CMS-10275 Home Health Care CAHPS Survey (Telephone/Proxy)

PROXY TELEPHONE INTERVIEW SCRIPT
FOR THE HOME HEALTH CARE CAHPS SURVEY
PROXY ID

Is there somebody such as a family member or friend who is familiar with
[SAMPLED MEMBER’S NAME]’s health care experiences?
PROBE TO FIND OUT IF PERSON IS AVAILABLE IN HOUSEHOLD TO DO
INTERVIEW.
1
2

YES
NO

[GO TO PROXY_INTRO]
[COLLECT NAME AND TELEPHONE NUMBER OF PROXY
AND SET A CALLBACK, OR IF NO PROXY EXISTS, GO TO
Q_END AND CODE AS MENTALLY/PHYSICALLY
INCAPABLE]

IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [ORGANIZATION]. I’d like to
speak with someone who is knowledgeable about [SAMPLE MEMBER
NAME]’s health and health care experiences for a study [ORGANIZATION] is
conducting about health care.
PROXY_INTRO

[Hello, this is {INTERVIEWER NAME} calling on behalf of {HOME
HEALTH AGENCY}]. [HOME HEALTH AGENCY] is participating in a
survey about the care people receive from their home health agencies. This
survey is part of a national effort to measure the quality of care from home
health care agencies. The survey results will be used by people when
choosing a home health care agency.
[SAMPLE MEMBER NAME]’s participation in this survey is completely
voluntary and will not affect [his/her] health care or any benefits [he/she]
receives. The interview will take about 12 minutes to complete. This call
may be monitored or recorded for quality improvement purposes.
NOTE: THE LENGTH OF THE INTERVIEW WILL DEPEND ON
WHETHER THE HHA ADDS SUPPLEMENTAL QUESTIONS TO
ITS HOME HEALTH CARE CAHPS SURVEY.

Q1.

According to our records, [SAMPLE MEMBER NAME] got care from the home
health agency, [HOME HEALTH AGENCY]. Is that right?
1
2

YES [GO TO Q2_INTRO]
NO [GO TO Q_INELIG]

M MISSING/DK

[GO TO Q_INELIG]

1

Q2_INTRO

As you answer the questions in this survey, think only about [SAMPLE
MEMBER NAME]’s experience with this agency. Please try to answer the
questions as best you can from [SAMPLE MEMBER NAME]’s point-of-view. If
you need to, you can answer the questions from the point-of-view of a family
member or caregiver helping [SAMPLE MEMBER NAME].

Q2.

When [SAMPLE MEMBER NAME] first started getting home health care from
this agency, did someone from the agency tell [him/her] what care and services
[he/she] would get?
1
2
3

YES
NO
DO NOT REMEMBER

M MISSING/DK
Q3.

When [SAMPLE MEMBER NAME] first started getting home health care from
this agency, did someone from the agency talk with [him/her] about how to set
up [his/her] home so [he/she] can move around safely?
1 YES
2 NO
3 DO NOT REMEMBER
M MISSING/DK

Q4.

When [SAMPLE MEMBER NAME] started getting home health care from this
agency, did someone from the agency talk with [him/her] about all the
prescription and over-the-counter medicines [he/she] was taking?
1
2
3

YES
NO
DO NOT REMEMBER

M MISSING/DK
Q5.

When [SAMPLE MEMBER NAME] started getting home health care from this
agency, did someone from the agency ask to see all the prescription and over-thecounter medicines [he/she] was taking?
1
2
3

YES
NO
DO NOT REMEMBER

M MISSING/DK

2

Q6_INTRO

These next questions are about all the different staff from [HOME HEALTH
AGENCY] who gave [SAMPLE MEMBER NAME] care in the last 2 months. Do
not include care [SAMPLE MEMBER NAME] got from staff from another home
health care agency. Do not include care [he/she] got from family or friends.

Q6.

In the last 2 months of care, was one of [SAMPLE MEMBER NAME]’s home
health providers from this agency a nurse?
1
2

YES
NO

M MISSING/DK
Q7.

In the last 2 months of care, was one of [SAMPLE MEMBER NAME]’s home
health providers from this agency a physical, occupational, or speech therapist?
1
2

YES
NO

M MISSING/DK
Q8.

In the last 2 months of care, was one of [SAMPLE MEMBER NAME]’s home
health providers from this agency a home health or personal care aide?
1
2

YES
NO

M MISSING/DK
Q9.

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 [SAMPLE
MEMBER NAME] got at home? Would you say…
1
2
3
4
5

Never,
Sometimes,
Usually,
Always, or
[SAMPLE MEMBER NAME] only had one provider in the last 2 months of
care?

M MISSING/DK

3

Q10.

In the last 2 months of care, did [SAMPLE MEMBER NAME] and a home health
provider from this agency talk about pain?
1
2

YES
NO

M MISSING/DK
Q11.

In the last 2 months of care, did [SAMPLE MEMBER NAME] take any new
prescription medicine or change any of the medicines [he/she] was taking?
1
2

YES
NO [GO TO Q15]

M MISSING/DK
Q12.

[GO TO Q15]

In the last 2 months of care, did home health providers from this agency talk with
[SAMPLE MEMBER NAME] about the purpose for taking [his/her] new or
changed prescription medicines?
1
2

YES
NO

M MISSING/DK
Q13.

In the last 2 months of care, did home health providers from this agency talk with
[SAMPLE MEMBER NAME] about when to take these medicines?
1
2

YES
NO

M MISSING/DK
Q14.

In the last 2 months of care, did home health providers from this agency talk with
[SAMPLE MEMBER NAME] about the side effects of these medicines?
1
2

YES
NO

M MISSING/DK

4

Q15.

In the last 2 months of care, how often did home health providers from this
agency keep [SAMPLE MEMBER NAME] informed about when they would
arrive at [his/her] home? Would you say…
1
2
3
4

Never,
Sometimes,
Usually, or
Always?

M MISSING/DK
Q16.

In the last 2 months of care, how often did home health providers from this
agency treat [SAMPLE MEMBER NAME] as gently as possible? Would you
say…
1 Never,
2 Sometimes,
3 Usually, or
4 Always?
M MISSING/DK

Q17.

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? Would you say…
1
2
3
4

Never,
Sometimes,
Usually, or
Always?

M MISSING/DK
Q18.

In the last 2 months of care, how often did home health providers from this
agency listen carefully to [SAMPLE MEMBER NAME]? Would you say…
1
2
3
4

Never,
Sometimes,
Usually, or
Always?

M MISSING/DK

5

Q19.

In the last 2 months of care, how often did home health providers from this
agency treat [SAMPLE MEMBER NAME] with courtesy and respect? Would
you say…
1
2
3
4

Never,
Sometimes,
Usually, or
Always?

M MISSING/DK
Q20_INTRO We want to know [SAMPLE MEMBER NAME]’s rating of [his/her] care from
this agency’s home health providers. Please try to answer the questions as best
you can from [SAMPLE MEMBER NAME]’s point-of-view. If you need to, you
can answer the questions from the point-of-view of a family member or caregiver
helping [SAMPLE MEMBER NAME].
Q20.

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 [SAMPLE
MEMBER NAME] use to rate [his/her] care from this agency’s home health
providers?
READ RESPONSE CHOICES ONLY IF NECESSARY
00
01
02
03
04
05
06
07
08
09
10

0 Worst home health care possible
1
2
3
4
5
6
7
8
9
10 Best home health care possible

M MISSING/DK

6

Q21_INTRO The next questions are about the office of [HOME HEALTH AGENCY].
Q21.

In the last 2 months of care, did [SAMPLE MEMBER NAME] contact this
agency’s office to get help or advice?
1 YES
2 NO [GO TO Q24]
M MISSING/DK

Q22.

In the last 2 months of care, when [SAMPLE MEMBER NAME] contacted this
agency’s office did [he/she] get the help or advice [he/she] needed?
1
2

YES
NO [GO TO Q24]

M MISSING/DK
Q23.

[GO TO Q24]

[GO TO Q24]

When [SAMPLE MEMBER NAME] contacted this agency’s office, how long did
it take for [him/her] to get the help or advice [he/she] needed? Would you say…
1
2
3
4

Same day,
1 to 5 days,
6 to 14 days, or
More than 14 days?

M MISSING/DK
Q24.

In the last 2 months of care, did [SAMPLE MEMBER NAME] have any
problems with the care [he/she] got through this agency?
1
2

YES
NO

M MISSING/DK
Q25.

Would [SAMPLE MEMBER NAME] recommend this agency to [his/her] family
or friends if they needed home health care? Would you say…
1
2
3
4

Definitely no,
Probably no,
Probably yes, or
Definitely yes?

M MISSING/DK

7

Q26_INTRO This last set of questions asks for information about [SAMPLE MEMBER
NAME]. Please listen to all response choices before making a selection.
Q26.

In general, how would [SAMPLE MEMBER NAME] rate [his/her] overall
health? Would you say that it is…
1
2
3
4
5

Excellent,
Very good,
Good,
Fair, or
Poor?

M MISSING/DK
Q27.

In general, how would [SAMPLE MEMBER NAME] rate [his/her] overall
mental or emotional health? Would you say that it is…
1
2
3
4
5

Excellent,
Very good,
Good,
Fair, or
Poor?

M MISSING/DK
Q28.

Does [SAMPLE MEMBER NAME] live alone?
1 YES
2 NO
M MISSING/DK

Q29.

What is the highest grade or level of school that [SAMPLE MEMBER NAME]
has completed? Would you say…
1
2
3
4
5
6

8th grade or less,
Some high school, but did not graduate,
High school graduate or GED,
Some college or 2-year degree,
4-year college graduate, or
More than 4-year college degree?

M MISSING/DK

8

Q30.

Is [SAMPLE MEMBER NAME] Hispanic or Latino/Latina?
1
2

YES
NO

M MISSING/DK
Q31.

What is [SAMPLE MEMBER NAME]’s race? You may choose one or more of
the following. Is he/she…
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or other Pacific Islander
5 American Indian or Alaska Native
M MISSING/DK

Q32.

What language does [SAMPLE MEMBER NAME] mainly speak at home?
1 English, [GO TO Q_END]
2 Spanish, or [GO TO Q_END]
3 Some other language? [GO TO Q32A]
M MISSING/DK [GO TO Q_END]

Q32A

What other language does [SAMPLE MEMBER NAME] mainly speak at home?
(ENTER RESPONSE BELOW).
{ALLOW UP TO 50 CHARACTERS}
M MISSING/DK

Q_END

These are all the questions I have for you. Thank you for your time. Have a good
(day/evening).

INELIGIBLE SCREEN:
Q_INELIG

Thank you for your time. Have a good (day/evening).

REFUSAL SCREEN:
Q_REF

Thank you for your time. Have a good (day/evening).

9