MEPD Protocols Medical Record Review Consent

MEPD Protocols Medical Record Review Consent.pdf

Medicaid Emergency Psychiatric Services Demonstration Evaluation

MEPD Protocols Medical Record Review Consent

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ATTACHMENT A
KEY INFORMANT INTERVIEW PROTOCOLS

MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
INTERVIEW GUIDE: MEPD PROJECT DIRECTOR
Round of Site Visit:
Site Visit Dates:
State:
Date of MEPD Implementation:
Informant(s) Name: [Using notes from the initial interview conducted during fall 2012, insert name, title, and role
and responsibilities in the demonstration]
Informant(s) Title:
Informant(s) Contact Information:
Date of Interview:
Time of Interview:
Interviewer:
Note taker:
I.

Introduction
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?

II.

Role and Responsibilities
1.

III.

Has your role and responsibilities changed since we last spoke on [insert date of fall 2012 interview]?
If so, please describe.

Program Design
2.

What specific service improvements are being made as part of the demonstration?

Please describe your procedures for monitoring the demonstration.
3a. How is this working?

What monitoring procedures have been most useful?

What suggestions do you have about demonstration monitoring for other states?

A-1

IV. Access to Inpatient Psychiatric Care
Next, I’d like to talk about access to care.
6.

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?

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?

Boarding Time in ER and General Hospital Scatter Beds
I’d like to shift the discussion to boarding in ERs and general hospital scatter beds.
9.

Can you discuss the extent of emergency room boarding in the state?

10. Can you discuss the extent of psychiatric boarding in general hospital scatter beds in the state?
11. 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?

12. Is this different for Medicaid beneficiaries?
13. 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?

14. Is this different for Medicaid beneficiaries?
VI. Referral and Admission
Next, I’d like to talk about referral and admission, stabilization, and discharge planning.
15. How do you verify that the patients admitted to the demonstration are suicidal, homicidal, or a
danger to themselves or others?
16. How do you verify that the participants in the demonstration are enrolled in Medicaid at the time
they are admitted to the IMD?
VII. Stabilization [Insert stabilization assessment requirements identified in the operating plan and/or interview
notes]
17. How are you ensuring that IMDs are adhering to stabilization assessment requirements?
18. How is this process going?
18a. What is going well?
18b. What would you like to be done differently?
19. How do stabilization criteria in your state differ from the criteria used for the demonstration?
VIII. Length of Stay
20. How does the average length of stay for patients enrolled in the demonstration compare to21 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

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alternatives.)
IX. Discharge Planning
21. What kinds of changes, if any, have occurred regarding post-discharge follow up procedures for
Medicaid beneficiaries as a result of the demonstration?
22. How are you monitoring discharge planning for demonstration patients and for non-demonstration
psychiatric patients at IMDs?
23. Are you experiencing challenges in monitoring discharge planning? If so, please describe.
24. Have IMDs reported challenges to discharge planning? If so, please describe.
25. Under the demonstration, has the proportion of Medicaid beneficiaries with psychiatric emergencies
discharged from participating IMDs to community-based residences changed?

PROBE:

How has it changed?

PROBE:

To where are demonstration patients being discharged most frequently?

Cost
26. Can you describe the effect the demonstration has had on costs to the state?
27. How has care provided by private IMDs impacted state Medicaid costs under the demonstration?
28. How have dollars saved by receiving the federal match been invested by the state?
29. What is your perspective on cost-shifting due to the demonstration?
30. What were the administrative costs to fully implement the demonstration (e.g., for staffing or
making changes to the physical environment)?

XI.

Context
Next, I’d like to talk about the context in which the demonstration is operating.
31. How are psychiatric emergency services provided in the state?
31a. How many psychiatric emergency providers are in the state?
32. Can you discuss the extent to which there is a shortage of inpatient psychiatric beds in the state?
33. How has the demonstration influenced state hospital bed capacity (e.g., crowding, waiting lists)?
34. Can you describe the levels and types of investments the state is making in community-based
behavioral health services (e.g., Assertive Community Treatment programs, mobile crisis treatment
teams, partial hospitalization programs)?
35. Can you describe the availability of psychiatric step-down and outpatient services in your state?
35a. Are psychiatric step-down and outpatient services reimbursed by Medicaid?
35b. If not, how are these services reimbursed?
36. Have there been any changes in mental health service delivery that could affect the demonstration
(e.g., closure of facilities, new IMDs opening)?
37. Is the state involved in other initiatives that could influence the demonstration (e.g., Institute for
Behavioral Health Care Improvement Collaborative)?
38. Are you aware of any state-level initiatives that may be changing the incidence of psychiatric
emergencies and access to services for patients experiencing a psychiatric emergency?

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39. Are there any planned changes in mental health services at the state level that could affect the
demonstration (e.g., change in payment structure)?
40. How will the 2014 Medicaid expansion influence the demonstration (e.g., expenditures and
population served)?
XII. Outcomes
I’d like to conclude the interview by talking about outcomes of the demonstration.
41. What are your thoughts about potential short-term effects of the demonstration?
42. What do you think are the two most important changes, if any, resulting from the demonstration?
43. What do you hope the demonstration will do?
XIII. Closing
That completes the questions we have for you today.
 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.

A-4

MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
INTERVIEW GUIDE: MEPD IMD STAFF MEMBER
Round of Site Visit:
Site Visit Dates:
Facility Name:
Facility State:
Date of MEPD Implementation:
Informant(s) Name: [Note if informant is IMD point of contact interviewed in fall 2012.]
Informant(s) Title:
Informant Contact Information:
Date of Interview:
Time of Interview:
Interviewer:
Note taker:

Introduction
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?

II.

Role and Responsibilities
1.

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

How long have you been in this role?

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

Are you aware that [insert name of IMD] is participating in the Medicaid Emergency Psychiatric
Demonstration?

A-5

[Interviewer: If informant is not aware of the demonstration, reword all questions referring to the ‘demonstration’
as the ‘date of implementation.’ See example in Q5 below.]
III.

Program Design
4.

What specific service improvements are being made as part of the demonstration?

[Interviewer: If informant is not aware of the demonstration, reword this question as: What specific service
improvements are being made since [insert month, year of demonstration implementation]]?
5.

What organizational changes were made to the facility as a result of the demonstration (e.g.,
staffing changes, changes in staff responsibilities)?

[Interviewer: Ask Q7 and Q8 only if informant is IMD point of contact, a hospital administrator and/or is familiar
with the monitoring of the demonstration.]
6.

What are your perceptions about the state’s procedures for monitoring the demonstration?

What would you change about the state’s monitoring procedures?

IV. Access to Inpatient Psychiatric Care
I would like to discuss access to care.
[Interviewer: If informant is not aware of the demonstration, reword all questions referring to the ‘demonstration’
as the ‘date of implementation.’]
8.

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?
9.

How has the mix of patients in this hospital changed since implementing the demonstration on
[insert date of implementation]?

10. [Ask only if informant is aware of the demonstration.] 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.
11. [Ask only if informant is aware of the demonstration.] Are you having challenges with
implementing patient eligibility criteria? If so, please describe these challenges.
[Interviewer: ask Q13 and Q14 only if the informant is the IMD point of contact we spoke with in fall 2012. Contact
state lead to obtain patient enrollment estimates if not known.]
12. Have there been any changes in patient enrollment estimates since we last spoke on [insert date]?
13. If there has been a change in patient enrollment estimates, what accounts for this change?
14. [Ask only if informant is aware of the demonstration.] How has bed capacity changed as a result of
the demonstration?
PROBE: Has the facility added beds, opened additional units, or started staffing beds that were previously not
used?
V.

Boarding Time in ER

[Interviewer: If informant is not aware of the demonstration, reword all questions referring to the ‘demonstration’
as ‘date of implementation.’]

A-6

Now I’d like to talk about the amount of time patients spend in the ER or intake department prior to
admission.
15. 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.]
16. 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?
17. Has this changed since the demonstration was implemented in [insert date of implementation]?
18. 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?
19. Is this different for Medicaid beneficiaries?
20. 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?
VI. Referral and Admission
[Interviewer: If informant is not aware of the demonstration, reword all questions referring to the ‘demonstration’
as the ‘date of implementation.’]
I’d like to shift the discussion to referral and admission to this hospital.
21. What is the primary source of referral for patients to this hospital?
22a.[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?
22. What are other sources of referral for patients to this hospital?
23a. [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?
23. How has your relationship with other sources of referral for admission of patients with psychiatric
emergencies changed as a result of the demonstration?
24. How does the referral process since the demonstration began differ from what you were doing
before the demonstration?
25. [Ask only if informant is aware of the demonstration.] What are your primary methods for
identifying patients for the demonstration?
VII. Stabilization
Next, I would like to discuss procedures for stabilizing patients.
[Interviewer: If informant is not aware of the demonstration, reword all questions referring to the ‘demonstration’
as the ‘date of implementation’.]
26. Please describe your stabilization assessment procedures.
27. How does the stabilization assessment under the demonstration differ from what you were doing
before the demonstration?
28. Are you experiencing any challenges adhering to the stabilization assessment requirements?

A-7

29. 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?
30. How does this treatment compare to the treatment received by non-Medicaid beneficiaries with
psychiatric emergencies treated in this hospital?
31. How does treatment of psychiatric emergencies differ from treatment provided to patients not
experiencing a psychiatric emergency?
VIII. Length of Stay
[Interviewer: Ask Q33 and Q34 only if time permits.]
32. 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.
33. [Ask only if informant is aware of the demonstration.] What is the average length of stay for
patients enrolled in the demonstration?
IX. Discharge Planning
Now I’d like to talk about discharge planning and post-discharge care.
Interviewer: If informant is not aware of the demonstration, reword all questions referring to the ‘demonstration’
as the ‘date of implementation.’
34. Could you please describe the hospital’s discharge planning procedures?
35a. [Ask only if informant is aware of the demonstration.] Are the discharge planning procedures
the same for demonstation patients? If not, how do they differ?
35. How does the discharge planning process differ now from what you were doing prior to the
demonstration?
36. How has the quality of discharge planning changed under the demonstration?
PROBE: Has the quality of discharge planning improved, worsened, or stayed the same?
37. How are patients at your hospital involved in discharge planning?
PROBE: How does patient involvement (or lack of) impact the patient’s discharge experience?
38. Is this different than how patients were involved in discharge planning before the demonstration?
39. 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?
40. 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?
41. 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?
42. To where is the majority of patients discharged?
PROBE: For example, home, group home or other structured setting, jail, or patients are homeless.

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43. [Ask only if informant is aware of the demonstration.] To where is the majority of demonstration
patients discharged?
44. What proportion of patients are discharged outside of the local area?
45a. [Ask only if informant is aware of the demonstration.] What proportion of demonstration
patients are discharged outside of the local area?
45. What types of aftercare services are provided to patients?
46a. [Ask only if informant is aware of the demonstration.] What types of aftercare services are
provided to demonstration patients?
46. Where do the majority of patients typically receive aftercare services?
47a. [Ask only if informant is aware of the demonstration.] Where do the majority of
demonstration patients typically receive aftercare services?
47. Could you please describe the post discharge follow up procedures for Medicaid beneficiaries?
48. [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?
X.

Cost
I’d like to ask next a few questions about cost.

Interviewer: ask Q50 – Q52 only if informant is IMD point of contact, a hospital administrator, and/or is aware of
the demonstration.
49. Can you describe the effect the demonstration has had on costs to your hospital?
50. How has the care provided under the demonstration impacted Medicaid costs?
51. 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)?
XI. Context
I’d like to talk about the availability of mental health services.
52. What types of psychiatric step-down and outpatient services are available for patients?
53a. [Ask only if informant is aware of demonstration.] What types of psychiatric step-down and
outpatient services are available for demonstration patients?
53. Are psychiatric step-down and outpatient services reimbursed by Medicaid?
54a. If not, how are these services funded?
54. Please describe the working relationship your facility has with psychiatric step-downor outpatient
providers.
55. 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)?
56. 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?

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XII. Outcomes
I’d like to conclude by talking about outcomes of the demonstration.
57. What are your thoughts about potential short-term effects of the demonstration?
58. What do you think are the two most important changes, if any, resulting from the demonstration?
59. What do you hope the demonstration will do?
XIII. Closing
That completes the questions we have for you today.
 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.

A-10

MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
INTERVIEW GUIDE: MEPD GH STAFF MEMBER
Round of Site Visit:
Site Visit Dates:
Facility Name:
Facility State:
Date of MEPD Implementation:
Informant(s) Name:
Informant(s) Title:
Informant(s) Contact Information
Date of Interview:
Time of Interview:
Interviewer:
Note taker:

Introduction
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?

II.

Role and Responsibilities
1. Please describe your role and responsibilities at [insert name of GH].
2.

How long have you been in this role?

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

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

[Interviewer: If respondent is not aware of the demonstration, reword all questions referring to the demonstration
as the date of implementation.]

A-11

III.

Program Design
5.

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.
IV. Access to Inpatient Psychiatric Care
Next, I would like to discuss access to care.
6.

Have you observed any changes in the number of patients being admitted to non-psychiatric units of
this hospital for treatment of a psychiatric emergency?

PROBE: Has it increased or decreased? Why?
7.
V.

If a change was noted in either direction, how has this change influenced the quality of care
delivered?

Boarding Time in ER
Now I’d like to talk about the amount of time patients spend in the ER prior to admission.
8.

In your experience, how long do patients admitted to your unit after experiencing a psychiatric
emergency wait in the ER before being admitted?

[Interviewer: If long waits are reported, ask why.]
9.

Has this changed since [insert start date of demonstration in state]?

10. If a change was observed, what factors do you think account for the change?
VI. Referral and Admission
I’d like to shift the discussion to referral and admission to this hospital.
11. Please describe the process for admitting patients with psychiatric emergencies from the ER to nonpsychiatric units of this hospital.
12. Have there been any changes in the admission process recently?
12a.If so, what has changed? Why?
VII. Stabilization
13. Next, please tell me about the types of treatments patients experiencing psychiatric emergencies
receive while in non-psychiatric units of this hospital.
14. How is stabilization of the psychiatric emergency assessed?
15. When does the assessment begin?
16. How often are stabilization assessments conducted?
17. 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?
VIII. Length of Stay
18. What is the average length of stay for psychiatric patients admitted to non- psychiatric units of this
hospital?

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19. 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?
IX. Discharge Planning
Now I’d like to talk about discharge planning and post-discharge care.
20. Please describe the discharge planning process for psychiatric patients admitted to non-psychiatric
units of this hospital.
21. When does discharge planning begin?
22. Who is involved in developing a discharge plan for psychiatric patients?
23. How are psychiatric patients receiving care from non-psychiatric units in your hospital involved in
discharge planning?
24. To where are psychiatric patients treated in non-psychiatric units of your hospital being discharged
most frequently?
25. What types of aftercare services are provided to psychiatric patients?
X.

Context
I’d like to talk about the context in which the demonstration is operating.

Interviewer note: ask Q26 – 31 only if hospital has a psychiatric unit.
26. How does having an inpatient psychiatric unit affect the extent of psychiatric boarding in your ER
and non-psychiatric units?
27. What are the referral sources for admission to the psychiatric unit of your hospital?
28. Have the sources of referral to the unit changed since the demonstration was implemented [insert
date of implementation]?
29. What types of patients are served by the psychiatric unit?
30. What impacts has the demonstration had on the hospital’s psychiatric unit, if any?
PROBE: Are they more likely to serve Medicaid beneficiaries or other patients with psychiatric emergencies?
31. Has the average length of stay or discharge planning process changed since implementing the
demonstration on [insert date of implementation]?
32. Have there been any changes in mental health service delivery that could affect the demonstration?
PROBE: For example, closure of facilities, new IMDs opening, changes in how psychiatric emergencies are
handled in your hospital or community, changes in availability in community-based services?
33. Are there any planned changes in mental health services at the state level that could affect the
demonstration?
PROBE: For example, change in payment structure?
XI. Closing
That completes the questions we have for you today.
 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.

A-13

MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
INTERVIEW GUIDE: MEPD ER STAFF MEMBER
Round of Site Visit:
Site Visit Dates:
Facility Name:
Facility State:
Date of MEPD Implementation:
Informant(s) Name:
Informant(s) Title:
Informant(s) Contact Information:
Date of Interview:
Time of Interview:
Interviewer:
Note taker:

Introduction
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?

II.

Role and Responsibilities
1.

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

How long have you been in this role?

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

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

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[Interviewer: If respondent is not aware of the demonstration, reword all questions referring to the
demonstration as the date of implementation].
III.

Program Design
5.

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.
IV. Access to Inpatient Psychiatric Care
Next, I would like to discuss access to care.
6.

How often do individuals experiencing a psychiatric emergency seek treatment in this ER?

Please describe how you work with individuals experiencing a psychiatric emergency.

[Interviewer: Ask Q8 only if this hospital has a psychiatric unit.]
8.

I understand that this hospital has a psychiatric unit. Do you contact the unit to determine bed
availability?
8a. If the psychiatric unit is not contacted, please explain why.

Which facilities do you contact for inpatient care for patients with a psychiatric emergency?

10. Are the facilities you contact the same facilities you contact for Medicaid beneficiaries?
PROBE: Why or why not? Is there a particular order in you contact hospitals?
11. What is your experience with the rate at which patients with psychiatric emergencies are accepted
by these hospitals?
11.a Is the acceptance rate different for Medicaid beneficiaries?
V.

Boarding Time in ER
Now I’d like to talk about the amount of time patients spend in the ER prior to admission.
12. 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?
13. Are wait times different for Medicaid beneficiaries?
14. Has this changed since [insert start date of demonstration in state]?
15. If a change was observed, what factors do you think account for the change?

VI. Referral and Admission
I’d like to shift the discussion to referral and admission of patients experiencing a psychiatric emergency to
psychiatric hospitals.
16. How do you determine whether someone in the ER is suicidal, homicidal, or a danger to themselves
or others?
17. How do you determine whether someone with a psychiatric emergency is in need of inpatient
psychiatric hospitalization?
18. Have you noticed any changes since [insert start of demonstration in state] in how patients who

A-15

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?
19. 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?
20. Has the admission process changed under the demonstration?
VII. Stabilization
21. Next, please describe how patients experiencing a psychiatric emergency are stabilized in the ER.
22. Have these processes changed since the demonstration was implemented?
VIII. Cost
[Interviewer: ask Q23 only if informant is a hospital administrator and/or is aware of the demonstration.]
23. What, if any, were your administrative costs to fully implement the demonstration (e.g., for staffing
or making changes to the physical environment)?
IX. Context
I’d like to talk about the context in which the demonstration is operating.
24. To what extent is psychiatric boarding an issue in your ER?
25. Is your hospital or department involved in other initiatives that could influence the demonstration
(e.g., ER diversion programs)?
26. Have there been any changes in the community that have affected the number of individuals with a
psychiatric emergency who present in the ER?
27. Does the [insert name of IMD] participation in the demonstration change how you refer patients?
PROBE: For example, are you more inclined to contact IMDs first?
X.

Outcomes
I’d like to conclude the interview by talking about outcomes of the demonstration.
28. What are your thoughts about potential short-term effects of the demonstration?
29. What do you think are the two most important changes, if any, resulting from the demonstration?
30. What do you hope the demonstration will do?

XI. Closing
That completes the questions we have for you today.



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.

A-16

ATTACHMENT B
MEDICAL RECORD REVIEW TOOLS

MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
MEDICAL RECORD REVIEW: MEPD INSTITUTION OF MENTAL DISEASE (IMD)
Round of Site Visit:
Site Visit Dates:
IMD Name:
State:
IMD Point of Contact:
IMD Point of Contact Information:
Date of MEPD Implementation:
Type of Information System:
__ Electronic, __ Paper, __ Combination
Brief description of system: ______________________________________________
Name of Information System:
Site Visitor:
Record Review Date:

B-1

RECORD 1
Mathematica Patient ID: [attach label or enter number]
Description of patient characteristics:

Access to Inpatient Psychiatric Care
1.

Source of referral to this IMD:

Was the patient previously admitted to this IMD?
Yes  [Enter date of most recent prior admission]
No
Unable to determine

Has the patient been hospitalized twice or more during the past year?
PROBE: During the 12 months prior to the date of this admission.
Yes
No
Unable to determine

Reviewer’s comments/notes about this section:

Boarding Time in Emergency Room
4.

When was this IMD contacted about bed availability for the patient’s most recent visit?
a.
b.
c.

am/pm

When was the patient transferred to this IMD for the most recent admission?
a.
b.
c.

Date hospital contacted:
Time hospital contacted:
Unable to determine

Date transferred to hospital:
Time transferred to hospital:
Unable to determine

am/pm

How was the patient transported to this hospital?
a.
b.
c.

Ambulance
Receiving hospital’s transportation
Other

Specify:
Unable to determine

Reviewer’s comments/notes about this section:

B-2

Admission to IMD
7.

When was the patient admitted to this hospital?
a.
b.
c.

Date of admission:
Time of admission: am/pm
Unable to determine

Did patient exhibit signs and symptoms of intoxication and/or withdrawal from drugs or alcohol
upon admission?
Yes
No
Unable to determine
8a.

If Yes, describe symptoms of withdrawal exhibited by patient.

When was the initial nursing assessment completed?
a.
b.
c.

Date of initial nursing assessment:
Time of initial nursing assessment:
Unable to determine

am/pm

10. When was the initial medical history and physical completed?
a.
b.
c.

Date of initial medical history and physical:
Time of initial medical history and physical:
Unable to determine

am/pm

11. When was the initial psychiatric evaluation completed?
a.
b.
c.

Date of initial psychiatric evaluation:
Time of initial psychiatric evaluation:
Unable to determine

am/pm

12. Which diagnoses were identified in the initial psychiatric evaluation completed at this hospital?
Dimension
1.

Axis I

Axis II

Axis III

Axis IV

Axis V

Diagnoses (Include DSM code and
description if provided.)

Reviewer’s comments/notes about this section:

B-3

Not
documented

Stabilization
13. Does the medical record include documentation that the patient was assessed for stabilization (that
is, to determine whether they remained suicidal, homicidal, or a danger to themselves or others) by
the third day of IMD admission?
Yes
No  GO TO Q.15
Unable to determine  GO TO Q.15
14. 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. [Interviewer: Ask
person assisting with chart review how the hospital defines stabilization assessment.]

Stabilization Assessment Date

Patient expressed suicidal or homicidal thoughts or
gestures, or is dangerous to self or others

a. MM/DD/YYYY

Yes No Not Documented

b. MM/DD/YYYY

Yes No Not Documented

c. MM/DD/YYYY

Yes No Not Documented

d. MM/DD/YYYY

Yes No Not Documented

e. MM/DD/YYYY

Yes No Not Documented

f. MM/DD/YYYY

Yes No Not Documented

15. 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 GO TO Q.17
Unable to determine GO TO Q.17
16. 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)

1.
2.
3.
4.
5.

B-4

Dose

Mode of
Administration
(IM, IV, PO, or SQ)

17. Was the patient physically restrained while at this IMD?
Yes
No GO TO Q.19
Unable to determine  GO TO Q.19
18. 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)

1.
2.
3.
4.
5.
6.

19. Was consultation ordered for evaluation of an active or chronic medical condition?
Yes
No  GO TO Q.21
Unable to determine  GO TO Q.21
20. Was treatment provided for an active or chronic medical condition as a result of the consultation?
Yes, treatment provided at this facility
Yes, treatment provided at a different facility
No
21. Did an injury or infection occur during the patient’s stay in this hospital?
Yes
No  GO TO Q.23
Unable to determine GO TO Q.23
22. What type of injury or infection did the patient have?
a.
b.
c.
d.

Self-inflicted injury
Nosocomial injury only
Nosocomial infection only
Both nosocomial injury and infection

Reviewer’s comments/notes about this section (describe the stabilization process):

B-5

Discharge Planning
23. What was the earliest date discharge plans, or a patient meeting with a discharge planner, was
documented?
Date:
Not documented  GO TO Q25
24. Does the discharge plan include documentation of patient’s preferences after discharge?
Yes
Not documented
25. When was the patient discharged from this IMD?
a.
b.

Date of discharge:
Time of discharge:

am/pm

26. Does the medical record include documentation that IMD staff contacted the patient’s other
providers for input into the discharge plan?
Yes
No
Unable to determine
27. 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  GO TO Q.29
Unable to determine  GO TO Q.29
28. Record date of appointment and provider.
a.
b.

Appointment date:
Provider’s name:

29. Does the medical record include documentation that medication reconciliation was conducted upon
discharge?
Yes
No
Unable to determine
30. Does the discharge plan include discharge medications?
Yes
No
Unable to determine
31. Does the discharge plan include the reason for hospitalization?
Yes
No
Unable to determine
32. Does the discharge plan include the principal discharge diagnosis?
Yes
No
Unable to determine

B-6

33. Does the discharge plan include the next level of care recommendations?
Yes
No
Unable to determine
34. Does the discharge plan include documentation that the discharge plan was sent to patient’s
aftercare provider?
Yes
No
Unable to determine
35. Does the discharge plan include the patient’s signature?
Yes
No
Unable to determine
Reviewer’s comments/notes about this section:

END

B-7

MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
MEDICAL RECORD REVIEW: MEPD GENERAL HOSPITAL (GH)
Round of Site Visit:
Site Visit Dates:
GH Name:
State:
GH Point of Contact:
GH Point of Contact Information:
Date of MEPD Implementation:
Type of Information System:
__ Electronic, __ Paper, __ Combination):
Brief description of system:_____________________________________________
Name of Information System:
Site Visitor:
Record Review Date:

B-8

RECORD 1
Mathematica Patient ID: [attach label or enter number]
Description of patient characteristics:
A.

Access to Inpatient Psychiatric Care
1.

Source of referral to this general hospital:

Was the patient previously admitted to this general hospital for psychiatric treatment in a nonpsychiatric unit?
Yes  [Enter date of most recent prior admission]
No
Unable to determine

Has the patient been hospitalized twice or more during the past year?
PROBE:

During the 12 months prior to the date of this admission.

Yes
No
Unable to determine
Reviewer’s comments/notes about this section:

Boarding Time in Emergency Room
4.

When was this general hospital contacted about bed availability for the patient’s most recent visit?
a.
b.
c.

am/pm

When was the patient transferred to this general hospital for the most recent admission?
a.
b.
c.

Date hospital contacted:
Time hospital contacted:
Unable to determine

Date transferred to hospital:
Time transferred to hospital:
Unable to determine

am/pm

How was the patient transported to this general hospital?
a.
b.
c.
d.

Ambulance
Receiving hospital’s transportation
Other
Specify:
Unable to determine

Reviewer’s comments/notes about this section:

B-9

Admission to GH
7.

When was the patient admitted to this general hospital?
a.
b.
c.

Date of admission:
Time of admission: am/pm
Unable to determine

Did patient exhibit signs and symptoms of intoxication and/or withdrawal from drugs or alcohol
upon admission?
Yes
No
Unable to determine
8a.

If Yes, describe symptoms of withdrawal exhibited by patient.

When was the initial nursing assessment completed?
a.
b.
c.

Date of initial nursing assessment:
Time of initial nursing assessment:
Unable to determine

am/pm

10. When was the initial medical history and physical completed?
a.
b.
c.

Date of initial medical history and physical:
Time of initial medical history and physical:
Unable to determine

am/pm

11. When was the initial psychiatric evaluation completed?
a.
b.
c.

Date of initial psychiatric evaluation:
Time of initial psychiatric evaluation:
Unable to determine

am/pm

12. Which diagnoses were identified in the initial psychiatric evaluation completed at this hospital?
Dimension
1.

Axis I

Axis II

Axis III

Axis IV

Axis V

Diagnoses
(Include DSM code and description if provided.)

Reviewer’s comments/notes about this section:

B-10

Not
documented

Stabilization
13. Does the medical record include documentation that the patient was assessed for stabilization (that
is, to determine whether they remained suicidal, homicidal, or a danger to themselves or others) by
the third day of admission?
Yes
No  GO TO Q.15
Unable to determine  GO TO Q.15
14. 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. [Note: Site visitor
will need to ask person assisting with chart review how the hospital defines stabilization assessment]

Stabilization Assessment Date

Patient expressed suicidal or homicidal thoughts
or gestures, or is dangerous to self or others

a. MM/DD/YYYY

Yes No Not Documented

b. MM/DD/YYYY

Yes No Not Documented

c. MM/DD/YYYY

Yes No Not Documented

d. MM/DD/YYYY

Yes No Not Documented

e. MM/DD/YYYY

Yes No Not Documented

f. MM/DD/YYYY

Yes No Not Documented

15. 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 GO TO Q.17
Unable to determine GO TO Q.17
16. 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)

1.
2.
3.
4.
5.
6.

B-11

Dose

Mode of
Administration
(IM, IV, PO, or SQ)

17. Was the patient physically restrained while at this general hospital?
Yes
No GO TO Q.19
Unable to determine  GO TO Q.19
18. 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)

1.
2.
3.
4.
5.
6.

Self-inflicted injury
Nosocomial injury only
Nosocomial infection only
Both nosocomial injury and infection

Reviewer’s comments/notes about this section (describe the stabilization process):

B-12

Date of discharge:
Time of discharge:

am/pm

26. Does the medical record include documentation that general hospital staff contacted the patient’s
other providers for input into the discharge plan?
Yes
No
Unable to determine
27. 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  GO TO Q.29
Unable to determine  GO TO Q.29
28. Record date of appointment and provider.
a.
b.

Appointment date:
Provider’s name:

B-13

END

B-14

MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
MEDICAL RECORD REVIEW: MEPD EMERGENCY ROOM (ER)
Round of Site Visit:
Site Visit Dates:
ER Hospital Name:
State:
ER Point of Contact:
ER Point of Contact Information
Date of MEPD Implementation:
Type of Information System:
__ Electronic, __ Paper, __ Combination
Brief description of System:
___________________________________________________________
Name of Information System:
Site Visitor:
Record Review Date:

B-15

RECORD 1
Mathematica Patient ID: [attach label or enter number]
Description of patient characteristics:
A.

Admission to Emergency Room (ER)
1.

When was the patient admitted to the ER?
a.
b.

Date of admission to ER:
Time of admission to ER: am/pm

Was the patient’s Medicaid number identified in the medical record?
Yes
No
Unable to determine

When was the initial medical history and physical examination completed?
a.
b.
c.

When was the patient medically cleared by a provider?
a.
b.
c.

am/pm

Suicidal?
Homicidal?
Dangerous to themselves?
Dangerous to others?
Unable to determine

When was the patient assessed by a provider to determine whether inpatient psychiatric treatment
was necessary?
a.
b.
c.

Date of medical clearance:
Time of medical clearance:
Unable to determine

Upon admission to the ER, was the patient identified as…
a.
b.
c.
d.
e.

Date of initial medical history and physical examination:
Time of initial medical history and physical examination: am/pm
Unable to determine

Date psychiatric emergency determined:
Time psychiatric emergency was determined:
Unable to determine

am/pm

What type of provider determined the presence of a psychiatric emergency?
a.
b.
c.
d.
e.
f.
g.

MD/DO
NP/CNS/PA
RN
LCSW
Psychologist
Licensed mental health professional (e.g., licensed counselor or therapist)
Other

Specify:
h.

Unable to determine

B-16

Was eligibility for the demonstration indicated in the ER medical record?
Yes, patient eligible
Yes, patient not eligible
Not documented
Not applicable, pre-demonstration

Which diagnoses were identified in the initial psychiatric evaluation completed at this ER?
Dimension

Axis I

Axis II

Axis III

Axis IV

Axis V

Diagnoses (Include DSM code and description if provided.)

Reviewer’s comments/notes about this section:

Stabilization
10. Was the patient evaluated for active substance use while in the ER?
Yes
No  GO TO Q.12
Unable to determine  GO TO Q.12
11. What type of evaluation was conducted?
a.
b.
c.

Specialist consult
Laboratory diagnostics
Other

Specify:
d.
Unable to determine
12. Was the patient treated for active substance use while in the ER?
Yes
No  GO TO Q.14
Unable to determine  GO TO Q.14
13. What type of treatment was provided to the patient?
a.
b.

Pharmacologic treatment
Other

Specify:
c.
Unable to determine

B-17

Not documented

14. Was the patient evaluated for an active or chronic medical condition while in the ER?
Yes
No  GO TO Q.16
Unable to determine  GO TO Q.16
15. What type of evaluation was conducted?
a.
b.
c.
d.

Specialist consult
Laboratory diagnostics
Radiographic or ultrasonic diagnostics
Other

Specify:
e.
Unable to determine
16. Was the patient treated for an active or chronic medical condition while in the ER?
Yes
No  GO TO Q.18
Unable to determine  GO TO Q.18
17. What type of treatment was provided to the patient?
a.
b.
c.

Pharmacologic treatment
Education/support
Other

Specify:
18. 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  GO TO Q.20
Unable to determine  GO TO Q.20
19. 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)

1.
2.
3.
4.
5.
6.

B-18

Dose

Mode of Administration
(IM, IV, PO, or SQ)

20. Was the patient physically restrained while at this ER?
Yes
No  GO TO Q.22
Unable to determine  GO TO Q.22
21. Enter the date(s), time(s), and mode of physical restraint.

Date

Time

Mode of Restraint
(Four point leather or cloth restraints, physical hold, hand mitts, other)

1.
2.
3.
4.
5.
6.

Reviewer’s comments/notes about this section:

Access to Inpatient Psychiatric Care
22. To where was the patient discharged or transferred from the ER?
Specify: __________________________________________
23. What facilities were contacted to see whether a bed was available for the patient?

Name of Facility

Date contacted
for bed
availability

1.
2.
3.

24. When was the patient discharged from the ER?
a.
b.

Date of discharge from ER:
Time of discharge from ER:

am/pm

B-19

Time contacted
for bed
availability

Date patient
accepted for
bed

Time patient
accepted for
bed

25. How was the patient transported to their discharge placement?
a.
b.
c.

Ambulance
Receiving facility transportation
Other

Specify:
Unable to determine

Reviewer’s comments/notes about this section:

END

B-20

ATTACHMENT C
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

C-1

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?

C-2

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]

C-3

(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?

[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?

C-4

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?

C-5

[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]?

C-6

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]

C-7

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.

C-8

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.

C-9

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 ___________________

_____________________________________________

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 _________
C-10

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

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.

C-11

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.

C-12

File Type	application/pdf
File Title	Medical Record Review and Interview Protocols & Consents for IRB submission
Author	Sharon D. Clark
File Modified	2014-02-25
File Created	2013-11-08