CMS-10403 CCTP 1st Admin Participant Exp Suvey Revised

OMB No.: 0938-1167

Expiration Date: 06-30-2015

COMMUNITY-BASED CARE TRANSITIONS PROGRAM (CCTP) PATIENT EXPERIENCE SURVEY

FIRST ADMINISTRATION (WITHIN 4 DAYS AFTER HOSPITAL DISCHARGE)

INFORMATION TO BE PRE-FILLED BY THE CBOs FROM THE LIST BILLS

Medicare Beneficiary ID (Health Insurance Claim Number or HICN):	| | | |-| | |-| | | | |-| | | |
Beneficiary Date of Birth:	| | | / | | | / | | | | | Month Day Year
Medicare Hospital ID (CMS Certification Number or CCN):	| | | | | | |
Date of Hospital Discharge:	| | | / | | | / | | | | | Month Day Year
CCTP CBO ID:	| | | | |

Date Interview Completed or Attempted: | | | / | | | / | | | | |

Month Day Year

SURVEY INTRODUCTION:

INTERVIEWER/COACH: YOU MAY INTRODUCE THE SURVEY BY READING THE BULLETS, OR USE YOUR OWN WORDS TO COVER THE FOLLOWING POINTS.

• This survey is part of Medicare's community-based care transitions program (also known as CCTP).

• The survey is about your most recent hospital stay.

• The information from all surveys combined will be used to improve care transitions after people have a hospital stay.

• There are no right or wrong answers and you should answer honestly.

• The survey is voluntary (it is your choice to take the survey).

• Whether or not you choose to take the survey will not affect your health care coverage.

• Your answers will not be shared with your doctors but only with people on the study team.

• You may skip any question that you don't want to answer.

• The survey should take about 10 minutes.

• Could we begin now?

1 □ Yes CONTINUE WITH THE INTERVIEW

0 □ No Thanks very much for your time. END INTERVIEW (SAVE FOR DATA ENTRY)

1 □ Yes CONTINUE WITH THE INTERVIEW (item 1)

2 □ Interview not attempted (MARK REASON INTERVIEWER DID NOT ATTEMPT INTERVIEW)

16 □ No translation available

17 □ Patient confused/poor memory/cognitive impairment/severe hearing loss

1

END INTERVIEW AND SAVE FOR DATA ENTRY

8 □ Interviewer did not do interview at intervention, then could not recontact

19 □ Other reason for not attempting interview (Specify reason)

3 □ No, patient refused Thanks for your time. (MARK REASON PATIENT GAVE FOR

NOT COMPLETING INTERVIEW)

21 □ Patient refused because too sick or too tired

22 □ Patient refused because too busy/did not have time

23 □ Patient refused for some other reason (Specify reason)

24 □ Patient refused, no reason specified

(IF YES):

Thank you. To begin, these questions are about what happened during your most recent hospital stay.

1. During this hospital stay, were you given any medicine that you had not taken before?

1 □ Yes

0 □ No GO TO Q.4

2. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Would you say never, sometimes, usually, or always?

MARK ONE ONLY

1 □ Never

2 □ Sometimes

3 □ Usually

4 □ Always

3. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? Would you say never, sometimes, usually, or always?

MARK ONE ONLY

1 □ Never

2 □ Sometimes

3 □ Usually

4 □ Always

4. During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

1 □ Yes 0 □ No

5. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

1 □ Yes 0 □ No

The next set of questions is about how prepared you felt when you left the hospital. Your answer choices are Disagree Strongly, Disagree, Agree, and Agree Strongly. Let’s start with the first question.

INTERVIEWER: DO NOT INTRODUCE THE OPTION TO PROVIDE A “DON’T KNOW/DON’T REMEMBER/NOT APPLICABLE” RESPONSE; OFFER IT ONLY IF IT BECOMES CLEAR THAT THE FOUR OTHER RESPONSES DO NOT PERTAIN.

	MARK ONE PER ROW
	DISAGREE STRONGLY	DISAGREE	AGREE	AGREE STRONGLY	DON’T KNOW/ DON’T REMEMBER/ NOT APPLICABLE
6. The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital. Would you say you disagree or agree? [THEN ASK: Do you disagree/agree strongly or just disagree/agree?]	1 □	2 □	3 □	4 □	d □
7. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. Would you say you disagree or agree? [THEN ASK: Do you disagree/agree strongly or just disagree/agree?]	1 □	2 □	3 □	4 □	d □
8. When I left the hospital, I clearly understood the purpose for taking each of my medications. Would you say you disagree or agree? [THEN ASK: Do you disagree/agree strongly or just disagree/agree?]	1 □	2 □	3 □	4 □	d □

The last set of questions is about how comfortable you feel taking care of your health. I want to assure you that there are NO right or wrong answers, and neither of us is being graded on how you answer, so I encourage you to be completely honest when you answer.

As with the earlier questions, your answer choices are Disagree Strongly, Disagree, Agree, and Agree Strongly.

	MARK ONE PER ROW
	DISAGREE STRONGLY	DISAGREE	AGREE	AGREE STRONGLY	NA
9. When all is said and done, I am the person who is responsible for taking care of my health	1 □	2 □	3 □	4 □	n □
10. Taking an active role in my own health care is the most important thing that affects my health	1 □	2 □	3 □	4 □	n □
11. I am confident I can help prevent or reduce problems associated with my health	1 □	2 □	3 □	4 □	n □
12. I know what each of my prescribed medications do	1 □	2 □	3 □	4 □	n □
13. I am confident that I can tell whether I need to go to the doctor or whether I can take care of a health problem myself	1 □	2 □	3 □	4 □	n □
14. I am confident that I can tell a doctor concerns I have even when he or she does not ask	1 □	2 □	3 □	4 □	n □
15. I am confident that I can follow through on medical treatments I may need to do at home	1 □	2 □	3 □	4 □	n □
16. I understand my health problems and what causes them	1 □	2 □	3 □	4 □	n □
17. I know what treatments are available for my health problems	1 □	2 □	3 □	4 □	n □
18. I have been able to maintain (keep up with) lifestyle changes, like eating right or exercising	1 □	2 □	3 □	4 □	n □
19. I know how to prevent problems with my health	1 □	2 □	3 □	4 □	n □
20. I am confident I can figure out solutions when new problems arise with my health	1 □	2 □	3 □	4 □	n □
21. I am confident that I can maintain lifestyle changes, like eating right and exercising, even during times of stress	1 □	2 □	3 □	4 □	n □

That is the end of our questions. Thank you very much for participating in the survey!

INTERVIEWER/COACH, PLEASE ANSWER THE FOLLOWING QUESTIONS:

A. Did you complete the interview with the patient alone, with the patient assisted by another person, or with someone else answering for the patient? 1 □ PATIENT ALONE GO TO C 2 □ PATIENT WITH ASSISTANCE 3 □ SOMEONE ELSE ANSWERING FOR PATIENT	B. Who assisted the patient or answered for them? 1 □ SPOUSE 2 □ ANOTHER RELATIVE 3 □ FRIEND 4 □ PAID CAREGIVER 5 □ SOMEONE ELSE (Specify)
C. How much of the questionnaire do you think this patient understood? 1 □ MOST OR ALL 2 □ SOME 3 □ NONE	D. Did you complete the interview in person or over the phone? 1 □ IN PERSON 2 □ OVER THE PHONE
E. Is there any other information you think we should know about this interview?

Prepared by Mathematica Policy Research