
#
11.

Section
IV. Access to
Inpatient
Pyschiatric Care

Question
#
8., 8a.

Action to be
performed
Revise as
follows:

12.

IV. Access to
9.
Inpatient
Psychiatric Care

Revise as
follows:

13.

IV. Access to
10.
Inpatient
Psychiatric Care

Revise as
follows:

14.

11., 11a.
IV. Access to
Inpatient
Psychiatric Care

Revise as
follows:

15.

V. Boarding
Time in ER
V. Boarding
Time in ER

Add as follows:

16.

13.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: I understand that this hospital has a
psychiatric unit. Do you contact the unit to determine
bed availability? If not, why not?
With: I understand that this hospital has a psychiatric
unit. Do you contact the unit to determine bed
availability? If the psychiatric unit is not contacted,
please explain why.
Replace: Which other facilities do you contact for
inpatient care for patients with a psychiatric
emergency?
With: Which facilities do you contact for inpatient
care for patients with a psychiatric emergency?
Replace: Are the facilities the same for Medicaid
beneficiaries? (Probe: Why or why not? Is there a
particular order in which you contact hospitals?)
With: Are the facilities you contact the same facilities
you contact for Medicaid beneficiaries?
PROBE: Why or why not? Is there a particular order
in which you contact hospitals?
Replace: What is your experience with the rate at
which patients with psychiatric emergencies are
accepted by these hospitals? Is it different for
Medicaid beneficiaries?
With: What is your experience with the rate at which
patients with psychiatric emergencies are accepted by
these hospitals? Is the acceptance rate different for
Medicaid beneficiaries?
Now I’d like to talk about the amount of time patients
spend in the ER prior to admission.
Replace: Is this different for Medicaid beneficiaries?
With: Are wait times different for Medicaid
beneficiaries?

Revised for clarity.

Revised for clarity

Revised for clarity.

Revised for clarity.

Added to introduce transition to a
different topic.
Revised for clarity.

22

Changes to MEPD ER Staff Member Interview Questions (continued)
Issue
#
17.

Section
IV. Referral and
Admission

Question
#

Action to be
performed
Add as follows:

18.

IV. Referral and 18.
Admission

Revise as
follows:

19.

IV. Referral and 19.
Admission

Revise as
follows:

20.

VII.
Stabilization

21.

Revise as
follows:

21.

VII.
Stabilization

22.

Revise as
follows:

Changes to the Protocol

Reason for the Change

I’d like to switch the discussion to referral and
admission of patients experiencing a psychiatric
emergency to psychiatric hospitals.
Replace: Have you noticed any changes since [start
date of demonstration in state] in how patients who
present with a psychiatric emergency in your ER are
admitted? (Probe: Do you contact a different person to
assess the patient’s level of need? Are the verification
process or eligibility criteria different?)
With: Have you noticed any changes since [insert start
of demonstration in state] in how patients who present
with a psychiatric emergency in your ER are admitted?
PROBE: Do you contact a different person to assess
the patient’s level of need? Are the verification
process or eligibility criteria different? Has the timing
of the verification process changed?
Replace: Have there been any changes in the types of
patients admitted? (Probe: Were there any patients not
admitted for inpatient care that you felt should have
been?)
With: Have there been any changes in the types of
patients admitted since [insert start of demonstration
in state]?
PROBE: Were there any patients not admitted for
inpatient care that you felt should have been?
Replace: Describe the stabilization processes you use
to treat psychiatric emergencies.
With: Next, please describe how patients experiencing
a psychiatric emergency are stabilized in the ER.
Replace: Have these changed since the demonstration
was implemented?
With: Have these processes changed since the
demonstration was implemented?

Added to introduce transition to a
different topic.
Revised for clarity.

Revised for clarity.

Revised for clarity.

Revised for clarity.

23

Changes to MEPD ER Staff Member Interview Questions (continued)
Issue
#
22.

Section

Question
#

Action to be
performed
Add as follows:

IX. Context

23.

X. Outcomes

Add as follows:

24.

XI. Closing

Add as follows:

25.

XI. Closing

Add as follows:

26.

XI. Closing

Add as follows:

27.

XI. Closing

Add as follows:

Changes to the Protocol

Reason for the Change

I’d like to talk about the context in which the
demonstration is operating.
I’d like to conclude the interview by talking about
outcomes of the demonstration.
That completes the questions we have you you today.

Added to introduce transition to a
different topic.
Added to introduce transition to a
different topic.
Added for conversational flow and to
make informant aware that the
interview is over.
Added for conversational flow and
rapport-building.
Added for conversational flow and
rapport-building.
Added to let informant know that we
appreciate their time.

Is there anything we should have asked about but
didn’t?
Do you have anything you would like to tell us, or
questions you would like to ask us?
Thank you again for taking the time to speak with us.
We appreciate and value your input.

24

Revisions to Attachment C, Sampling Procedures for Medical Record Review
Issue
#
1.

2.

3.

3.

Section
B1. Sampling
Procedures,
Roster
Descriptions
and Patient
Sample Sizes
by Facility
Types
B1. Sampling
Procedures,
Roster
Descriptions
and Patient
Sample Sizes
by Facility
Types
B1. Sampling
Procedures,
Roster
Descriptions
and Patient
Sample Sizes
by Facility
Types

B1. Sampling
Procedures,
Roster
Descriptions
and Patient
Sample Sizes
by Facility
Types

Action to be
performed
Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: IMDs—The site visit team will request three
different rosters of IMD patients.
With: IMDs—The site visit team will request two
different rosters of IMD patients.

The pilot test found that open medical
records are still on the treatment unit
rather than in medical records storage
and that not all of the information
needed is available in open records.
Therefore, we will no longer be
reviewing open records.

Revise as
follows:

Replace: A total of 10 patients will be chosen from
among the three rosters, as follows:
With: A total of 10 patients will be chosen from
among the two rosters, as follows:

The pilot test found that open medical
records are still on the treatment unit
rather than in medical records storage
and that not all of the information
needed is available in open records.
Therefore, we will no longer be
reviewing open records.

Delete as
follows:

- Two patients will be selected from a roster of
demonstration patients currently receiving inpatient
treatment for 24 hours or more (open medical
records)2. Selecting open medical record for patients
who have been in the IMD for at least 24 hours
ensures that site visitors will be able to assess the
timeliness of completing initial assessments.
This change includes deletion of footnote 2: “We will
arrange in advance for the IMDs to provide this roster
on the day of the site visit.”
Replace: Three patients will be selected from a roster
of demonstration patients discharged 30 - 60 days
prior to the start of the site visit (closed medical
records).
With: Five patients will be selected from a roster of
demonstration patients discharged 30 - 60 days prior to
the start of the site visit (closed medical records).

The pilot test found that open medical
records are still on the treatment unit
rather than in medical records storage
and that not all of the information
needed is available in open records.
Therefore, we will no longer be
reviewing open records.

Revise as
follows:

Instead of reviewing two open
medical records, we will review two
additional closed medical records of
demonstration patients discharged 30
– 60 days prior to the start of the site
visit.

25

Changes to Sampling Procedures for MEPD Medical Record Review (continued)
Issue
#
5.

6.

7.

8.

Section
B1. Sampling
Procedures,
Roster
Descriptions
and Patient
Sample Sizes
by Facility
Types

Action to be
performed
Revise as
follows:

B1. Sampling
Procedures,
Roster
Descriptions
and Patient
Sample Sizes
by Facility
Types
B2. Sampling
Labels

Revise as
follows:

B2. Sampling
Labels

Revise as
follows:

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: - Five patients will be selected from among
Medicaid patients admitted to the ER with psychiatric
emergencies 30 - 60 days prior to the start of the site
visit.
With: • Five patients will be selected from among
Medicaid patients discharged from the ER with
psychiatric emergencies 30 - 60 days prior to the start
of the site visit.
Replace: - Five patients will be selected from among
Medicaid patients admitted to the ER with psychiatric
emergencies 30 - 60 days prior to the implementation
of the demonstration.
With: • Five patients will be selected from among
Medicaid patients discharged from the ER with
psychiatric emergencies 30 - 60 days prior to the
implementation of the demonstration.
Replace: The Mathematica number will indicate the
state, type of facility (IMD, ER, or GH), roster from
which the patient was selected, and a 2-digit suffix
unique to the patient.
With: The Mathematica number will indicate the state,
type of facility (IMD, ER, or GH), and a 2-digit suffix
unique to the patient.
Replace: We will identify IMD patients with open
medical records by suffixes between 11 and 15, IMD
patients discharged 30 - 60 days prior to the site visit
by suffixes between 21 and 25, and IMD patients
discharged 30 - 60 days prior to the demonstration by
suffixes between 31 and 39.
With: We will identify IMD patients discharged 30 60 days prior to the site visit by suffixes between 21
and 29, and IMD patients discharged 30 - 60 days
prior to the demonstration by suffixes between 31 and
39.

Technicality—patients are not
technically “admitted” to ERs.

Technicality—patients are not
technically “admitted” to ERs.

Deleted “roster from which the patient
was selected”—no longer needed
because all rosters will be closed
medical records.

The pilot test found that open medical
records are still on the treatment unit
rather than in medical records storage
and that not all of the information
needed is available in open records.
Therefore, we will no longer be
reviewing open records. Additional
digits needed to cover number of
records obtained.

26

Changes to Sampling Procedures for MEPD Medical Record Review (continued)
Issue
#
9.

Section
B2. Sampling
Labels

Action to be
performed
Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: We will identify patients admitted to an ER
Technicality—patients are not
30 - 60 days prior to the site visit by suffixes between
technically “admitted” to ERs.
41 and 49 and patients admitted to an ER 30 - 60 days
prior to the demonstration by suffixes between 51 and
59.
With: We will identify patients discharged from an ER
30 - 60 days prior to the site visit by suffixes between
41 and 49 and patients discharged from an ER 30 - 60
days prior to the demonstration by suffixes between 51
and 59.

27

Revisions to Attachment D, MEPD Medical Record Review Tool: IMD Medical Records
Issue
#

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

All

Separate
protocols by key
informant group

Revised to allow for ease of
administration.

Add as follows:

For the 60-day Federal Register notice, all medical
record review questions were presented in a single
table with separate columns for each facility type. The
questions have now been divided into separate
protocols for each facility type.
Description of patient characteristics

1.
Access to
Inpatient
Psychiatric Care
2.
Access to
Inpatient
Psychiatric Care

Revise as
follows:

Replace: Referral source
With: Source of referral to this IMD:

Revise as
follows:

5.

3.
Access to
Inpatient
Psychiatric Care

Revise as
follows:

6.

Access to
Inpatient
Psychiatric Care

Add as follows:

Replace: Was patient previously treated at this IMD
for a psychiatric emergency?
If yes, when was patient’s last admission?
With: Was the patient previously admitted to this
IMD?
Replace: Has patient been hospitalized twice or more
for psychiatric emergencies during the past year?
With: Has the patient been hospitalized twice or more
(deleted “for psychiatric emergencies”) during the past
year?
PROBE: During the 12 months prior to the date of this
admission.
Reviewer’s comments/notes about this section:

1.

Section
(Evaluation
Focus)
All

2.

3.
4.

Site visitor will briefly summarize
reason medical record was sampled
for review (e.g., co-morbidities, highrisk behavior, etc.) by describing the
patient’s situation and medical
conditions.
Revised for clarity.
Revised for clarity and ease of data
extraction.

Revised for clarity and ease of data
extraction.

Added space for reviewer notes (if
needed) about this section.

28

Changes to MEPD IMD Medical Record Review Tool (continued)
Issue
#

Section
(Evaluation
Focus)
Boarding Time
in ER

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

4.

Revise as
follows:

Revised for clarity and ease of data
extraction.

8.

Boarding Time
in ER

5.

Revise as
follows:

9.

Boarding Time
in ER

6.

Revise as
follows:

10.

Boarding Time
in ER
Admission to
IMD

Add as follows:

Replace: What date/time was the IMD called to see
whether a bed was available for the patient?
With: When was this IMD contacted about bed
availability for the patient’s most recent visit?
Replace: What date/time was patient transferred to the
IMD?
With: When was the patient transferred to this IMD
for the most recent admission?
Replace: How was the patient transported to the IMD?
-Ambulance
-Receiving IMD’s transportation
-Other (specify)
-Unable to determine
With: How was the patient transported to this hospital?
a.Ambulance
b.Receiving hospital’s transportation
c.Other (Specify)
d.Unable to determine
Reviewer’s comments/notes about this section:

Delete as
follows:

Date of admission authorization to IMD
Time of admission authorization to IMD

Revise as
follows:

Replace: Date of admission to IMD
Time of admission to IMD
With: When was the patient admitted to this hospital?
Date of admission:
Time of admission:
Unable to determine

7.

11.

12.

Admission to
IMD

7.

Revised for clarity and ease of data
extraction.
Revised to use words used by the
facilities to refer to themselves.

Added space for reviewer notes (if
needed) about this section.
Deleted—In pilot site, authorization
given by administrative service
organization and obtained by
emergency room or general hospital;
information not likely found in IMD
records.
Revised for clarity and ease of data
recording.

29

Changes to MEPD IMD Medical Record Review Tool (continued)
Issue
#
13.

Section
(Evaluation
Focus)
Admission to
IMD

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

8.

Revise as
follows:

Replace: Did patient exhibit signs and symptoms of
withdrawal from drugs or alcohol within the first 72
hours of treatment?
With: Did patient exhibit signs and symptoms of
intoxication and/or withdrawal from drugs or alcohol
upon admission?
If yes, describe symptoms of withdrawal exhibited by
patient.
Does the patient have a history of drug or alcohol use?

Broadened to better determine
whether the patient’s psychiatric
emergency was complicated by
substance use.

14.

Admission to
IMD

Delete as
follows:

15.

Admission to
IMD

9.

Revise as
follows:

16.

Admission to
IMD

10.

Revise as
follows:

Deleted to decrease burden and
because may be found among
diagnosis codes (question #12).
Revised for clarity and ease of
administration and data recording.

Replace: Date initial nursing assessment was
completed
Time initial nursing assessment was completed
With: When was the initial nursing assessment
completed?
Date of initial nursing assessment:
Time of initial nursing assessment:
Unable to determine
Replace: Date medical/psychiatric history and physical Revised for clarity and ease of
administration and data recording.
was completed
Time medical/psychiatric history and physical was
completed
With: When was the initial medical (deleted
“psychiatric”) history and physical completed?
Date of initial medical history and physical
Time of initial medical history and physical
Unable to determine

30

Changes to MEPD IMD Medical Record Review Tool (continued)
Issue
#

Section
(Evaluation
Focus)
Admission to
IMD

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

11.

Revise as
follows:

Revised for clarity and ease of
administration and data recording.

18.

Admission to
IMD

12.

Revise as
follows:

19.

Admission to
IMD
Stabilization

Replace: Date initial psychiatric evaluation was
completed
Time initial psychiatric evaluation was completed
With: When was the initial psychiatric evaluation
completed?
Date of initial psychiatric evaluation
Time of initial psychiatric evaluation
Unable to determine
Replace: Diagnoses identified in initial psychiatric
evaluation done at the IMD
With: Which diagnoses were identified in the initial
psychiatric evaluation completed at this hospital?
(Inserted data collection chart with first column listing
Axis I – V in 5 separate rows, second column with
space to record diagnoses, and third column with “Not
Documented” check box.)
Reviewer’s comments/notes about this section:

17.

20.

Add as follows:
14.

Revise as
follows:

Replace: How frequently was documentation provided
regarding whether the patient was suicidal, homicidal,
or a danger to themselves or others?
With: Enter date(s) of stabilization assessment
documentation provided in the medical record
regarding whether the patient was suicidal, homicidal,
or a danger to themselves or others.
(Inserted data collection chart with first column to
record dates of up to 6 stabilzation assessments,
second column with check boxes to indicate if on the
given assessment date the patient expressed suicidal or
homicidal gestures, or is dangerous to self or others.
Check box choices are: Yes, No, Not Documented)

Revised for clarity; chart for ease of
data recording.

Added space for reviewer notes (if
needed) about this section.
Revised for clarity and ease of
administration and data recording.

31

Changes to MEPD IMD Medical Record Review Tool (continued)
Issue
#

Question
#

21.

Section
(Evaluation
Focus)
Stabilization

Action to be
performed

Changes to the Protocol

Reason for the Change

Delete as
follows:

How many utilization reviews were conducted for this
patient during this admission?

15.

Revise as
follows:

Stabilization

16.

Revise as
follows:

Stabilization

17.

Revise as
follows:

Replace: Was the patient chemically restrained while
at the IMD?
With: Was the patient chemically restrained, that is
given psycho-active medication to subdue behavior
while at this IMD?
Yes, patient requested medication
Yes, staff initiated medication
No, skip next question
Unable to determine, skip next question
Replace: If so, what mode of restraint was used?
-Injection
-Oral
-Intravenous
-Unable to determine
What pharmacological agent was administered?
With:
Enter the date(s) and time(s) of chemical restraint,
name of pharmacological agent(s) administered,
dosage, and mode of administration.
-Date
-Time
-Name of Pharmacological Agent(s)
-Dose
-Mode of Administration (IM, IV, PO, or SQ)
(Inserted a 6-row, data collection chart with each item
listed above as a column heading.)
Replace: Was the patient physically restrained while at
the IMD?
With: Was the patient physically restrained while at
this IMD?

Deleted because data not found in
medical records reviewed during pilot
site visit.
Revised for clarity.

22.

Stabilization

23.

24.

Revised for clarity.

Revised for clarity.

32

Changes to MEPD IMD Medical Record Review Tool (continued)
Issue
#

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

25.

Section
(Evaluation
Focus)
Stabilization

18.

Revise as
follows:

Revised for clarity.

26.

Stabilization

19.

Revise as
follows:

Replace: If so, what type of restraint was used?
-Four point leater or cloth restraints
-Physical hold
-Seclusion room
-Hand mitts
-Other (specify)
-Unable to determine
With:
Enter the date(s), time(s), and mode of physical
restraint.
-Date
-Time
-Mode of Restraint (Four point leather or cloth
restraint, physical hold, hand mitts, other
(Inserted a 6-row, data collection chart with each item
listed above)
Replace: Was patient evaluated for an active or
chronic medical condition while in the IMD?
If so, what type of evaluation was conducted?
-Specialist consult
-Laboratory diagnostics
-Radiographic or ultrasonic diagnostics
-Electrocardiogram
-Other
With: Was consultation ordered for evaluation of an
active or chronic medical condition?

Revised for clarity.

33

Changes to MEPD IMD Medical Record Review Tool (continued)
Issue
#

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

27.

Section
(Evaluation
Focus)
Stabilization

20.

Revise as
follows:

Revised for clarity.

28.

Stabilization

21.

Revise as
follows:

29.

Stabilization

22.

Revise as
follows:

30.

Stabilization

Replace: Was patient treated for an active or chronic
medical condition while in the IMD?
If so, what type of treatment was provided?
-Pharmacologic treatment
-Education/support provided
-Transferred to an acute care facility for treatment
-Other (specify)
-Unable to determine
With: Was treatment provided for an active or chronic
medical condition as a result of the consultation?
Replace: Did an injury or infection occur during the
IMD stay?
With: Did an injury or infection occur during the
patient’s stay in this hospital?
Replace: If so, what type?
-Self-inflicted injury
-Nosocomial injury only
-Nosocomial infection only
-Both nosocomial injury and infection
-Neither inury nor infection
-Not applicable
-Don’t know/refused
With:
What type of injury or infection did the patient have?
a. Self-inflicted injury
b. Nosocomial injury only
c. Nosocomial infection only
d. Both nosocomial injury and infection
Reviewer’s comments/notes about this section
(describe stabilization process):

Add as follows:

Revised for clarity.

Revised for clarity.

Added space for reviewer notes (if
needed) about this section.

34

Changes to MEPD IMD Medical Record Review Tool (continued)
Issue
#

Section
(Evaluation
Focus)
Discharge
planning

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

25.

Revise as
follows:

Revised for clarity, moved question
up in order, and deleted NA-OMR
footnote becaues we no longer plan to
review open medical records.

32.

Discharge
planning

23.

Revise as
follows:

33.

Discharge
planning

24.

Revise as
follows:

34.

Discharge
planning

26.

Revise as
follows:

Replace: Date of discharge [NA-OMR*]
*NA-OMR = Item is not applicable for open medical
record reviews.
With: When was the patient discharged from this
IMD?
Date of discharge:
Time of discharge:
Replace: Does the medical record include
documentation indicating that the discharge plan was
initiated at the time of admission?
With: What was the earliest date discharge plans, or a
patient meeting with a discharge planner, was
documented?
-Date:
-Not documented.
Replace: Does the medical record included
documentation indicating that the patient was involved
in the discharge planning process? If so, describe.
With: Does the discharge plan include documentation
of patient’s preferences after discharge?
Replace: Does the medical record include
documentation that staff contacted the patient’s other
providers for input into the discharge plan? If so,
describe (e.g., who contacted, when, by what means,
and for what reason?).
With: Does the medical record include documentation
that IMD staff contacted the patient’s other providers
for input into the discharge plan?

31.

Revised for clarity.

Revised for clarity.

Revised for clarity.

35

Changes to MEPD IMD Medical Record Review Tool (continued)
Issue
#

Section
(Evaluation
Focus)
Discharge
planning

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

27.

Revise as
follows:

Revised for clarity.

36.

Discharge
planning

28.

Revise as
follows:

37.

Discharge
planning

29.

Revise as
follows:

Replace: Does the discharge plan include a follow-up
aftercare appointment within 7 days of the discharge
date?
With: Does the discharge plan include a follow-up
aftercare appointment scheduled within 7 days of the
discharge date?
-Yes
-Yes, but not scheduled for within 7 days of the
discharge date
-No
-Unable to determine
Replace: If so, indicate date of appointment and
provider.
With: Record date of appointment and provider.
Appointment date:
Provider’s name:
Replace: Does the medical record include
documentation that medication reconciliation was
conducted?
With: Does the medical record include documentation
that medication reconciliation was conducted upon
discharge?

35.

Revised for ease of data recording.

Revised for clarity.

36

Revisions to Attachment D, MEPD Medical Record Review Tool: General Hospital Medical Records
Issue
#
1.

Section
(Evaluation
Focus)
All

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

All

Separate
protocols by key
informant group

Revised to allow for ease of
administration.

Add as follows:

For the 60-day Federal Register notice, all medical
record review questions were presented in a single
table with separate columns for each facility type. The
questions have now been divided into separate
protocols for each medical record review at each
facility type. Medical records are reviewed with
assistance from facility staff.
Description of patient characteristics

1.
Access to
Inpatient
Psychiatric Care
Access to
2.
Inpatient
Psychiatric Care

Revise as
follows:

Replace: Referral source
With: Source of referral to this general hospital:

Revise as
follows:

Access to
3.
Inpatient
Psychiatric Care

Revise as
follows:

Replace: Was patient previously treated at this hospital
for a psychiatric emergency?
If yes, when was patient’s last admission?
With: Was the patient previously admitted to this
general hospital for a psychiatric treatment in a nonpsychiatric unit?
Replace: Has patient been hospitalized twice or more
for psychiatric emergencies during the past year?
With: Has the patient been hospitalized twice or more
(deleted “for psychiatric emergencies”) during the past
year?
PROBE: During the 12 months prior to the date of this
admission.

2.

3.
4.

5.

Site visitor will briefly summarize
reason medical record was sampled
for review (e.g., co-morbidities or
high risk behaviors or multiple
admissions). This provides a brief
description of patient’s situation and
medical conditions.
Revised for clarity.
Revised for clarity and ease of data
extraction.

Revised for clarity and ease of data
extraction.

37

Changes to MEPD General Hospital Medical Record Review Tool (continued)
Issue
#

Section
Question
(Evaluation
#
Focus)
Access to
Inpatient
Psychiatric Care
Boarding Time 4.
in ER

Action to be
performed

Changes to the Protocol

Reason for the Change

Add as follows:

Reviewer’s comments/notes about this section:

Added space for reviewer notes (if
needed) about this section.

Revise as
follows:

Revised for clarity and ease of data
extraction.

8.

Boarding Time
in ER

5.

Revise as
follows:

9.

Boarding Time
in ER

6.

Revise as
follows:

10.

Boarding Time
in ER
Admission to
GH

Add as follows:

Replace: What date/time was the GH unit called to see
whether a bed was available for the patient?
With: When was this general hospital contacted about
bed availability for the patient’s most recent visit?
Replace: What date/time was patient transferred to the
IMD?
With: When was the patient transferred to this general
hospital for the most recent admission?
Replace: How was the patient transported to the IMD?
-Ambulance
-Receiving IMD’s transportation
-Other (specify)
-Unable to determine
With: How was the patient transported to this general
hospital?
a.Ambulance
b.Receiving hospital’s transportation
c.Other (Specify)
d.Unable to determine
Reviewer’s comments/notes about this section:

Delete as
follows:

Date of admission authorization to GH
Time of admission authorization to GH

6.
7.

11.

Revised for clarity and ease of data
extraction.
Revised to correct intention.

Added space for reviewer notes (if
needed) about this section.
Deleted—In pilot site, authorization
given by administrative service
organization; information not likely
found in medical records.

38

Changes to MEPD General Hospital Medical Record Review Tool (continued)
Issue
#

Section
(Evaluation
Focus)
Admission to
GH

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

7.

Revise as
follows:

Revised for clarity and ease of data
recording.

13.

Admission to
GH

8.

Revise as
follows:

14.

Admission to
GH

Replace: Date of admission to GH
Time of admission to GH
With: When was the patient admitted to this general
hospital?
Date of admission:
Time of admission:
Unable to determine
Replace: Did patient exhibit signs and symptoms of
withdrawal from drugs or alcohol within the first 72
hours of treatment?
With: Did patient exhibit signs and symptoms of
intoxication and/or withdrawal from drugs or alcohol
upon admission?
If yes, describe symptoms of withdrawal exhibited by
patient.
Does the patient have a history of drug or alcohol use?

15.

Admission to
GH

12.

Delete as
follows:
9.

Revise as
follows:

Replace: Date initial nursing assessment was
completed
Time initial nursing assessment was completed
With: When was the initial nursing assessment
completed?
Date of initial nursing assessment:
Time of initial nursing assessment:
Unable to determine

Broadened to better determine
whether the patient’s psychiatric
emergency was complicated by
substance use.

Deleted to decrease burden and
because may be found among
diagnosis codes (question #12).
Revised for clarity and ease of
administration and data recording.

39

Changes to MEPD General Hospital Medical Record Review Tool (continued)
Issue
#

Section
(Evaluation
Focus)
Admission to
GH

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

10.

Revise as
follows:

Revised for clarity and ease of
administration and data recording.

17.

Admission to
GH

11.

Revise as
follows:

18.

Admission to
GH

12.

Revise as
follows:

19.

Admission to
GH

Replace: Date medical/psychiatric history and physical
was completed
Time medical/psychiatric history and physical was
completed
With: When was the initial medical (deleted
“psychiatric”) history and physical completed?
Date of initial medical history and physical
Time of initial medical history and physical
Unable to determine
Replace: Date initial psychiatric evaluation was
completed
Time initial psychiatric evaluation was completed
With: When was the initial psychiatric evaluation
completed?
Date of initial psychiatric evaluation
Time of initial psychiatric evaluation
Unable to determine
Replace: Diagnoses identified in initial psychiatric
evaluation done at the general hospital
With: Which diagnoses were identified in the initial
psychiatric evaluation completed at this hospital?
(Inserted data collection chart with first column listing
Axis I – V in separate rows, second column with
space to record diagnoses, and third column with “Not
Documented” check box.
Reviewer’s comments/notes about this section:

16.

Add as follows:

Revised for clarity and ease of
administration and data recording.

Revised for clarity; chart for ease of
data recording.

Added space for reviewer notes (if
needed) about this section.

40

Changes to MEPD General Hospital Medical Record Review Tool (continued)
Issue
#
20.

Section
(Evaluation
Focus)
Stabilization

21.

Stabilization

22.

Stabilization

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

14.

Revise as
follows:

Replace: How frequently was documentation provided
regarding whether the patient was suicidal, homicidal,
or a danger to themselves or others?
With: Enter date(s) of stabilization assessment
documentation provided in the medical record
regarding whether the patient was suicidal, homicidal,
or a danger to themselves or others.
(Inserted data collection chart with first column to
record dates of up to 6 stabilization assessments,
second column with check boxes to indicate if on the
given assessment date the patient expressed suicidal or
homicidal gestures, or is dangerous to self or others.
Check box choices are: Yes, No, Not Documented)
How many utilization reviews were conducted for this
patient during this admission?

Revised for clarity and ease of
administration and data recording.

Delete as
follows:
15.

Revise as
follows:

Replace: Was the patient chemically restrained while
at the general hospital?
With: Was the patient chemically restrained, that is
given psycho-active medication to subdue behavior
while at this general hospital?
Yes, patient requested medication
Yes, staff initiated medication
No, skip next question
Unable to determine, skip next question

Deleted because data not found in
medical records reviewed during pilot
site visit.
Revised for clarity.

41

Changes to MEPD General Hospital Medical Record Review Tool (continued)
Issue
#

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

23.

Section
(Evaluation
Focus)
Stabilization

16.

Revise as
follows:

Revised for clarity.

24.

Stabilization

17.

Revise as
follows:

Replace: If so, what mode of restraint was used?
-Injection
-Oral
-Intravenous
-Unable to determine
What pharmacological agent was administered?
With:
Enter the date(s) and time(s) of chemical restraint,
name of pharmacological agent(s) administered,
dosage, and mode of administration.
-Date
-Time
-Name of Pharmacological Agent(s)
-Dose
-Mode of Administration (IM, IV, PO, or SQ)
(Inserted a 6-row, data collection chart with each item
listed above as a column heading.)
Replace: Was the patient physically restrained while at
the hospital?
With: Was the patient physically restrained while at
this general hospital?

Revised for clarity.

42

Changes to MEPD General Hospital Medical Record Review Tool (continued)
Issue
#

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

25.

Section
(Evaluation
Focus)
Stabilization

18.

Revise as
follows:

Revised for clarity.

26.

Stabilization

19.

Revise as
follows:

Replace: If so, what type of restraint was used?
-Four point leater or cloth restraints
-Physical hold
-Seclusion room
-Hand mitts
-Other (specify)
-Unable to determine
With:
Enter the date(s), time(s), and mode of physical
restraint.
-Date
-Time
-Mode of Restraint (Four point leather or cloth
restraint, physical hold, hand mitts, other
(Inserted a 6-row, data collection chart with each item
listed above)
Replace: Was patient evaluated for an active or
chronic medical condition while in the general
hospital?
If so, what type of evaluation was conducted?
-Specialist consult
-Laboratory diagnostics
-Radiographic or ultrasonic diagnostics
-Electrocardiogram
-Other
With: Was consultation ordered for evaluation of an
active or chronic medical condition?

Revised for clarity.

43

Changes to MEPD General Hospital Medical Record Review Tool (continued)
Issue
#

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

27.

Section
(Evaluation
Focus)
Stabilization

20.

Revise as
follows:

Revised for clarity.

28.

Stabilization

21.

Revise as
follows:

29.

Stabilization

22.

Revise as
follows:

30.

Stabilization

Replace: Was patient treated for an active or chronic
medical condition while in the hospital?
If so, what type of treatment was provided?
-Pharmacologic treatment
-Education/support provided
-Transferred to an acute care facility for treatment
-Other (specify)
-Unable to determine
With: Was treatment provided for an active or chronic
medical condition as a result of the consultation?
-Yes, treatment was provided at this facility
-Yes, treatment was provided at a different facility
-No
Replace: Did an injury or infection occur during the
general hospital stay?
With: Did an injury or infection occur during the
patient’s stay in this hospital?
Replace: If so, what type?
-Self-inflicted injury
-Nosocomial injury only
-Nosocomial infection only
-Both nosocomial injury and infection
-Neither inury nor infection
-Not applicable
-Don’t know/refused
With:
What type of injury or infection did the patient have?
a. Self-inflicted injury
b. Nosocomial injury only
c. Nosocomial infection only
d. Both nosocomial injury and infection
Reviewer’s comments/notes about this section
(describe stabilization process):

Add as follows:

Revised for clarity.

Revised for clarity.

Added space for reviewer notes (if
needed) about this section.
44

Changes to MEPD General Hospital Medical Record Review Tool (continued)
Issue
#

Section
(Evaluation
Focus)
Discharge
planning

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

25.

Revise as
follows:

Revised for clarity, moved question
up in order, and deleted NA-OMR
footnote because we no longer plan to
review open medical records.

32.

Discharge
planning

23.

Revise as
follows:

33.

Discharge
planning

24.

Revise as
follows:

34.

Discharge
planning

26.

Revise as
follows:

Replace: Date of discharge
With: When was the patient discharged from this
general hospital?
Date of discharge:
Time of discharge:
Replace: Does the medical record include
documentation indicating that the discharge plan was
initiated at the time of admission?
With: What was the earliest date discharge plans, or a
patient meeting with a discharge planner, was
documented?
-Date:
-Not documented.
Replace: Does the medical record included
documentation indicating that the patient was involved
in the discharge planning process? If so, describe.
With: Does the discharge plan include documentation
of patient’s preferences after discharge?
Replace: Does the medical record include
documentation that staff contacted the patient’s other
providers for input into the discharge plan? If so,
describe (e.g., who contacted, when, by what means,
and for what reason?).
With: Does the medical record include documentation
that general hospital staff contacted the patient’s other
providers for input into the discharge plan?

31.

Revised for clarity.

Revised for clarity.

Revised for clarity.

45

Changes to MEPD General Hospital Medical Record Review Tool (continued)
Issue
#

Section
(Evaluation
Focus)
Discharge
planning

Question
#

Action to be
performed

Changes to the Protocol

Reason for the Change

27.

Revise as
follows:

Revised for clarity.

36.

Discharge
planning

28.

Revise as
follows:

37.

Discharge
planning

29.

Revise as
follows:

Replace: Does the discharge plan include a follow-up
aftercare appointment within 7 days of the discharge
date?
With: Does the discharge plan include a follow-up
aftercare appointment scheduled within 7 days of the
discharge date?
-Yes
-Yes, but not scheduled for within 7 days of the
discharge date
-No
-Unable to determine
Replace: If so, indicate date of appointment and
provider.
With: Record date of appointment and provider.
Appointment date:
Provider’s name:
Replace: Does the medical record include
documentation that medication reconciliation was
conducted?
With: Does the medical record include documentation
that medication reconciliation was conducted upon
discharge?

35.

Revised for ease of data recording.

Revised for clarity.

46

Revisions to Attachment D, MEPD Medical Record Review Tool: ER Medical Records
Issue
#
1.

Section
All

Question
#*
All

2.

Action to be
performed
Separate
protocols by key
informant group
Add as follows:

3.

Admission to
Emergency
Room (ER)

1.

Revise as
follows:

4.

Admisison to
Emergency
Room (ER)
Admission to
Emergency
Room (ER)

2.

Revise as
follows:

3.

Add as follows:

4.

Add as follows:

5.

6.

Admission to
Emergency
Room (ER)

Changes to the Protocol

Reason for the Change

For the 60-day Federal Register notice, all interview
questions were presented in a single table with
separate columns for each key informant group. The
questions have now been divided into separate
protocols for each key informant group.
Description of patient characteristics

Revised to allow for ease of
administration.

Replace: Date of admission to ER
Time of admission to ER
With:
When was the patient admitted to the ER?
Date of admission to ER
Time of admission to ER
Replace: Was patient Medicaid number identified?
With: Was the patient’s Medicaid number identified in
the medical record?
When was the initial medical history and physical
examination completed?

Site visitor will briefly summarize
reason medical record was sampled
for review (e.g., co-morbidities, risky
behavior, etc.) by providing a brief
description of the patient’s situation
and medical conditions.
Revised for clarity.

Revised for clarity

Added to establish timeline of steps
occurring in ER and to distinguish
evaluation of an active or chronic
medical condition (questions 14) from
initial examination.
When was the patient medically cleared by a provider? Added to establish timeline of steps
occurring in ER.

47

Changes to MEPD ER Medical Record Review Tool (continued)
Issue
#
7.

Section
Admission to
Emergency
Room (ER)

Question
#*
5.

Action to be
performed
Revise as
follows:

8.

Admission to
Emergency
Room (ER)

6.

Revise as
follows:

9.

Admission to
Emergency
Room (ER)

7.

Revise as
follows:

10.

Admission to
Emergency
Room (ER)

8.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: Was patient identified as
-suicidal?
-homicidal?
-dangerous to themselves?
-dangerous to others?
With: Upon admission to ER, was the patient
identified as…
a. Suicidal?
b. Homicidal?
c. Dangerous to themselves?
d. Dangerous to others?
e. Unable to determine
Replace: What date/time was the patient assessed by a
provider to determine whether psychiatric inpatient
treatment was necessary?
With: When was the patient assessed by a provider to
determine whether inpatient psychiatric treatment was
necessary?
Date psychiatric emergency determined:
Time psychiatric emergency was determined:
Replace: What type of provider conducted the
assessment?
With: What type of provider determined the presence
of a psychiatric emergency?
Replace: Was eligibility for the demonstration
assessed while patient was in the ER? [Not
applicable/Pre-Demonstration]
With: Was eligibility for the demonstration indicated
in the ER medical record?
Yes, patient eligible
Yes, patient not eligible
Not documented
Not applicable, pre-demonstration

Revised for clarity

Revised for clarity and ease of data
recording.

Revised for clarity

Revised for clarity

48

Changes to MEPD ER Medical Record Review Tool (continued)
Issue
#
11.

12.

Section
Admission to
Emergency
Room (ER)

Question
#*
9.

Action to be
performed
Revise as
follows:

13.

Admission to
Emergency
Room (ER)
Stabilization

Add as follows:
11.

Revise as
follows:

14.

Stabilization

13.

Revise as
follows:

15.

Stabilization

15.

Revise as
follows:

16.

Stabilization

17.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: Diagnoses identified in initial psychiatric
evaluation done at the emergency room
With: Which diagnoses were identified in the initial
psychiatric evaluation completed at this ER?
(Inserted data collection chart with first column listing
Axis I – V in 5 separate rows, second column with
space to record diagnoses, and third column with “Not
Documented” check box.)
Reviewer’s comments/notes about this section:

Revised for clarity and ease of data
recording

Replace: If so, what type of evaluation was
conducted?
-Specialist consult
-Laboratory diagnostics
-Other
-Unable to determine
With: What type of evaluation was conducted?
a. Specialist consult
b. Laboratory diagnostics
c. Other, Specify:
d. Unable to determine
Replace: If so, what type of treatment was provided?
With: What type of treatment was provided to the
patient?
Replace: If so, what type of evaluation was
conducted?
With: What type of evaluation was conducted?
Replace: If so, what type of treatment was provided?
With: What type of treatment was provided to the
patient?

Revised for clarity

Added space for reviewer notes (if
needed) about this section.

Skip pattern negates need for “If so.”
Revised for clarity.
Skip pattern negates need for “If so.”
Skip pattern negates need for “If so.”
Revised for clarity.

49

Changes to MEPD ER Medical Record Review Tool (continued)
Issue
#
17.

Section
Stabilization

Question
#*
18.

Action to be
performed
Revise as
follows:

18.

Stabilization

19.

Revise as
follows:

19.

Stabilization

20.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: Was the patient chemically restrained while
at the ER?
With: Was the patient chemically restrained, that is,
given psycho-active medication to subdue behavior
while at this ER?
-Yes, patient requested medication
-Yes, staff initiated medication
-No
-Unable to determine
Replace: If so, what mode of restraint was used?
-Injection
-Oral
-Intravenous
-Unable to determine
What pharmacological agent was administered?
With:
Enter the date(s) and time(s) of chemical restraint,
name of pharmacological agent(s) administered,
dosage, and mode of administration.
-Date
-Time
-Name of Pharmacological Agent(s)
-Dose
-Mode of Administration (IM, IV, PO, or SQ)
(Inserted a 6-row, data collection chart with each item
listed above as a column heading.)
Replace: Was the patient physically restrained while at
the ER?
With: Was the patient physically restrained while at
this ER?

Revised for clarity and ease of data
recording.

Revised for clarity

Revised for clarity

50

Changes to MEPD ER Medical Record Review Tool (continued)
Issue
#
20.

Section
Stabilization

Question
#*
21.

Action to be
performed
Revise as
follows:

21.

23.
Access to
Inpatient
Psychiatric Care

Revise as
follows:

22.

Access to
24.
Inpatient
Psychiatric Care

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: If so, what type of restraint was used?
-Four point leater or cloth restraints
-Physical hold
-Seclusion room
-Hand mitts
-Other (specify)
-Unable to determine
With:
Enter the date(s), time(s), and mode of physical
restraint.
-Date
-Time
-Mode of Restraint (Four point leather or cloth
restraint, physical hold, hand mitts, other
(Inserted a 6-row, data collection chart with each item
listed above)
Replace: What facilities were called to see whether a
bed was available for the patient?
What date/time was a bed located that would accept
the patient?
With: What facilities were contacted to see whether a
bed was available for the patient?
(Inserted 4-row chart with the following data
collection items as column headings for each facility
contacted: Name of facility; Date contacted for bed
availability; Time contacted for bed availability; Date
patient accepted for bed; Time patient accepted for
bed.)
Replace: Date of discharge from ER
Time of discharge from ER
With: When was the patient discharged from the ER?
Date of discharge from ER:
Time of discharge from ER:

Revised for clarity and added a chart
for ease of administration and data
recording.

Revised for clarity and added a chart
for ease of administration and data
recording.

Revised for clarity and ease of data
recording.

51

Changes to MEPD ER Medical Record Review Tool (continued)
*The order of the questions was changed significantly to facilitate flow of data collection. Question numbers are those in the revised protocol (questions
were not numbered in the previous version of the protocol).

52

Revisions to Attachment B, Key Informant Interview Questions: MEPD Beneficiary Interview Questions
Issue Section
#
1.
All

2.

I. Introduction

Question #
All

Action to be
performed
Separate
protocols by
key informant
group
Add as
follows:

Changes to the Protocol

Reason for the Change

For the 60-day Federal Register notice, all
interview questions were presented in a single
table with separate columns for each key
informant group. The questions have now been
divided into separate protocols for each key
informant group.
Hi, can I please speak with [beneficiary first
and last name]?
If beneficiary answers the phone: This is
[interviewer name] from Mathematica Policy
Research. I’m calling because you agreed to
participate in an interview. Does this sound
familiar to you? [Interviewer pause and wait
for recognition to ensure we have correct
person on the phone].
I’d like to hear your perspective on the
experience you had recently at [IMD]. You
mentioned that you were available to talk with
us today - is this still a good time? [If not,
schedule another day/time and confirm contact
information].
Thanks so much for taking the time to talk with
me today. You will receive a $20 check in the
mail for completing the interview. [If there is
a note taker on the phone] I have another
staff member [colleague’s name] from our
company on the phone today to take notes
during our discussion. Is that OK with you? [If
not, have colleague hang up and the
interviewer will take notes].

Revised to allow for ease of administration.

Added to provide instruction to the
interviewer to remind the beneficiary about
their prior consent without violating
confidentiality if someone else answers the
phone. Provides script for obtaining
permission to record the interview and have
a second notetaker present. Reminds the
beneficiary of confidentiality and right to
not answer questions.

53

Changes to MEPD Beneficiary Interview Questions (continued)
Issue Section
#
2
(continued)

3.
4.

Access to
Inpatient
Psychiatric Care
Access to
Inpatient
Psychiatric Care

Question #

Action to be
performed

Delete as
follows:
1c.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Are you comfortable with our discussion being
audio taped to ensure that we remember
everything correctly? The audio tape will be
destroyed after 90 days. I want to remind you
that your answers will be kept confidential in
that your name will not be associated with your
answers.
Your answers are really important to help us
learn about quality of care for people
experiencing psychiatric emergencies. If I go
through the questions too quickly or you don’t
understand something, please stop me at any
point. Talking about your hospital stay may
bring up sensitive issues. If there are any
questions you do not want to answer, we can
skip them or end the discussion at any time.
Please just let me know, and I will move on to
the next question. Do you have any questions
before we begin?
How does it compare to other places you might
have gone or that you have gone in the past?

Deleted because solicits same information
as other questions in the section.

Replace: How many other times this year
(2013) did you seek help for an emotional or
mental crisis?
With: How many other times since [state
demonstration start date] did you seek help for
an emotional or mental crisis through an
emergency room, hospital, or other crisis
service?

Revised to clarify timing in relation to the
start of the demonstration.

54

Changes to MEPD Beneficiary Interview Questions (continued)
Issue Section
#
5.
Access to
Inpatient
Psychiatric Care

Question #
1d.i.

Action to be
performed
Revise as
follows:

6.

Access to
Inpatient
Psychiatric Care

1d.ii

Revise as
follows:

7.

Access to
Inpatient
Psychiatric Care

1d.iii

Revise as
follows:

8.

Access to
Inpatient
Psychiatric Care

2., 2a.-2e.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: [If sought help other times this year]
When you had other crises, were you also
admitted to a hospital? If so, did you go to the
same hospital as this time?
With: [If sought help other times since the
demonstration began] When you had other
crises, were you also admitted to a hospital? If
so, did you go to [IMD]?
Replace: If not, where did you go instead of
[IMD]? How did it compare to [IMD]?
With: [If did not go to [IMD] Where did you
go instead of [IMD]? How did it compare to
[IMD]?
Replace: Where would you prefer to go in the
future?
With: Where would you prefer to go in the
future? Why?
Replace: Now I’d like to ask you the same
question, but for last year. In 2012, how many
times did you seek help for an emotional or
mental crisis through an emergency room,
hospital, or other crisis service?
(Probe: That would be in the
year before last Christmas. Do you think you
went to the emergency room more or less often
than this year, or about the same?)
[If sought help at any time during 2012]:
When you had other crises in the past (2012),
were you also admitted to a hospital? If so, did
you go to the same hospital as this time? If not,
where did you go instead of [IMD]?

Revised for clarity.

Clarified interviewer instruction rather than
asking the beneficiary “if not.”

Added probe to solicit comparative
information.
Revised to simplify, to clarify timing in
relation to the start of the demonstration,
and to improve conversational flow.

55

Changes to MEPD Beneficiary Interview Questions (continued)
Issue Section
#
8.
(continued)

Question #

Action to be
performed

Changes to the Protocol
[If no crises in 2012] When was the last time
(before 2013) that you sought help for an
emotional or mental crisis through an
emergency room, hospital, or other crisis
service? [If sought help before 2013]: Were ou
admitted to the hospital? If so, did you go to
the same hospital as this time? If not, where did
you go instead of [IMD]?
With: Before [state demonstration start date],
how many times did you seek help for an
emotional or mental crisis through an
emergency room, hospital, or other crisis
service?
a. [If sought help at any time prior to [state
demonstration start date] and used an
emergency room] About how many times per
year did you use the emergency room for a
psychiatric emergency before [state
demonstration date]? How many times have
you used the emergency room for a psychiatric
emergency since [state demonstration start
date]? (Probe: Do you think you went to the
emergency room more or less this past year
compared to years before?)
b. [If experienced any crisis before
demonstration start date] When was the last
time before [state demonstration start date] that
you sought help for an emotional or mental
crisis through an emergency room, hospital, or
other crisis service?
c. Were you admitted to the hospital?
d. If so, did you go to [IMD]?
e. [If did not go to [IMD]] Where did you go
instead of [IMD]? How did it compare to
[IMD]? (Probe: admission process, types of
treatment received)

Reason for the Change

56

Changes to MEPD Beneficiary Interview Questions (continued)
Issue Section
#
9.
Access to
Inpatient
Psychiatric Care

Question #
Interviewer
note

Action to be
performed
Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: If beneficiary has not experienced
prior crises, omit all questions regarding prior
crises throughout the remainder of the protocol.
With: If beneficiary has not experienced crises
within 3 years prior to [date of demonstration]
that required hospitalization, omit all questions
regarding prior crises throughout the remainder
of the protocol. If beneficiary has experienced
a crisis within 3 years prior to [date of
demonstration] that required hospitalization,
note the approximate date of that crisis and any
other details provided so that you can refer
clearly to that event throughout the interview.
We are interested in comparing (1) the
hospitalization that occurred just prior to the
site visits and (2) the most recent
hospitalization (if any) before the
demonstration date.

Clarified interviewer instructions to
facilitate administration. Limited number of
years back that we are asking beneficiary to
remember, to reduce burden and improve
reliability.

57

Changes to MEPD Beneficiary Interview Questions (continued)
Issue Section
#
10. Boarding Time in
the ER

Question #
3.

Action to be
performed
Revise as
follows:

Changes to the Protocol

Reason for the Change

Revised for clarity, using the term “walk
Replace: I know that the hospital admission
process can often be quite challenging. In your in” as a probe.
situation, do you recall going to an emergency
room before going into [IMD] (last month)? If
so, which emergency room did you use? If not,
how did you get into the hospital? (Probe: Did
a doctor admit you directly into the hospital?
Did a mobile crisis team take you there? Did
you go directly to the hospital yourself?)
With: I know that the hospital admission
process can often be quite challenging. In your
situation, do you recall going to an emergency
room right before going into [IMD]? If so,
which emergency room did you use? If not,
how did you get into the hospital? [Interviewer
note: keep the discussion focused on their
hospital admission before the site visit]
(Probe: Did a doctor admit you directly into the
hospital? Did a mobile crisis team take you
there? Did you go directly to the hospital
yourself (walk-in)?)

58

Changes to MEPD Beneficiary Interview Questions (continued)
Issue Section
#
11. Boarding Time in
the ER

12.

Boarding Time in
the ER

Question #
3d, 3i

3e, 3j

Action to be
performed
Revise as
follows:

Add as
follows:

Changes to the Protocol

Reason for the Change

Replace: To the best of your ability, could you
describe what your experience was like while
waiting in the emergency room or general
medical unit? What type of treatment did you
receive (e.g., counseling, medication)? What
was the environment like?
With: To the best of your ability, could you
describe what your experience was like while
waiting in the emergency room (or general
medical unit or alternative)? What type of
treatment did you receive (e.g., counseling,
medication)? What was the environment like?
Or, if walk-in to IMD, with: To the best of
your ability, could you describe what your
experience was like while waiting to be
admitted to [IMD]? What type of treatment did
you receive (e.g., counseling, medication)?
What was the environment like?
Replace: For prior crises, did you use the same
emergency room (or crisis service)? If not, how
did you get help?
With: For [the crisis prior to demonstration
date], did you use the same emergency room
(or alternative)? If not, how did you get help?
Or, if walk-in to IMD, with:
For [the crisis prior to demonstration date],
how did you get help? (Probe: walk-in,
emergency room or alternative)

Demonstration payment and monitoring
data show that few of the demonstration
participants go to emergency rooms before
admission to the IMD. Revised for those
who do not.

Revised to clarify relation to demonstration
start date and allow for admissions not
preceded by emergency room visits.

59

Changes to MEPD Beneficiary Interview Questions (continued)
Issue Section
#
13. Boarding Time in
the ER

14.

Boarding Time in
the ER

Question #
3f., 3k

3g, 3l

Action to be
performed
Revise as
follows:

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: [If experienced prior crises in 2012
or earlier, ask the following questions;
otherwise, skip to the Referral and Admission
section]: How did your experiences during
your most recent crisis compare to your
experiences during prior crises?
With: How did your experiences waiting for
admission during your most recent crisis
compare to your experiences during [the crisis
prior to the demonstration date]?
Replace: In the past, when you went to an
emergency room for an emotional or mental
crisis and needed hospitalization, did you wait
a longer or shorter time to be admitted to a
hospital than the most recent time?
With: For [the crisis prior to demonstration
date], when you went to an emergency room
(or alternative) for an emotional or mental
crisis and needed hospitalization, did you wait
a longer or shorter time to be admitted to a
hospital than the most recent time?
Or, if walk-in to IMD, with: For [the crisis
prior to demonstration date], did you wait a
longer or shorter time to be admitted to a
hospital than the most recent time?

Revised to clarify relation to demonstration
start date and allow for admissions not
preceded by emergency room visits.

Revised to clarify relation to demonstration
start date and allow for admissions not
preceded by emergency room visits.

60

Changes to MEPD Beneficiary Interview Questions (continued)
Issue Section
#
15. Boarding Time in
the ER

Question #
3h, 3m

Action to be
performed
Revise as
follows:

16.

Referral and
Admission

4.

Revise as
follows:

17.

Referral and
Admission

4a.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: In the past, did the emergency room
ever move you to a bed in the main part of the
hospital? If so, what kind of unit was it?
(Probe: psychiatric unit, other unit?)
How long did you stay there?
With: [If ER was used for crisis prior to
demonstration date] For [the crisis prior to
demonstration date], did the emergency room
ever move you to a bed in the main part of the
hospital? If so, what kind of unit was it?
(Probe: psychiatric unit, other unit?) How long
did you stay there?
Replace: Why did you first go to the
emergency room (or alternative) before you
were hospitalized most recently?
With: Why did you first go to the emergency
room (or alternative) before you were
hospitalized?
Or, if walk-in to IMD, with: What led you to
go to [IMD]?
Replace: Do you recall feeling suicidal,
homicidal, or that you were a danger to
yourself or others? Did the emergency (or
crisis) staff ask you questions about this?
With: Do you recall feeling suicidal,
homicidal, or that you were a danger to
yourself or others? Did the emergency staff (or
alternative or IMD staff) ask you questions
about this?

Revised to clarify relation to demonstration
start date and allow for admissions not
preceded by emergency room visits.

Added language to recognize possibility of
walk-in.

Revised to recognize possibility of walk-in.

61

Changes to MEPD Beneficiary Interview Questions (continued)
Issue Section
#
18. Referral and
Admission

Question #
4d.

Action to be
performed
Revise as
follows:

19.

Referral and
Admission

4e.

Revise as
follows:

20.

Stabilization

5.

Revise as
follows:

21.

Stabilization

5a.

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: Did you give your [name of Medicaid
program] card to someone at the hospital? Did
someone explain to you which hospital you
would go to and what was happening?
With: Did you give your Medicaid card to
someone at the emergency room (or
alternative)? Did someone explain to you
which hospital you would go to and what was
happening?
Or, if walk-in to IMD, with: Did you give your
Medicaid card to someone at [IMD]?
Replace: How did your experience during this
most recent crisis compare to previous crises?
Did you notice anything different this time?
With: How did your experience with referral
and admission to [IMD] during this most recent
crisis compare to [the crisis prior to
demonstration date]? Did you notice anything
different this time?
Replace: What types of group or individual
activities did you engage in while you were in
the hospital?
With: What types of group or individual
activities did you engage in while you were at
[IMD]?
Replace: Were these activities helpful? If so,
how?
With: Were these activities helpful? If so, how?
If not, why not?

Revised for clarity and to add alternative
hospital or walk-in.

Revised for clarity.

Revised for clarity.

Revised for clarity.

62

Changes to MEPD Beneficiary Interview Questions (continued)
Issue Section
#
22. Stabilization

Question #
5f.

Action to be
performed
Revise as
follows:

23.

Discharge
Planning

7.

Revise as
follows:

24.

Discharge
Planning

7g.

Add as
follows:

Changes to the Protocol

Reason for the Change

Replace: How did the care you received
compare to care you have received during other
hospitalizations for your mental health?
With: How did the care you received compare
to care you have received during the
hospitalization for your mental health prior to
[the demonstration date]?
Replace: When patients are ready to leave the
hospital, the hospital may give them
instructions about what to do after leaving the
hospital. This is called a discharge plan.
Sometimes it includes instructions about which
medications to take, when to see the doctor, or
where to go if you have questions or need help.
Did you receive instructions like this before
you left the hospital?
With: When patients are ready to leave the
hospital, the hospital may give them
instructions about what to do after leaving the
hospital. This is called a discharge plan.
Sometimes it includes instructions about which
medications to take, when to see the doctor, or
where to go if you have questions or need help.
Did you receive instructions like this before
you left [IMD]?
Did the services or support you received after
you left the hospital seem different from what
you received when you left the hospital back in
[date of crisis prior to demonstration]?

Revised to clarify relation to demonstration
start date.

Revised for clarity.

Added to obtain comparative data.

63

Changes to MEPD Beneficiary Interview Questions (continued)
Issue Section
#
25. Closing/FollowUp

Question #

Action to be
performed
Add as
follows:

Changes to the Protocol

Reason for the Change

That completes the questions we have for you
today. [If there is remaining time: Is there
anything we should have asked about but
didn’t? Do you have anything else you would
like to tell us, or questions you would like to
ask us?] I’d like to give you the phone number
for the crisis hotline so that you can contact
someone who can help you if, for any reason,
you feel upset after ending the call with us. Do
you have something to write it down? It’s 1800-273-8255. It’s pretty easy to remember if
you need it because it spells out 1-800-273TALK.
I also just want to make sure that the
information I have is correct so that I can send
you a check in appreciation for your
completing the interview. [Go over spelling of
name, address, and, if relevant, fiduciary
guardian information]. OK, so we will process
this as soon as possible to get you your check
[if respondent wants to know when they will
receive the check say “you should receive the
check in about 6 weeks”]. Thank you so much
for taking the time to speak with us - we really
appreciate and value your input.

Added to let the beneficiary know that the
interview is over and the next steps for
receiving promised payment. Crisis hotline
number provided to the beneficiary so they
can call if, for any reason, they feel upset
after ending the call with us.

64

Revisions to Attachment E, MEPD Beneficiary Consent Form and Recruitment Script
Issue
#
1.

Section

Item

Action to be
performed
Revise as
follows:

Changes to the Protocol

Reason for the Change

Beneficiary
Consent Form

Paragraph 5

Replace: The audiotape will be destroyed after the
contents are transcribed, no later than seven days after
the interview.
With: The audio tape will be destroyed
after the contents are transcribed, no later than 90 days
after the interview.
All reference to “patient” changed to “beneficiary.”

Pilot test revealed that seven days was
not enough time to have the contents
transcribed and checked to ensure
accuracy and completeness.

2.

Recruitment
Script

All

Revise as
follows:

3.

Recruitment
Script

Paragraph 3

Revise as
follows:

Replace: BE SURE TO GIVE THE PATIENT A
COPY OF THE CONSENT FORM AND THE
STUDY FACT SHEET.
With: STAFF MEMBER, HAND FACT SHEET TO
BENEFICIARY AND SAY: This sheet provides
information about the study.

4.

Recruitment
Script

Paragraphs
4 and 5

Add as
follows:

Do you think you might like to participate?
YES
STAFF MEMBER, TURN PAGE OVER
AND FOLLOW INSTRUCTIONS
NO
STAFF MEMBER REPLY TO
BENEFICIARY: Thank you for your
consideration.

Reworded in order to remind IMD
staff to only obtain consents from
Medicaid beneficiaries participating in
the demonstration.
Revised instruction for ease of
administration and clarification
purposes. Moved instruction from the
end of the script to the beginning.

Added for clarification and ease of
administration purposes.

65

Changes to MEPD Beneficiary Consent Form and Recruitment Script (continued)
Issue
#
5.

6.

Section

Item

Recruitment
Script

Staff
Member
Instructions,
Bullet 1

Recruitment
Script

Staff
Member
Instructions,
Bullet 2

Action to be
performed
Revise as
follows:

Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: STAFF MEMBER: IF A PATIENT THINKS Revised for clarification purposes.
THEY MIGHT LIKE TO PARTICIPATE BUT DOES
NOT HAVE A PERSONAL PHONE, INQUIRE
ABOUT OTHER PHONES THYE MIGHT USE,
SUCH AS ONE BELONGING TO A FRIEND OR
FAMILY MEMBER OR A PROGRAM THEY
REGULARLY ATTEND.
With: • If the beneficiary does not have a personal
phone (home, work, or cell phone), inquire about
other phones the beneficiary might use or have access
to—for example, a phone belonging to a relative or
someone the beneficiary lives with.
Revised for clarification purposes.
Replace: IF A PATIENT THINKS THEY MIGHT
LIKE TO PARTICIPATE, READ THE CONSENT
FORM TO THEM, OR ASK THEM TO READ THE
CONSENT FORM. IF THE PATIENT AGREES TO
PARTICIPATE, PRINT THEIR NAME, PHONE
NUMBER, AND EMAIL ADDRESS (IF WILLING
TO PROVIDE IT) ON THE CONSENT FORM, AND
HAVE THEM SIGN IT.
With: • If the beneficiary agrees to participate in the
study, ask the beneficiary to read the consent form.
Print the beneficiary’s name, phone number, and email
address on the consent form, and have the beneficiary
sign and date the consent form. Ask the witness (this
might be you) to sign and date the consent form.

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Changes to MEPD Beneficiary Consent Form and Recruitment Script (continued)
Issue
#
7.

Section

Item

Recruitment
Script

Staff
Member
Instructions,
Bullet 3

Action to be
performed
Revise as
follows:

Changes to the Protocol

Reason for the Change

Replace: IF A PATIENT AGREES TO
PARTICIPATE BUT HAS A LEGAL GUARDIAN
AND CANNOT LEGALLY PROVED CONSENT,
PLEASE ALSO PROVIDE CONTACT
INFORMATION FOR THE GUARDIAN AND
OBTAIN THEIR SIGNATURE.
With: • If the beneficiary agrees to participate and
cannot legally provide consent on his or her own
behalf, but has a legal guardian, please obtain consent,
a signature, and contact information from the
guardian.

Revised for clarification purposes.

67