Form 10-0450 Veterans Choice Program Survey

V1.0

Veterans Access, Choice, and Accountability Act (VACAA): Veterans Choice Program Survey

OMB 2900-0770

Estimated burden: 10 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 ten (10) 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.

Table of Contents

1. Instructions 3

2. Background about the Veterans Choice Program 3

3. Veterans Choice Cards 4

4. Contacting the Veterans Choice Program 4

4.1 CHOICE TOLL-FREE NUMBER 4

4.2 APPOINTMENT SCHEDULEING 5

5. Non-VA Healthcare Services 6

6. Part A: Veterans Choice Program Satisfaction – For participants who have received Veteran Choice Program services 6

6. Part B: Veterans Choice Program Satisfaction – For participants who have NOT received a referral to the Veterans Choice Program or have NOT received non-VA care through the Veterans Choice Program 7

7. Demographics 8

1. OMB Control Number XXXX-XXXX

1. Instructions

Welcome to Veterans Choice Program (VCP) Survey. The purpose of this survey is to collect information about your experience with the Veterans Choice Program. By participating in this survey you will help the VA to improve the quality of care Veterans receive.

Please be assured that all information collected through the survey will be protected and not used to identify you.

The public reporting burden for this collection of information is estimated at 10 minutes per response, including the time for reviewing instructions, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Veterans Affairs, 810 Vermont Avenue Northwest, Washington, DC 20571 [Insert OMB Control Number – TBD]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

If you have any questions about this survey, please contact the Government Project Officer:

Name: Marvin Rydberg

Agency: Veterans Health Administration

Office of Strategic Integration (10A5)

Address: 810 Vermont Avenue, NW, Washington, DC 20420

Phone Number: 503.841.6432

Email: [email protected]

CONSENT STATEMENT – I have read the Consent Statement above and I voluntarily agree to participate in this survey.

Yes, I voluntarily agree to participate in the survey [CONTINUE]

No, I do not wish to participate in the survey [FILTER OUT] – Thank you for your time.

2. Background about the Veterans Choice Program

In August 2014, the Veterans Access, Choice, and Accountability Act of 2014 was enacted, which created a new program, called the Veterans Choice Program, to improve access to care and meet the short-term healthcare needs of our Nation’s Veterans. This is a new, temporary benefit allowing some Veterans to receive healthcare in their communities rather than waiting for a VA appointment or traveling to a VA facility. As part of this new program, the VA has issued a Veterans Choice Card to all Veterans who are potentially eligible for the program. The Veterans Choice Card allows Veterans to choose to receive care from a non-VA healthcare provider if they qualify for the new program.

3. Veterans Choice Cards

Veterans Choice Cards have been distributed to all potentially eligible Veterans. The following questions are about your experiences with the information you received in the mail.

1. As part of the Veterans Choice Program (VCP), the VA has mailed a Veterans Choice Card to all potentially eligible Veterans. Did you receive a Veterans Choice Card?

Yes (Go to #2)

No (Skip to #6)

Do not know (Skip to #6)

		Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree	Don’t Know/ Not Applicable
	It was easy to determine whether I would be eligible for Veterans Choice Program from the information I received in the mail.
	The information I received with my card helped me understand how to use the Veterans Choice Program.
	I understand the process to get healthcare through a non-VA provider under the Veterans Choice Program including determining eligibility, connecting with a provider, and scheduling an appointment.
	I am satisfied with the amount of information available to me on the Veterans Choice Program.

4. Contacting the Veterans Choice Program

4.1 CHOICE TOLL-FREE NUMBER

The Choice toll-free number, 1-866-606-8198, is a resource for Veterans to talk to a live representative and get more information about the Veterans Choice Program, to determine whether you are eligible, and to receive non-VA healthcare referrals. Please share your experiences below.

6. Did you contact the Choice toll-free number with questions regarding the Veterans Choice Program?

Yes (Go to #7)

No (Skip to #11)

		Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree	Don’t Know
	I was satisfied with the speed in which my call was answered.
	The Choice toll-free number representative was respectful, professional, and courteous.
	The Choice toll-free number was a useful way for me to receive information about the Veterans Choice Program.
	The Veterans Choice Program website was easy to navigate in finding information on Veterans Choice Program eligibility.

11. You are eligible for the Veterans Choice Program if you enrolled in the VA before August 1^st, 2014 (or are a recently discharged combat Veteran who enrolled after that date) and meet one of the requirements below –

• Are unable to schedule an appointment with a VA provider within 30 days from a date medically determined by your provider.

• Live more than 40 miles from the nearest VA medical facility.

• Must travel by air, boat, or ferry to reach a VA medical facility.

• Face unusual or excessive travel burden (i.e. you cannot travel to a local VA due to a body of water or land barrier that cannot be crossed by road or highway).
  
  

Based on these requirements, do you believe you qualify for the Veterans Choice Program?

Yes (Go to #12)

No (Skip to #37)

4.2 SCHEDULING

Once the VA assists the Veteran in determining eligibility for Veteran Choice Program benefits, the VA will refer the Veteran to a non-VA healthcare coordinator, such as Health Net or TriWest.

12. Have you requested a non-VA healthcare referral?

Yes (Go to #13)

No (Skip to #33)

		Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree	Don’t Know
	The Choice representative was knowledgeable about my eligibility in the Veterans Choice Program and the benefits the program provides.
	I was able to schedule a timely appointment with the non-VA healthcare provider.
	The location of the non-VA healthcare provider is more convenient and accessible than my VA provider.

16. How many appointments have you scheduled using the Veterans Choice Program?

None (Go to #34)

1

2

3

4

5 to 9

10 or more

(All other responses will go to question #17)

17. How many of these appointments did you have to wait more than 30 days between scheduling the appointment and receiving care?

None

1 time

2

3

4

5 to 9

10 or more times

5. Non-VA Healthcare Services

Veterans eligible for the Veteran Choice Program can receive a referral to a non-VA healthcare provider, with whom the Veteran may schedule an appointment. The term “doctor” below will refer to the non-VA doctor(s) you saw through the Veterans Choice Program.

		Never	Sometimes	Usually	Always
	How often did your doctor see you in a timely manner?
	How often did your doctor explain things in a way that was easy to understand?
	How often did your doctor listen carefully to you?
	How often did your doctor show respect for what you had to say?
	How often did your doctor spend enough time with you?

23. Did you pay any out of pocket expenses to the non-VA healthcare provider, such as a co-payment?

Yes

No

Don’t know

	Strongly Agree		Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree	Don’t Know
I am aware of my financial responsibility for a Veterans Choice Program appointment.
The non-VA healthcare provider made it clear what services were covered by the VA.

6. Part A: Veterans Choice Program Satisfaction – For participants who have received Veteran Choice Program services

OVERALL SATISFACTION WITH THE VETERANS CHOICE PROOGRAM

The Veterans Choice Program allows eligible Veterans the option to receive healthcare from a non-VA healthcare coordinator, such as Health Net or TriWest. The program was designed to improve Veteran Health services. Please share your perceptions of the Veterans Choice Program below.

		Strongly Agree	Agree	Neither Agree nor Disagree		Disagree	Strongly Disagree	Don’t Know
	I would use the Veterans Choice Program to see a non-VA healthcare provider.
	I am satisfied with the healthcare I have received through the Veterans Choice Program. [If Disagree or Strongly Disagree – pull #30]
	I believe the Veterans Choice Program will improve the way I receive healthcare.
	I would recommend the Veterans Choice Program to other Veterans in my community. [If Disagree or Strongly Disagree – pull #31]

30. Why do you say you are dissatisfied with Veterans Choice Program?

[Only participants who respond “Disagree” or “Strongly Disagree” – to Survey Item #27 will receive this question]

[OPEN ENDED]

31. Why do you say you would not recommend the Veterans Choice Program to other Veterans in your community?

[Only participants who respond “Disagree” or “Strongly Disagree” – to Survey Item #29 will receive this question]

[OPEN ENDED]

32. What recommendations would you make to improve the Veterans Choice Program?

[OPEN ENDED]

6. Part B: Veterans Choice Program Satisfaction – For participants who have NOT received a referral to the Veterans Choice Program or have NOT received non-VA care through the Veterans Choice Program

33. [If “No” to #12] Why have you not requested a referral through the Veterans Choice Program?

Dissatisfied with the services offered by the Veterans Choice Program

Prefer to be seen by a VA provider

Prefer military network referral

Prefer to see my private, non-VA doctor

Other_________________________________________________

OVERALL SATISFACTION WITH THE VETERANS CHOICE PROGRAM

The Veterans Choice Program allows eligible Veterans the option to receive care from a non-VA healthcare provider. The program was designed to improve Veteran Health services. Please share your perceptions of the Veterans Choice Program below.

		Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree	Don’t Know
	I would use the Veterans Choice Program to see a non-VA provider. [If Disagree or Strongly Disagree – pull #36]
	I believe the Veterans Choice Program will improve the way Veterans receive healthcare.

36. Why would you say you prefer not to see a non-VA care provider?

[Only participants who respond “Disagree” or “Strongly Disagree” – to Survey Item #34 will receive this question]

[OPEN ENDED]

37. What comments do you have about the healthcare benefits you currently receive from the VA?

[OPEN ENDED]

7. Demographics

The following information is collected for demographic purposes only and will not be used to identify any respondents. Your responses are private and will be combined with those of other respondents for reporting purposes.

38. Please enter the United States Postal zip code for your primary residence:

39. Please select your gender.

Female

Male

Prefer not to answer

40. What is your age group? This information will only be used for purposes of identifying the generation in which you belong.

Less than 35 years

35-44 years

45-54 years

55-64 years

65-74 years

75 years or older

Prefer not to answer

41. How did you hear about this survey?

I called the VA and was invited to participate in the VCP Survey.

The VA contacted me with an invitation to participate in the VCP Survey.

That concludes our survey. Thank you very much for your time.

If you would like to access the VA Veterans Choice Program, please visit the Veterans Choice Program website link below:

http://www.va.gov/opa/choiceact/

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