Form CMS-10275 Home Health Care CAHPS Survey (English)

HOME HEALTH CARE CAHPS® SURVEY

2013

3.

SURVEY INSTRUCTIONS
•

Answer all the questions by checking the
box to the left of your answer.

•

You are sometimes told to skip over
some questions in this survey. When this
happens you will see an arrow with a
note that tells you what question to
answer next, like this:
Yes

4.

If Yes, go to Q1 on Page 1.

No

YOUR HOME HEALTH CARE
1.

According to our records, you got care
from the home health agency,
[AGENCY NAME]. Is that right?
As you answer the questions in this
survey, think only about your
experience with this agency.

2.

1

Yes

2

No

5.

If No, please stop and
return the survey in the
envelope provided.

When you first started getting home
health care from this agency, did
someone from the agency tell you
what care and services you would get?
1

Yes

2

No

3

Do not remember

1

When you first started getting home
health care from this agency, did
someone from the agency talk with
you about how to set up your home so
you can move around safely?
1

Yes

2

No

3

Do not remember

When you started getting home health
care from this agency, did someone
from the agency talk with you about
all the prescription and over-thecounter medicines you were taking?
1

Yes

2

No

3

Do not remember

When you started getting home health
care from this agency, did someone
from the agency ask to see all the
prescription and over-the-counter
medicines you were taking?
1

Yes

2

No

3

Do not remember

9.

YOUR CARE FROM HOME
HEALTH PROVIDERS IN THE
LAST 2 MONTHS
These next questions are about all the
different staff from [AGENCY NAME]
who gave you care in the last 2 months. Do
not include care you got from staff from
another home health care agency. Do not
include care you got from family or friends.

6.

7.

8.

In the last 2 months of care, was one
of your home health providers from
this agency a nurse?
1

Yes

2

No

10.

In the last 2 months of care, was one
of your home health providers from
this agency a physical, occupational,
or speech therapist?
1

Yes

2

No

11.

In the last 2 months of care, was one
of your home health providers from
this agency a home health or personal
care aide?
1

Yes

2

No

12.

2

In the last 2 months of care, how often
did home health providers from this
agency seem informed and up-to-date
about all the care or treatment you got
at home?
1

Never

2

Sometimes

3

Usually

4

Always

5

I only had one provider in the
last 2 months of care

In the last 2 months of care, did you
and a home health provider from this
agency talk about pain?
1

Yes

2

No

In the last 2 months of care, did you
take any new prescription medicine or
change any of the medicines you were
taking?
1

Yes

2

No

If No, go to Q15.

In the last 2 months of care, did home
health providers from this agency talk
with you about the purpose for taking
your new or changed prescription
medicines?
1

Yes

2

No

3

I did not take any new
prescription medicines or
change any medicines

13.

14.

In the last 2 months of care, did home
health providers from this agency talk
with you about when to take these
medicines?

17.

1

Yes

1

Never

2

No

2

Sometimes

3

I did not take any new
prescription medicines or
change any medicines

3

Usually

4

Always

18.

In the last 2 months of care, did home
health providers from this agency talk
with you about the side effects of
these medicines?

16.

In the last 2 months of care, how often
did home health providers from this
agency listen carefully to you?
1

Never

1

Yes

2

Sometimes

2

No

3

Usually

3

I did not take any new
prescription medicines or
change any medicines

4

Always

19.
15.

In the last 2 months of care, how often
did home health providers from this
agency explain things in a way that
was easy to understand?

In the last 2 months of care, how often
did home health providers from this
agency keep you informed about when
they would arrive at your home?
1

Never

2

Sometimes

3

Usually

4

Always

In the last 2 months of care, how often
did home health providers from this
agency treat you as gently as possible?
1

Never

2

Sometimes

3

Usually

4

Always

3

In the last 2 months of care, how often
did home health providers from this
agency treat you with courtesy and
respect?
1

Never

2

Sometimes

3

Usually

4

Always

20.

We want to know your rating of your
care from this agency’s home health
providers.

22.

Using any number from 0 to 10, where
0 is the worst home health care
possible and 10 is the best home
health care possible, what number
would you use to rate your care from
this agency’s home health providers?

23.

0 Worst home health care
possible
1
2
3
4
5

In the last 2 months of care, when you
contacted this agency’s office did you
get the help or advice you needed?
1

Yes

2

No

3

I did not contact this agency

If No, go to Q24.

When you contacted this agency’s
office, how long did it take for you to
get the help or advice you needed?
1

Same day

2

1 to 5 days

3

6 to 14 days

4

More than 14 days

5

I did not contact this agency

6
24.

7
8
9

1

Yes

10 Best home health care possible

2

No

25.

YOUR HOME HEALTH AGENCY
The next questions are about the office of
[AGENCY NAME].
21.

In the last 2 months of care, did you
have any problems with the care you
got through this agency?

In the last 2 months of care, did you
contact this agency’s office to get help
or advice?
1

Yes

2

No

If No, go to Q24.

4

Would you recommend this agency to
your family or friends if they needed
home health care?
1

Definitely no

2

Probably no

3

Probably yes

4

Definitely yes

30.

ABOUT YOU
26.

2

No

31.

What is your race? Please select one
or more.

Excellent

2

Very good

1

White

Good

2

Black or African-American

Fair

3

Asian

Poor

4

Native Hawaiian or other Pacific
Islander

5

American Indian or Alaska
Native

5

29.

Yes

1

4

28.

1

In general, how would you rate your
overall health?

3

27.

Are you Hispanic or Latino/Latina?

In general, how would you rate your
overall mental or emotional health?
1

Excellent

2

Very good

3

Good

4

Fair

5

Poor

32.

What language do you mainly speak at
home?
1

English

2

Spanish

3

Some other language:

Do you live alone?
1

Yes

2

No

_________________________
(Please print.)
33.

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

8th grade or less

2

Some high school, but did not
graduate

3

High school graduate or GED

4

Some college or 2-year degree

5

4-year college graduate

6

More than 4-year college degree

5

Did someone help you complete this
survey?
1

Yes

2

No

If No, please return the
completed survey in the
postage-paid envelope.

34.

How did that person help you? Check
all that apply.
1

Read the questions to me

2

Wrote down the answers I gave

3

Answered the questions for me

4

Translated the questions into my
language

5

Helped in some other way:
_________________________
(Please print.)

6

No one helped me complete this
survey

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

6