Sources of Survey Items

Part B, Attachment 1
Sources of Survey Items

Part B, Attachment 1 – Sources of Survey Items
Domain/Survey
Item

National Survey of
Beneficiaries
6- and 12Baseline
Month
Followup

Source

Wellness Program Participant Surveys
Baseline

6- Month
Followup

12- Month
Followup

Q.1-11d

Q.1-11d

Q.1-11d

N/A

N/A

N/A

N/A

N/A

N/A

Q. 22-23b

Q. 22-23b

Health Status
General Health
Status

SF-36

Q.1-11d

Vision
Hearing
Height
Weight

1

Adapted
from MCBS

Arthritis

Q.12

Q.12

Q.13

Q.13

Q.14

Q.14

Q.15

Q.15

Q.16

Diabetes

CHIS

Pre-diabetes

Q.17

Q.19-20

Q.19-20

Flu Shot

MCAHPS

Q.21

Preventing falls
Managing chronic
conditions
Recommendation
by provider
Awareness of
wellness
programs

N/A

Q.21

Q. 22

N/A

Q. 23

N/A

Q. 24

N/A

Q. 25
Q. 26

Newly
Developed

Q.17
Q.18

Adapted
from MCBS

Adapted
from TTM

Q.16
N/A

Q.18

Smoking

Healthy foods
Weight
management
Regular exercise

Q.1-11d

N/A
N/A

N/A

Q. 27

Q.22

Q. 28

Q.23

Lifestyle Modification
Participation in
wellness
programs

1

Newly
Developed

Q.29-33

Q.22

Q.24-25

Question items that were modified from the source are identified as being “adapted.”

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Part B, Attachment 1
Sources of Survey Items

Part B, Attachment 1 – Sources of Survey Items (cont.)
National Survey of
Beneficiaries
Domain/Survey
Source
6- and 12Item
Baseline
Month
Followup
Making Healthcare Decisions and Self-Efficacy
Getting medical
care

Q.34

Wellness Program Participant Surveys
Baseline

6- Month
Followup

12- Month
Followup

N/A

N/A

Q.26

MCBS

Medication
review

Q.35

Self-efficacy

N/A

Q.27

Chen

Q.36-43

Q.28-35

PHQ-2

Q.44a-b

N/A

Q.36a-b

N/A

N/A

RAPA

Q45a-h

Q. 12a-h

Q.37a-h

Q.12a-h

Q. 12a-h

Adapted
from HOS

Q46a

Q. 13

Q.38a

Q.13

Q. 13

Adapted
from BRFSS

Q46b

Q. 14

Q.38b

Q.14

Q. 14

HOS

Q.47

Q. 15

Q.39

Q.15

Q. 15

HOS

Q.48

N/A

Q.40

N/A

N/A

Fear Of Falls

Da Costa

Q. 49

Q. 16

Q.41

Q.16

Q. 16

Balance
Confidence

ABC

Q.50a-f

Q.17a-f

Q.42a-f

Q.17a-f

Q. 17a-f

CDSMP

Q.51-54

Q.18-21

Q.43-46

Q.18-21

Q.18-21

Q.55a-d

N/A

Q.47a-d

N/A

N/A

Depression
Emotional WellBeing

Physical Activity
Activity Intensity

Falls and Balance
Falls History
Falls Injury
History
Problem with
Balance &
Walking
Doctor’s
recommendation
on fall prevention

Medications
Medication
Adherence

Getting Help From Others
Social Supports

RAND MOS

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Part B, Attachment 1
Sources of Survey Items

Part B, Attachment 1 – Sources of Survey Items (cont.)
Domain/Survey
Item

Source

National Survey of
Beneficiaries
6- and 12Baseline
Month
Followup

Wellness Program Participant Surveys
Baseline

6- Month
Followup

12- Month
Followup

N/A

N/A

Demographics
Gender

Q.56

Q.48

Ethnicity

Q.57

Q.49

Race

Q.58

Q.50

Q.59

Q.51

English
Proficiency

Q.60

Q.52

Marital Status

Q.61

Q.53

Education

Q.62

Q.54

Q.63

Q.55

Birth Date

Living
Arrangement

HOS

Adapted
from HOS

N/A

Living Alone

Q.64

Employment
Status

Q.65

Q.57

Health Insurance

Q.66

Q.58

Q67-68

Q.59-60

Q.69

Q.61

Q.70

Q.62

Q.71

Q.63

N/A

Q.64a-b

Caregiver Status

HOS

Transportation
Access
Survey
Completion
Person
Income Category
Personal
Verification

Newly
Developed

Version: 3/11/2014

Q.56

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Part B, Attachment 1
Sources of Survey Items

Part B, Attachment 1 – Sources of Survey Items (cont.)
Domain/Survey
Item

Source

National Survey of
Beneficiaries
6- and 12Baseline
Month
Followup

Wellness Program Participant Surveys
Baseline

6- Month
Followup

12- Month
Followup

Q.65

Q.26

Q.24

Miscellaneous
Survey
Completion Date
Willingness to pay
for program
Best Thing about
Program
Flags for current
participation &
noncompleter

Newly
Developed

Ill Health

Newly
Developed

Unmet health
needs Flag
Reasons for
Leaving Program
Other Reasons for
Leaving
Program
Improvements

Q.72

Q. 23

Q.24
Q. 25
Q. 27-28
N/A

N/A

N/A

Q.29

N/A

Q.30a-30b
Q.31a-m
Q. 32
Q.33

Legend:
ABC:

Activities-Specific Balance Confidence (ABC) Scales (Activities-specific-BalanceConfidence-Scale.rtf)

BRFSS:

Behavioral Risk Factor Surveillance System (http://www.cdc.gov/brfss/)

CDSMP:

Stanford Chronic Disease Self-Management Program
(http://patienteducation.stanford.edu/research/)

Chen:

Chen, G., Gully, S. M., & Eden, D. (2001). Validation of a new general selfefficacy scale. Organizational Research Methods, 4(1), 62-83.
(http://orm.sagepub.com/content/4/1/62.abstract)

CHIS:

California Health Interview Survey
(http://healthpolicy.ucla.edu/chis/Pages/default.aspx)

da Costa:

da Costa, E. M., Pepersack, T., Godin, I., Bantuelle, M., Petit, B., & Levêque, A.
(2012). Fear of falling and associated activity restriction in older people. results
of a cross-sectional study conducted in a Belgian town. Archives of public
health, 70(1), 1. (http://www.ncbi.nlm.nih.gov/pubmed/22958732)

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Part B, Attachment 1
Sources of Survey Items
HOS:

Medicare Health Outcome Survey
(http://www.hosonline.org/Content/Default.aspx)

MCBS:

Medicare Current Beneficiary Survey (http://www.cms.gov/Research-StatisticsData-and-Systems/Research/MCBS/index.html?redirect=/MCBS)

MCAHPS:

Medicare Consumer Assessment of Healthcare Providers and Systems
(http://www.ma-pdpcahps.org/content/homepage.aspx)

MEPS:

Medical Expenditure Panel Survey (http://meps.ahrq.gov/mepsweb/)

N/A:

Not applicable

PHQ-8:

Patient Health Questionnaires (http://www.phqscreeners.com/)

RAND MOS:

Medical Outcomes Study
(http://www.rand.org/health/surveys_tools/mos.html)

RAPA:

Rapid Assessment of Physical Activity (http://depts.washington.edu/hprc/rapa)

SF-36:

Short Form 36 Health Survey (http://www.sf-36.org/)

TTM:

Transtheoretical Model of Behavior Change
(http://www.umbc.edu/psyc/habits/content/the_model/)

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