CMS-10487 Beneficiary Interview Protocol, Consent Form; and Recrui

ATTACHMENT E
BENEFICIARY INTERVIEW PROTOCOL, CONSENT FORM, AND
RECRUITMENT SCRIPT

MEPD Beneficiary Interview Guide
(Approximate length: 30-60 minutes)
Round of Site Visit:
Site Visit Dates:
Facility Name:
Facility State:
Date of MEPD Implementation:
Informant ID Number:
Informant Contact Information:
Date of Interview:
Time of Interview:
Interviewer:
Note taker:
SOC station number:

Introduction
[If this is a scheduled interview, start here]
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].
[If no/unsure recognition] Is there another [beneficiary first and last name] in
your household? Is that person available to speak with me? [If no] Do you know
when might be a good time to reach him/her? Ok, thank you. I’ll try calling back
another time.
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].
If someone else answers and questions the purpose of the call: I’m calling in relation to
an interview that [beneficiary name - Mr./Ms. X] agreed to participate in. Is [he/she]
available? [If not] Do you know when might be a good time to reach him/her? Thank you,
I’ll call back another time.
If someone else continues to probe about purpose: I’m sorry, I would like to be able to
answer your questions but we are committed to maintaining the privacy of the people we

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interview. Is it possible for [beneficiary name - Mr./Ms. X] to talk with me? [If not] Do you
know when might be a good time to reach him/her? Thank you, I’ll call back another time.
[If interview is conducted during the initial contact, start here]
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].
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. [If respondent consents to recording, start recorder] [If respondent does not
consent to recording and the interviewer is using a phone line with automatic audio
recording, then (1) turn off the recording feature, or (2) notify the beneficiary that they
should stay on the line and hold while the interviewer transfers the call to a non-recorded
phone line, or (3) request that the beneficiary hang up the phone and the interviewer will
call them back from a non-recorded line].
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?
[Interviewer note: beneficiary will receive $20 incentive if they participate for 30 minutes.
Schedule another call to try to finish if they can only complete 15 minutes at a time, even if
it takes 3 calls to finish. If they don’t like the questions and don’t want to answer them
note it below the question(s) and at the end of the interview guide. Do not give the
incentive if they never show up for later interviews or hang up without explanation after
only completing 15 minutes].

Access to Inpatient Psychiatric Care
1. I know that you were recently hospitalized for a psychiatric crisis at [name of IMD]. Was
it your choice to go to [IMD]?
[Follow-up]
a. If so, why did you choose to go there?
b. If not, how was it decided that you would go there? (Probe: Who decided, and
why?)
c. 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?

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d. [If sought help other times since the demonstration began] When you had
other crises, were you also admitted to a hospital?
i.

If so, did you go to [IMD]?

ii.

[If did not go to [IMD]] Where did you go instead of [IMD]? How did it
compare to [IMD]?

iii.

Where would you prefer to go in the future? Why?

2. 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)
[Interviewer note: 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 visit and (2) the most recent hospitalization (if any) before
the demonstration date].

Boarding Time in the ER
3. 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]

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(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)?)
[If used emergency room or alternative, ask a-h]
a. Why did you go to this particular emergency room (or alternative)?
b. Before going to [IMD], how long did you wait in the emergency room (or
alternative)?
c. [If ER] Before you went to [IMD], did the staff move you to a bed in the main part
of the hospital? If so, was it in a psychiatric unit or some other kind of hospital
unit? How long did you stay there?
d. 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?
e. [If experienced a crisis prior to [demonstration date], ask the following
questions from e-h; otherwise, skip to the Referral and Admission section]:
For [the crisis prior to demonstration date], did you use the same emergency
room (or alternative)? If not, how did you get help?
f.

How did your experiences waiting for admission during your most recent crisis
compare to your experiences during [the crisis prior to the demonstration date]?

g. 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?
h. [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?
[If walk-in to IMD, ask i-m]
i.

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?

j.

[If experienced a crisis prior to demonstration date ask i-l]: For [the crisis
prior to demonstration date], how did you get help? (Probe: walk-in, emergency
room or alternative)

k. How did your experiences waiting for admission during your most recent crisis
compare to your experiences during [the crisis prior to the demonstration date]?
l.

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?

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m. [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?

Referral and Admission
4. [If used ER or alternative] Why did you first go to the emergency room (or alternative)
before you were hospitalized at [IMD]?
[If walk-in to IMD] What led you to go to [IMD]?
[Interviewer note: keep the discussion focused on their hospital admission before the
site visit]
a. 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?
b. How do you recall the process of your admission? (Probe: Who decided? Why?)
c. How were you involved in the decision to go to the hospital? Were you
accompanied by someone? Did anyone ask you where you would prefer to
receive treatment?
d. [If used emergency room or alternative] 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?
[If walk-in to IMD] Did you give your Medicaid card to someone at [IMD]?
e. [If experienced a crisis prior to [demonstration date], ask the following
questions; otherwise, skip to the Stabilization section]: 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?

Stabilization
5. What types of group or individual activities did you engage in while you were at [IMD]?
[Interviewer note: keep the discussion focused on their hospital admission before the
site visit]
a. Were these activities helpful? If so, how? If not, why not?
b. Did someone explain your treatment plan to you?
c. How frequently were you offered the opportunity to speak with a doctor?
d. How was the decision made that you were ready to leave the hospital?
(Probe: Who made the decision? How were you involved in making the decision?)
e. When the hospital told you that you could leave, did you feel safe to leave the
hospital?

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f.

[If experienced a crisis prior to [demonstration date], ask the following
questions; otherwise, skip to the next section]: How did the care you received
compare to care you have received during the hospitalization for your mental
health prior to [the demonstration date]?

Length of Stay
6. For your recent admission to [IMD], how long did you stay in the hospital? [Interviewer
note: keep the discussion focused on their hospital admission before the site visit]
a. [If experienced a crisis prior to [demonstration date], ask the following
questions; otherwise, skip to the next section]: How does this length of stay
compare to the time when you were hospitalized for a psychiatric emergency
prior to [demonstration date]?

Discharge Planning
7. 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]? [Interviewer note: keep the discussion focused on their hospital discharge
before the site visit]
a. If so, did the instructions seem to cover all of your questions or concerns? Was
there anything you wished was in the instructions but wasn’t? Did anyone talk
to you about your preferences and goals when developing the discharge plan?
Did you feel that staff listened to you?
b. Did you feel that you were ready to leave the hospital when you were
discharged? Why or why not?
c. Where did you go after you were discharged from the hospital? How did you get
there?
d. What kinds of services or support did you receive after you left the hospital?
e. Did the instructions you received give you enough information?
(Probe: Too much or too little information; was it clearly written or did it use a
lot of medical words?)
f.

Were you offered resources or techniques that you could use after discharge to
help you manage uncomfortable feelings? If so, please describe.

g. [If experienced a crisis prior to [demonstration date]]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]?

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Closing/Follow-Up
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? [wait until
they are ready or, if no writing implement say “It’s pretty easy to remember—it’s 1-800273-TALK,” skipping saying the numbers.] It’s 1-800-273-8255. It’s pretty easy to
remember if you need it because it spells out 1-800-273-TALK.
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.

Post-Interview Notes and Impressions
[Interviewer use this space to document additional information such as reasons why the
beneficiary did not complete the interview, questions the beneficiary asked that you could
not answer, observations regarding accuracy of responses, or anything else that could be
of importance]

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Responding to Beneficiary in Crisis during the Interview
Situation

Interviewer Action

Follow-Up

Consumer
becomes
upset/agitated

Pause to let the consumer collect
their thoughts. Ask, as needed:

Use the “Post-Interview Notes”
section in the interview guide to
describe this interaction and the
resolution. Use the interview
tracking document on the secure N
drive to indicate partially
completed interview and
whether/when interview was
rescheduled.

Are you alright?
Would you like to continue?
Would you prefer I call back at
another time?
Provide crisis hotline number in case
consumer experiences distress after
the call: 1-800-273-TALK (1-800-2738255)
Consumer is a
danger to
him/herself
(expresses a
plan to harm
him/herself or
others)

Terminate the interview using the
following script:
Let’s stop the interview and I’d like
to give you the phone number for the
crisis hotline so that you can talk to
someone and get help. The phone
number is 1-800-273-TALK (1-800273-8255). I’m going to hang up the
phone now so that you can call the
hotline number, it’s 1-800-273-TALK.
Thank you for talking with me today,
take care.

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Inform Crystal Blyler (Project
Director) and Bonnie O’Day
(Qualitative Team Lead) of this
event. The team will debrief.
Crystal (202) 250-3502
Bonnie O’Day (202) 264-3455

BENEFICIARY INTERVIEW CONSENT FORM
The Centers for Medicare & Medicaid Services (CMS) is sponsoring a study called the
Medicaid Emergency Psychiatric Demonstration (MEPD). The study will look at expanding
Medicaid coverage to include psychiatric inpatient services to adults experiencing psychiatric
emergencies.
As part of the study, CMS wants to learn about your recent experiences in the emergency room
and with the hospital admission and discharge processes. CMS would also like to learn how
these experiences compare with your previous hospitalizations for psychiatric emergencies.
Mathematica Policy Research is an independent research company hired by CMS to conduct
the study. Mathematica is a leader in policy research and has been conducting studies about
health for more than 40 years. You can learn more about Mathematica by visiting its website at
http://www.mathematica-mpr.com.
Your participation is completely voluntary, but very important. If you would like to participate, a
study team member from Mathematica may call you to set up a time that is convenient for you
to participate in a 30- to 60-minute interview over the telephone. Because Mathematica will
randomly select individuals to participate in this study, there is a chance that you will not be
selected.
If you are selected for an interview, your answers will be kept confidential; that is, your
information will be used only for this study, and your name will not be associated with your
answers. If you are comfortable with it and give the interviewer permission, the interview will be
audio taped to ensure that the interviewer remembers correctly everything said during the
interview. No one will listen to the audio tape except the Mathematica study team members
who transcribe it (that is, the person[s] who writes down what was said on the audio tape) and
who check to make sure that the written notes are accurate. The audio tape will be destroyed
after the contents are transcribed, no later than 90 days after the interview. You may request to
listen to the audio tape before it is destroyed. If you are not comfortable having the interview
audio taped, the interviewer will conduct the interview without taping it; instead, notes will be
taken about your answers. The written version of the interview and interviewer notes will be
kept in a secure study-specific electronic folder to which only a few members of the
Mathematica study team who need to use them for study purposes will have access.
Your decision to participate in the study will not change any of your Medicaid benefits or any
other benefits you currently receive or may qualify for in the future. As a token of appreciation,
you will receive a $20 check for participating in the interview.
If you would like to be part of the study, please review the information on the reverse side of
this form. Print your name and telephone number in the spaces provided so a member of the
Mathematica study team can call you to schedule a time to talk to you. You will receive a copy
of this form for your records.
For more information about the study, please call Amy Overcash at Mathematica Policy
Research at (609) 750-2009.

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SIGNATURE AND CONTACT INFORMATION

• I understand I have been invited to take part in an interview about my recent
experiences in the emergency room and with the hospital admission and discharge
processes.
• I have read the information on this form, or someone read it to me.
• I understand that I do not have to take part in the study.
• I understand that, if I am comfortable with it and give the interviewer permission, the
interview will be audio taped.
• If I am not comfortable having the interview audio taped, the interviewer will conduct the
interview without taping it and notes will be taken instead.
• I give the study team from Mathematica Policy Research permission to call me at the
telephone number provided, if I am selected to participate.
• I may change my mind and take back my permission at any time.
• If I take back my permission, the Mathematica study team will not pursue an interview
with me.
Signature

_____________________________________________

Date ___________________

Print Name ________________________________________________________________________
Telephone Number __________________________________________________________________
Email Address ______________________________________________________________________
Witness

_____________________________________________

Date ___________________

If the beneficiary has a legal guardian and cannot legally provide consent, the guardian must
sign below; the beneficiary must also sign above to indicate his or her agreement to participate.
If the beneficiary can legally provide consent but has a financial guardian, please provide the
financial guardian’s contact information below so that the study team can contact him or her to
make arrangements for the $20 payment for the beneficiary’s participation in the interview. Note
that the financial guardian does not have to sign the form unless he or she also serves as the
guardian for personal decision-making purposes.
Guardian’s Signature ______________________________________

Date ___________________

Print Name ________________________________________________________________________
Telephone Number __________________________________________________________________
Relationship to Beneficiary ____________________________________________________________
Email Address ______________________________________________________________________
Please indicate whether guardianship pertains to financial or personal decision-making
purposes. If both apply, please check each line.
Financial Decisions _________
Personal Decisions _________
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RECRUITMENT SCRIPT FOR STAFF MEMBER TO READ TO BENEFICIARY BEFORE
DISCHARGE

[Mr./Ms./Mrs.] [Fill in name],
I would like to see if you are interested in participating in an interview about your
experiences in the emergency room and with the admission and discharge processes at
this hospital. The interview is part of a study that the Centers for Medicare & Medicaid
Services (or CMS) is sponsoring to learn more about inpatient psychiatric treatment. The
study is called the Medicaid Emergency Psychiatric Demonstration. The information you
provide about your experiences may help others in the future. An interviewer from the
study team would like to talk to you over the telephone in the next few weeks, at a time
that is convenient for you.
If you want to participate, all you have to do is provide a phone number at which you can
be reached. Someone from the study team may call you to schedule a time that is
convenient for you to talk. The team will select people randomly so there is a chance you
will not be called. If you are selected for an interview, your answers will be kept
confidential; that is, your information will be used only for this study, and your name will
not be associated with your answers. Your decision to participate in the study will not
change any of your Medicaid benefits or any other benefits you currently receive or may
qualify for in the future.
STAFF MEMBER, HAND FACT SHEET TO BENEFICIARY AND SAY: This sheet provides
information about the study.
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.

Please seek consent only from Medicaid beneficiaries receiving services as a result of a
psychiatric emergency through the Medicaid Emergency Psychiatric Demonstration.
1

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STAFF MEMBER INSTRUCTIONS:

IF RESPONDENT ANSWERED “YES”, PLEASE FOLLOW
THESE INSTRUCTIONS:

1. Read the consent form to the beneficiary, or ask beneficiary to read the consent form.
•

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.

•

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.

•

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.

•

If the beneficiary can legally provide consent but has a financial guardian, please
obtain the financial guardian’s contact information so that the study team can contact
him or her to make arrangements for the $20 payment (check) for the beneficiary’s
participation in the interview. Note that the financial guardian does not have to sign the
form unless he or she also serves as the guardian for personal decision-making
purposes.

2. Tell the beneficiary that someone from Mathematica Policy Research may call him or her in
a few weeks to schedule an interview at a convenient time.
3. Give the beneficiary a copy of the consent form. If the beneficiary has questions about the
study, refer him or her to the fact sheet and/or the Mathematica contact person listed on the
consent form.

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