10-10131 Maternity Care Coordination Survey

OMB Number 2900-0770

Estimated Burden: 5 mins

EXP Date: XX/XX/2014

Pregnant Veterans Maternity Care Coordination Survey

OMB 2900-0770

Estimated burden: 5 minutes

Expiration Date xx/xx/xxxx

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average five (5) minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to achieve services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

VA Form 10-10131

Veteran Affairs

VA Maternity Care Coordination Study

Dr. Kristin Mattocks, VA Central Western Massachusetts Healthcare System

Manuel, Howard L.



Your VA Primary Care Provider

1. Our records show that you got care from a VA primary care provider at some point in the last year.

1a. Is that right?

■ 1 Yes

■ 2 No

1b. Is this the VA provider you usually see if you want advice about a health problem or get sick?

■ 1 Yes

■ 2 No →

Please think of your VA primary care provider as you answer this survey.

2. How long have you been going to this provider?

■ 1 Less than 6 months

■ 2 At least 6 months but less than 1 year

■ 3 At least 1 year but less than 3 years

■ 4 At least 3 years but less than 5 years

■ 5 5 years or more

Care from Your VA Primary Care Provider and This Provider’s Office

The following questions ask about the care you received from your VA primary care provider.

3. Some offices remind patients about appointments. Before your most recent visit with this provider, did you get a reminder from this provider’s office about the appointment?

■ 1 Yes

■ 2 No

4. Before your most recent visit with this provider, did you get instructions telling you what to expect or how to prepare for the visit?

■ 1 Yes

■ 2 No

5. In the last year, how often did this provider cancel or change the date of an appointment?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

6. People have busy lives and miss appointments for many reasons. In the last year, how often did you miss an appointment with this provider?

■ 1 Never → If Never, go to #9

■ 2 Sometimes

■ 3 Usually

■ 4 Always

7. In the last year, when you missed an appointment with this provider, how often did someone from his or her office contact you to make a new appointment?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

8. In the last year, how often did you have to repeat information that you had already provided during the same visit?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

9. In the last year, how often did this provider seem to know the important information about your medical history?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

10. In the last year, how often did this provider ask about things in your work or life at home that affect your health?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

11. In the last year, how often did this provider explain things in a way that was easy to understand?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

12. In the last year, how often did this provider listen carefully to you?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

13. In the last year, how often did this provider show respect for what you had to say?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

14. In the last year, how often did this provider spend enough time with you?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

15. In the last year, how often did this provider ask whether you had ideas about how to improve your health?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

16. How would you rate this provider’s knowledge of your values and beliefs that are important to your health care?

■ 1 Poor

■ 2 Fair

■ 3 Good

■ 4 Excellent

17. In the last year, did this provider talk with you about setting goals for your health?

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No → If No, go to #19 on page 3

18. In the last year, did the care you received from this provider help you meet your goals?

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

Care from Other Staff at Your VA Primary Care Provider’s Office

19. People often get instructions about their health from more than one person in the same office, such as other doctors, nurses, nutritionists, and social workers. In the last year, did you get any instructions about your health from any other staff in the office of your VA primary care provider?

■ 1 Yes

■ 2 No → If No, go to #23

20. In the last year, how often did these other staff
seem up-to-date about the care you were receiving from this provider?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

21. In the last year, how often did these other staff
talk with you about the care you were receiving from
this provider?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

22. In the last year, how often did these other staff
seem to know the important information about your medical history?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

Care from Someone in Your VA Primary Care Provider’s Office

The following questions ask about the care you received from your VA primary care provider or someone in his or her office.

23. In the last year, did this provider or someone in his or her office order a blood test, x-ray, or other test for you?

■ 1 Yes

■ 2 No → If No, go to #27

24. In the last year, when this provider or someone in his or her office ordered a blood test, x-ray, or other test for you, how often did this provider or someone from his or her office follow up to give you those results?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

25. In the last year, how often did you have to request your test results before you got them?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

26. In the last year, how often were your test results presented in a way that was easy to understand?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

27. In the last year, were there things that made it hard for you to take care of your health?

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No → If No, go to #30 on page 4

28. In the last year, did this provider or someone in his or her office ask you about these things that make it hard for you to take care of your health?

■ 1 Yes

■ 2 No

29. In the last year, did you and this provider or someone in his or her office come up with a plan to help you deal with the things that make it hard for you to take care of your health?

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

30. In the last year, how often did this provider or someone in his or her office help you identify the most important things for you to do for your health?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

31. In the last year, did you need services at home to help you take care of your health?

■ 1 Yes

■ 2 No → If No, go to #33

32. In the last year, how often did this provider or someone in his or her office help you get these services at home to take care of your health?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

33. In the last year, did this provider or someone in his or her office give you instructions about how to take care of your health?

■ 1 Yes

■ 2 No → If No, go to #36

34. In the last year, how often were you able to follow these instructions about taking care of your health?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

35. In the last year, how often did the instructions you received help you take care of your health?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

36. In the last year, if you had any trouble taking care of your health at home, would you know who to ask for help?

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

37. In the last year, did you take any prescription medicine?

■ 1 Yes

■ 2 No → If No, go to #41

38. In the last year, how often did this provider or someone in his or her office talk with you about how you were supposed to take your medicine?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

39. There are many reasons why people may not always
be able to take their medicines as prescribed. In the last year, how often were you able to take your medicine as prescribed?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

40. In the last year, how often did this provider or someone in his or her office talk with you about what to do if you have a bad reaction to your medicine?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

41. In the last year, how often did this provider or someone in his or her office contact you between visits to see how you were doing?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

42. In the last year, did you try to contact this provider’s office with a medical question after regular office hours?

■ 1 Yes

■ 2 No → If No, go to #44 on page 5

43. In the last year, when you tried to contact this provider’s office after regular office hours, how often
did you get an answer to your medical question in a
timely manner?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

Care from Your Obstetrical Provider

44. In the last year, did you receive care from an obstetrical provider?

■ 1 Yes

■ 2 No → If No, go to #53

45. In general, how often does your VA primary care provider seem informed and up-to-date about the care you get from your obstetrical provider?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

46. In general, how often do you have to remind your VA primary care provider about care you receive from your obstetrical provider?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

47. During your pregnancy, did your obstetrical provider prescribe medicine for you?

■ 1 Yes

■ 2 No → If No, go to #49

48. In general, how often does your VA primary care provider talk with you about the medicines prescribed by your obstetrical provider?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

The Obstetrical Provider You Saw Most Often in the Last Year

The following questions ask about care you received from the obstetrical provider you saw most often during your pregnancy.

49. When you see this obstetrical provider, does he or she seem to know enough information about your medical history?

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

50. When you see this obstetrical provider, how often do you have to repeat information that you have already given to your VA primary care provider?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

51. When you see this obstetrical provider, how often does this obstetrical provider seem to know your important test results from other providers?

■ 1 Never

■ 2 Sometimes

■ 3 Usually

■ 4 Always

Your Most Recent Hospital Stay

52. For your most recent pregnancy, were you admitted to the hospital for the delivery or for other reasons related to your pregnancy?

■ 1 Yes

■ 2 No → If No, go to #60 on page 6

53. After your most recent hospital stay, did your VA primary care provider or someone in his or her office contact you to see how you were doing?

■ 1 Yes

■ 2 No

54. After your most recent hospital stay, were you prescribed any medicines?

■ 1 Yes

■ 2 No → If No, go to #56 on page 6

55. After your most recent hospital stay, did your VA primary care provider or someone in his or her office contact you to check if you were able to follow instructions about any medicines you were prescribed?

■ 1 Yes

■ 2 No

56. After your most recent hospital stay, were you given instructions about caring for yourself at home?

■ 1 Yes

■ 2 No → If No, go to #58

57. After your most recent hospital stay, were the instructions you were given easy to understand?

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

58. After your most recent hospital stay, did your VA primary care provider seem to know the important information about this hospital stay?

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

Your Overall Experience

59. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the last year?

■ 0 Worst health care possible

■  1

■  2

■  3

■  4

■  5

■  6

■  7

■  8

■  9

■  10 Best health care possible

60. People sometimes need to manage their medical care by making appointments with multiple providers, following their instructions, and taking medicines as prescribed. Using any number from 0 to 10, where 0 is hard and 10 is easy, what number would you use to rate how easy it was for you to manage your medical care in the last year?

■ 0 Hard to manage

■  1

■  2

■  3

■  4

■  5

■  6

■  7

■  8

■  9

■  10 Easy to manage

61. In the last year, was there one provider who knew about all your medical care needs?

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

62. In the last year, was there one provider who knew about all the medicines you were taking?

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

63. In the last year, was there one provider who knew you well as a person?

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

About You

64. In general, how would you rate your overall health?

■ 1 Excellent

■ 2 Very good

■ 3 Good

■ 4 Fair

■ 5 Poor

65. In the next year, what do you think will happen
to your overall health?

■ 1 It will get much better

■ 2 It will get somewhat better

■ 3 It will not change

■ 4 It will get somewhat worse

■ 5 It will get much worse

66. In the last year, how much of a problem were each of these for you?

a. Lack of information about your medical conditions.

■ 1 Not a problem at all

■ 2 A small problem

■ 3 A moderate problem

■ 4 A big problem

■ 5 A very big problem

b. Lack of information about treatment options.

■ 1 Not a problem at all

■ 2 A small problem

■ 3 A moderate problem

■ 4 A big problem

■ 5 A very big problem

c. Bringing up concerns about your health or health care with your providers.

■ 1 Not a problem at all

■ 2 A small problem

■ 3 A moderate problem

■ 4 A big problem

■ 5 A very big problem

67. In the last year, did you ever need assistance with the following?

a. Taking medicines

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

b. Making medical-related appointments

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

c. Getting to or from a medical appointment

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

d. Understanding information from a health care provider

■ 1 Yes, definitely

■ 2 Yes, somewhat

■ 3 No

68. In the last year, did one or more friends or relatives help you with any of the tasks in Question 68?

■ 1 Yes

■ 2 No

Other Questions About You

69. Please indicate how much you agree or disagree with each of the following statements. Please be as honest and accurate as you can. Try not to let your response to one statement influence your responses to other statements. There are no “correct” or “incorrect” answers. Answer according to your own feelings, rather than how you think “most people” would answer.

a. In uncertain times, I usually expect the best.

■ 1 I agree a lot

■ 2 I agree a little

■ 3 I neither agree nor disagree

■ 4 I disagree a little

■ 5 I disagree a lot

b. It is easy for me to relax.

■ 1 I agree a lot

■ 2 I agree a little

■ 3 I neither agree nor disagree

■ 4 I disagree a little

■ 5 I disagree a lot

c. If something can go wrong for me, it will.

■ 1 I agree a lot

■ 2 I agree a little

■ 3 I neither agree nor disagree

■ 4 I disagree a little

■ 5 I disagree a lot

d. I am always optimistic about my future.

■ 1 I agree a lot

■ 2 I agree a little

■ 3 I neither agree nor disagree

■ 4 I disagree a little

■ 5 I disagree a lot

e. I hardly ever expect things to go my way.

■ 1 I agree a lot

■ 2 I agree a little

■ 3 I neither agree nor disagree

■ 4 I disagree a little

■ 5 I disagree a lot

f. I rarely count on good things happening to me.

■ 1 I agree a lot

■ 2 I agree a little

■ 3 I neither agree nor disagree

■ 4 I disagree a little

■ 5 I disagree a lot

g. Overall, I expect more good things to happen to me than bad.

■ 1 I agree a lot

■ 2 I agree a little

■ 3 I neither agree nor disagree

■ 4 I disagree a little

■ 5 I disagree a lot

70. What is your age?

■ 1 18 to 24

■ 2 25 to 34

■ 3 35 to 44

■ 4 45 to 54

■ 5 55 to 64

■ 6 65 to 74

■ 7 75 or older

71. Are you male or female?

■ 1 Male

■ 2 Female

72. 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

73. Are you of Hispanic or Latino origin or descent?

■ 1 Yes, Hispanic or Latino / Latina

■ 2 No, not Hispanic or Latino / Latina

74. What is your race? Please mark one or more.

■ 1 White

■ 2 Black or African-American

■ 3 Asian

■ 4 Native Hawaiian or Other Pacific Islander

■ 5 American Indian or Alaska Native

■ 6 Other

75. Are you married or living with a significant other?

■ 1 Yes

■ 2 No

76. We are interested in how Veterans are getting along financially these days. Income can come from a number of sources: a job, pension, Social Security, SSI, welfare, dividends, interest, and any other source. What was your total household income in 2014 before taxes?

■ 1 Less than $10,000

■ 2 $10,000 to $14,999

■ 3 $15,000 to $19,999

■ 4 $20,000 to $29,999

■ 5 $30,000 to $39,999

■ 6 $40,000 to $49,999

■ 7 $50,000 to $74,999

■ 8 $75,000 to $99,999

■ 9 $100,000 or more

77. How many people age 15 or older lived in your household in 2014, including you?

■ 1 1 (I lived alone)

■ 2 2

■ 3 3

■ 4 4

■ 5 5 or more

78. Did someone help you complete this survey?

■ 1 Yes

■ 2 No → Thank you. Please return the completed survey in the postage-paid envelope

79. How did that person help you? Please mark one or more.

■ 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

How did they help? (Please print)