Form 1 CCQM-PC

Appendix A:
Care Coordination Quality
Measure for Primary Care
(CCQM-PC)

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Care Coordination Measure Development
Draft Survey – All Items
Version: post-R1 cognitive testing

Language: English
Reference Period: In the last 12 months
Each survey item has been labeled to indicate the domain, construct source, and CAHPS or other survey indicator.
The lists below provide the abbreviations used. For example, if a question is labeled: (EA/AT,T/HP5-AM-m1),
it means this question is from the Establish accountability or negotiate responsibility domain, the construct came
from the ATLAS, 2010 and Technical Expert Panel, and the question wording is a modified version of the
CAHPS Health Plan 5.0 Adult Medicaid Question #1. The headings in this survey are meant for respondent
navigation, not domain headings.
Survey Domain Name
EA=Establish accountability or negotiate responsibility
CG=Communicate: general
CIP=Communicate: interpersonal communication
CIF=Communicate: information transfer
FG=Facilitate transitions: general
FAS=Facilitate transitions: across settings
FAN=Facilitate transitions: as needs change
ANG=Assess needs and goal
CPC=Create a proactive plan of care
MFU=Monitor, follow up and respond to change
SSM=Support self-management goals
LCR=Link to community resources
ARP=Align resources with patient and population needs
RC=Respondent Characteristics
All the questions have a domain label.
Construct Source
AT=ATLAS, 2010
ATU=ATLAS, updated 2013
F=Formative research including focus groups and in-depth interviews
CI1=Cognitive Interviews Round 1
CI2=Cognitive Interviews Round 2
T=Technical Expert Panel
A=Agency for Healthcare Research and Quality
NI=New Item

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Survey Indicator
PC1-A-Q#
SC1-A-Q#
PCMHS-A-Q#
PCMHS1.1-C-Q#
CPCQ-Q#
FCCST-F-Q#
CSHCN-Q#
MHILV-Q#
MHFIS-Q#
PCAT-CE-Q#
PCAT-AE-Q#
RSSM-Q#
MPOC-Q#
FCD-Q#
PCMHVCI-Q#
PCSSW-Q#
PPOC-Q#
ACES-Q#
PC-Q#
CPCI-Q#
B5AP-Q#
PPCCMP-Q#
RMCSMLTC-Q#
PPIC-Q#
PCCPP-Q#
PACIC-Q#
MCQ-Q#
HP5-AM-Q#
HP4-AS-Q#
CG2-AS-Q#
HPQ-Q#

CAHPS Adult Primary Care 1.0, Question #
CAHPS Adult Specialty Care 1.0, Question #
CAHPS Patient-Centered Medical Home Supplementary Survey Adult, Question #
CAHPS Patient-Centered Medical Home Supplementary Survey Child Version 1.1*, Question #
Client Perception of Coordination Questionnaire (CPCQ), Question #
Family-Centered Care Self-Assessment Tool Family Version, Question #
National Survey of Children With Special Health Care Needs (CSHCN)
Medical Home Index Long Version (MHI-LV)
Medical Home Family Index and Survey (MHFIS)
Primary Care Assessment Tool Child Expanded Edition (PCAT-CE)
Primary Care Assessment Tool Adult Expanded Edition (PCAT-AE)
Resources and Support for Self-Management (RSSM)
Measure of Processes of Care (MPOC-28)
Follow Up Care Delivery
Primary Care Multimorbidity Hassles for Veterans With Chronic Illnesses
Primary Care Satisfaction Survey for Women (PCSSW)
Patient Perceptions of Care (PPOC)
Ambulatory Care Experiences Survey (ACES)
Patient Perception of Continuity Instrument (PC)
Components of Primary Care Index (CPCI)
Brief 5 A’s Patient Survey
Patient Perceived Continuity of Care from Multiple Providers
Relational and Management Continuity Survey in Patients with Multiple Long-Term
Conditions
Patient Perception of Integrated Care Survey (PPIC)
Primary Care Questionnaire for Complex Pediatric Patients
Patient Assessment of Care for Chronic Conditions
Medical Care Questionnaire
CAHPS Adult Health Plan Medicaid 5,0, Question #
CAHPS Adult Health Plan Supplemental 4.0, Question #
CAHPS Clinician & Group Supplemental 2.0, Question #
Health and Work Performance Questionnaire (HPQ)— World Health Organization (WHO)-developed as part of the WHO Composite International Diagnostic Interview

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OVERVIEW SURVEY DOMAINS
This Domain Overview provides a quick overview of the items in the survey. It is NOT meant to list hypothesized
composite items. There are a mix of screener, assessment/composite, and single items listed under each domain. It
also does NOT list out every item but rather is meant to cover unique constructs. For example, if there is a
screener item and an assessment item that measure the same construct, then the assessment item is listed.

I.

SEEKING CARE IN THE LAST 12 MONTHS


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
II.

Visited primary care provider’s office to get care
Contacted primary care provider or another primary care professional
Different primary care professionals seen within primary care provider’s office
Different primary care professionals seen outside primary care provider’s office
KNOWING WHO DOES WHAT







III.

Knew the responsibilities of each health care team member
Knew what aspect of care was responsible for
Talked about what to do if condition got worse or came back
Identify health care team member in charge of making sure respondent got all needed care
Identify health care team member in charge of keeping track of all care needed and received
Knew which health care professional to get in touch with for care
COMMUNICATING WITH YOUR HEALTH CARE PROVIDERS


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IV.

Given information about what to do if needed care after hours
Got an answer same day during regular office hours
Got help or advice needed after regular office hours
Got an answer as soon as needed when e-mailed
Got answers as soon as needed when asked
Easy to discuss care in preferred language
Got to talk to primary care professional who knows respondent best
Explain things in a way easy to understand
Listen carefully to respondent
Encouraged to ask all questions
Asked if understood all information given
Talk about concerns about health or treatment
Felt comfortable asking questions
Felt completely comfortable talking about personal problems
Talked about things in life that might get in the way of taking care of health
Asked if there was a period of time when felt sad, empty or depressed
SHARING HEALTH INFORMATION




Given all information needed on health condition
Given all information needed about chances of getting better

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
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


V.

Given test results as follow up
Had to request test results
Received a copy of care plan if requested
Primary care provider or other primary care professionals knew about past health problems
Talked about all prescription medications taken
Rate primary care provider’s knowledge of medical history
If saw health care professional outside primary are provider’s office, primary care provider knew
If saw health care professional outside primary are provider’s office, primary care provider knew about
tests or results
Up-to-date health information
Received medical records when requested
DEVELOP AND EXECUTE A PLAN OF ACTION FOR YOUR CARE: ASSESSING YOUR NEEDS
AND GOALS









VI.

Talked about how to pay for care
Talked about what is and is not covered by insurance plan
Primary care provider or other primary care professional remembered special needs
Asked about health habits
Talked about people who can help with health or treatment
Talked about support needed to take care of health
Asked about goals for taking care of health
Helped set goals for taking care of health
DEVELOP AND EXECUTE A PLAN OF ACTION FOR YOUR CARE: COLLABORATION ON THE
DESIGN OF CARE











VII.

Considered preferences for how wanted to receive care
Considered preferences for where wanted to receive care
Agree with primary care provider on best way to take care of health
Agree with other primary care professional on best way to take care of health
Told there was more than once choice for health care or treatment
Talked about reasons for choosing one option
Talked about reasons for not choosing one option
Asked which choice thought was best
Had as much choice as wanted in care received
Family involved as much as wanted in planning care
DEVELOP AND EXECUTE A PLAN OF ACTION FOR YOUR CARE: CREATING A HEALTH CARE
PLAN OF ACTION








Create a plan of action used everyday
Plan included different ways to communicate with primary care practice
Plan included outcomes showing goals were met
Plan included a schedule for follow up
Plan included what to do if there was a problem or change in health
Helped to plan ahead to take care of health during difficult or stressful times

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VIII.







VIII.







VIII.










DEVELOP AND EXECUTE A PLAN OF ACTION FOR YOUR CARE: FOLLOWING UP,
IDENTIFYING PROBLEMS AND MAKING ADJUSTMENTS
Had follow up at next visit or by phone for a health problem
Asked how health or treatment affected daily life
Had follow up to see what was working well
Discussed whether getting the health care needed
Felt someone in the primary care practice was available to listen to concerns
Plan of action was reviewed and updated
CONNECTING YOU TO OTHER SOURCES OF CARE
Got a referral when needed
Helped in making appointments
Satisfied with care received
Given information about available community based services
Had follow up about use of community based services
Helped connect with other people with similar health issues
HELPING YOU TAKE CARE OF YOURSELF
Asked how took care of health
Received explanation for tests or exams to manage health
Got reminders between visits
Asked if had enough services at home
Arranged services at home to help manage condition
Activities recommended took into account responsibilities at work or home
Taught how to monitor health
Given health information such as booklets or videos

CASE MIX ADJUSTERS





Rating of overall physical health
Age
Sex

RESPONDENT CHARACTERISTICS

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


Rating of overall mental or emotional health
Got health care 3 or more times for same condition
Got health care 3 or more times for condition lasted for at least 3 months
Take medicine prescribed by a doctor
Take medicine for condition lasted for at least 3 months
Was hospitalized for at least one night
Was in a nursing home or rehabilitation facility
Had health insurance in last 12 months
Education level
Ethnicity
Race
Preferred Language

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




Rating of English language skills
Helped to complete this survey
How helped to complete this survey
List of health conditions

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Form Approved
OMB No. XXXX-XXXX
Exp. Date
MM/DD/YYYY

Your Care Coordination Experience

Introduction
This survey asks questions about your experience with care coordination. Care coordination refers to
health care that is provided in a planned way that meets the needs and preferences of the patient. When
care is coordinated well, the patient and his or her doctors, nurses, other health care providers, family,
and other caregivers all know who is responsible for different parts of the patient’s care and they
communicate with each other so that everyone has the information they need.
Your answers to this survey will help us learn more about people’s experiences with care coordination.

Survey Instructions
Answer each question by marking the box to the left of your answer. You are sometimes told to skip
over some questions in this survey. When this happens you will see an arrow with a note that tells you
what question to answer next, like this:
1
2

Yes
No  If No, go to #1

Public reporting burden for this collection of information is estimated to average 25
minutes per response, which is the estimated time required to complete the survey. An
agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to: AHRQ Reports
Clearance Officer; Attention: PRA, Paperwork Reduction Project (0935-0176); AHRQ;
540 Gaither Road, Room # 5036; Rockville, MD 20850.

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Definitions
Below are several definitions of terms that are used throughout the survey. Some of these definitions are
relevant to specific sections of the survey and are also included at the beginning of that section.
Your primary care provider: The doctor or other provider who cares for most of your usual health care
needs and who you normally see when you need care for a new illness or injury, to maintain or control a
health issue, or to prevent health problems so you can stay healthy.
Other primary care professionals in this office: doctors, nurse practitioners, physician assistants, nurses,
and others who work in the same office or group as your primary care provider and also help people get
better, maintain their health, and prevent problems to stay healthy.
Primary care office: A group of primary care professionals and the staff that work with them in an
office. The primary care professionals and other staff in the office all work for the same organization or
business that shares a common goal of caring for the health needs of patients and keeping patients
healthy. A primary care office is designed to be the first place patients go to get their health needs met.
Other health care professionals: doctors, nurse practitioners, physician assistants, nurses, and others who
work outside of your primary care practice to provide specialized care for specific health problems or
health needs.
Health care team: this includes your primary care provider, other primary care professionals and other
health care professionals who care for you. It also includes people who are not primary care
professionals for example, the people in your life such as yourself, family members, or friends that help
you get the care you need to feel better or stay healthy.
“Plan of action” or “care plan”: Sometimes, in order to coordinate care, the patient and/or family creates
a care plan, together with one or more health care providers. It covers the patient’s needs and goals for
health care and identifies any gaps in care coordination. The plan may set goals for the patient and the
patient’s providers. Ideally, it anticipates routine needs and tracks current progress toward a patient’s
goals. This plan is often called a “care plan” or a “plan of action”.

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Seeking care in the last 12 months
1. In the last 12 months, how many times did you visit your primary care provider’s office to get care
for yourself from your primary care provider or other primary care professional? [NI/HP5-AMm11]
1
2
3
4
5
6
7

None
1
2
3
4
5 to 9
10 or more times

2. In the last 12 months, apart from scheduling appointments, how many times did you contact your
primary care provider or another primary care professional in this office about your health, for
example by email or phone call? [A, CI1/HP4-AS-mC01]
1
None
2
1
3
2
4
3
5
4
6
5 to 9
7
10 or more times
3. In the last 12 months, including your primary care provider, how many different primary care
professionals at your primary care provider’s office have you seen for a health reason? [CI1/HP5AM-m19]
1
1
2
2
3
3 or more
4
I did not get care from this primary care provider’s office in the last 12 months.
4. In the last 12 months, how many health care professionals outside of your primary care provider’s
office have you seen for a health reason? [NI/HP4-AS-mH5]
1
None
2
1
3
2
3
3 or more

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Knowing Who Does What
Care coordination: this refers to health care that is provided in a planned way that meets the needs and
preferences of the patient. When care is coordinated well, the patient and his or her doctors, nurses,
other health care providers, family, and other caregivers all know who is responsible for different parts
of the patient’s care and they communicate with each other so that everyone has the information they
need.
Health care team: this includes your primary care provider, other primary care professionals and other
health care professionals who care for you. It also includes people who are not primary care
professionals for example, the people in your life such as yourself, family members, or friends that help
you get the care you need to feel better or stay healthy.
5. In the last 12 months, how often did you know what the responsibilities were of each member of
your health care team? [EA/AT/CPCQ-m9]
1
2
3
4

Never
Sometimes
Usually
Always

6. In the last 12 months, how often did you know what aspects of your care you were responsible for?
[EA/NI]
1
Never
2
Sometimes
3
Usually
4
Always
7. In the last 12 months, if you had health problems, how often did your primary care provider or other
primary care professional in this office talk with you about what to do if your condition got worse or
came back? [CIP/AT/PC1-A-mC2f]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not have a health problem in the last 12 months.

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8. In the last 12 months, who in your health care team was most often in charge of making sure you got
all the care you needed? [EA/T, CI1,NI]
1
2
3
4
5
6
7

My primary care provider
Another primary care professional in the same office as my primary care provider
Another health care professional outside of my primary care provider’s office
Myself
Family or caregiver(s)
Myself and family or caregiver(s)
There was nobody in charge of making sure I got all the care I needed

9. In the last 12 months, who in your health care team was most often in charge of keeping track of the
care you needed and got? [EA/CI1,NI]
1
2
3
4
5
6
7

My primary care provider
Another primary care professional in the same office as my primary care provider
Another health care professional outside of my primary care provider’s office
Myself
Family or caregiver(s)
Myself and family or caregiver(s)
There was nobody in charge of making sure I got all the care I needed

10. In the last 12 months, if you saw more than one health care professional for your health care needs,
how often did you know which one to get in touch with when you needed medical care? [EA/ATU /
RMCSMLTC-mQ36]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not see more than one health care professional for my health care needs in the last 12
months.

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Communicating with your health care providers
11. In the last 12 months, how often did someone in your primary care provider’s office give you
information about what to do if you needed care during evenings, weekends, or holidays?
[CIP/ATU/PCMHS2-A-mPCMH2]
1
2
3
4

Never
Sometimes
Usually
Always

12. In the last 12 months, if you called your primary care provider’s office with a medical question
during regular office hours, how often did you get an answer that same day? [CIP/AT/ACES-m6]
1

Never
Sometimes
3
Usually
4
Always
5
I did not call my primary care provider’s office with a medical question during regular office
hours in the last 12 months.
2

13. In the last 12 months, if you called your primary care provider’s office after regular office hours,
how often did you get the help or advice you needed? [CIP/AT/ACES-m7]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not call my primary care provider’s office after regular office hours in the last 12 months.

14. In the last 12 months, if you e-mailed your primary care provider’s office with a question, how often
did you get an answer as soon as you needed it? [CIP/AT/ PC1-A-mAE2]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not e-mail my primary care provider’s office with a question in the last 12 months.

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15. In the last 12 months, when you asked questions of your primary care provider or other primary care
professional in this office, how often did you get answers as soon as you needed them? [CIP/AT/
PPOC-m9]
1
2
3
4

16.

Never
Sometimes
Usually
Always

In the last 12 months, how often did the primary care professionals in your primary care provider’s
office make it easy for you to discuss your care in your preferred language? [CPC/AT/FCCST-Fm1.3A]
1
2
3
4

Never
Sometimes
Usually
Always

17. In the last 12 months, if you needed to talk to your primary care provider or another primary care
professional in this office, how often did you get to talk to the primary care professional who knows
you best? [CIP/AT/PCAT-AE-mD4]
1

Never
Sometimes
3
Usually
4
Always
5
I did not need to talk to my primary care provider or another primary care professional in this
office in the last 12 months.
2

18. In the last 12 months, how often did your primary care provider or other primary care professionals
in this office explain things in a way that was easy to understand? [CIP/ AT /SCI1-A-m14]
1
2
3
4

Never
Sometimes
Usually
Always

19. In the last 12 months, how often did your primary care provider or other primary care professionals
in this office listen carefully to you? [CIP/AT/PCAT-CE-mD2]
1
2
3
4

Never
Sometimes
Usually
Always

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20. In the last 12 months, how often did your primary care provider or other primary care professionals
in this office encourage you to ask all the questions you had? [CIP/AT/FCD-m4]
1
2
3
4

Never
Sometimes
Usually
Always

21. In the last 12 months, how often did your primary care provider or other primary care professional in
this office ask you if you understood all of the information he or she gave you? [CIP/AT/FCD-m6]
1
2
3
4

Never
Sometimes
Usually
Always

22. In the last 12 months, when you had concerns about your health or treatment, how often did you talk
with your primary care provider or other primary care professional in this office about your
concerns? [CIP/AT/PPOC-m20]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not have concerns about my health or treatment in the last 12 months.

23. In the last 12 months, how often have you felt comfortable asking questions of your primary care
provider or other primary care professionals you saw in this office? [CIP/AT, T/PC-m2E]
1
2
3
4

Never
Sometimes
Usually
Always

24. In the last 12 months, how often did you feel completely comfortable talking with your primary care
provider or other primary care professional in this office about personal problems? ([CIP/AT, T/PCm2C]
1
2
3
4

Never
Sometimes
Usually
Always

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25.

In the last 12 months, how often did your primary care provider or other primary care
professionals you saw in this office talk to you about things in your life that might get in the way
of your taking care of your health? [CPC/ATU /PPCCMP-m4]
1
2
3
4

26.

Never
Sometimes
Usually
Always

In the last 12 months, how often did your primary care provider or other primary care professional
in this office ask you if there was a period of time when you felt sad, empty or depressed? [CPC/
AT /PCSSW-mQ12d]
1
2
3
4

Never
Sometimes
Usually
Always

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Sharing health information
27. In the last 12 months, how often did your primary care provider or other primary care professional in
this office give you all of the information that you needed on your health or health condition(s)?
[CIF/ AT /PCMHVCI-m13]
1
2
3
4

Never
Sometimes
Usually
Always

28. In the last 12 months, if you had a health problem, how often did your primary care provider or other
primary care professional in this office give you all the information that you needed about your
chances of getting better? [CIF/AT, CI1/PCMHVCI-m14]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not have a health problem in the last 12 months

29. In the last 12 months, if you had a blood test, x-ray, or other test, how often did your primary care
provider or other primary care professional in this office follow up to give you those results?
[CIF/AT/FCCST-F-m1.A]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not have a blood test, x-ray, or other test in the last 12 months.

30. In the last 12 months, if you had a blood test, x-ray or other test ordered by your primary care
provider or other primary care professional in this office, how often did you have to request the
results before you got them? [CIF/ATU, CI1/PPIC-m20]
1
2
3
4
5

Never
Sometimes
Usually
Always
Primary care professionals in my provider’s office did not order medical tests for me in the
last 12 months.

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31. In the last 12 months, how often did your primary care provider or other primary care professionals
in this office know about your past health problems or past treatments? [CIP/ATU/MCQ-m8]
1
2
3
4

Never
Sometimes
Usually
Always

32. In the last 12 months, if you had health problems, how often has your primary care provider or other
primary care professional in this office known about all of your health problems? [CIF/AT, T/PCm1G]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not have health problems in the last 12 months.

33. In the last 12 months, if you took any prescription medications, how often did your primary care
provider or other primary care professional in this office talk with you about all of the prescription
medications you were taking? [CIP/AT/SCI-A-mCC1]
1
2
3
4

Never
Sometimes
Usually
Always

34. In the last 12 months, how would you rate your primary care provider’s knowledge of your medical
history? [CIF/AT/ACES-m20]
1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

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35. In the last 12 months, if you saw a health care professional outside of your primary care provider’s
office, how often did your primary care provider know that these visits happened? [CIP/AT, A,
/PCAT-AE-mE7]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not see a health care professional outside of my primary care provider’s office in the last
12 months.

36. In the last 12 months, if you saw a health care professional outside of your primary care provider’s
office, how often did your primary care provider know about any tests or results from these visits?
[CIP/ AT/PCAT-AE-mE7]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not a health care professional outside of my primary care provider’s office in the last 12
months.

37. In the last 12 months, how often has it seemed like your primary care provider’s office keeps health
information about you complete and up-to-date? [CIF/ATU/RMCSMLTC-mQ27]
1
2
3
4

Never
Sometimes
Usually
Always

38. In the last 12 months, if you asked someone at your primary care provider’s office for your medical
records, how often did you get them as soon as you needed? [CIF/AT/PCAT-AE-mF3]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not ask my primary care provider’s office for my medical records in the last 12 months.

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Develop and execute a plan of action for your care: Assessing your needs and
goals
39. In the last 12 months, how often did someone in your primary care provider’s office talk to you
about how to pay for the care you need? [CPC/AT/MHILV-m3.5LevelOne]
1
2
3
4

40.

In the last 12 months, if you had a health insurance plan, how often did your primary care provider
or other primary care professional in this office talk with you about what is and is not covered by
your insurance plan? [CPC/AT/MHILV-m3.5LevelThree]
1
2
3
4
5

41.

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always
I did not have health insurance in the last 12 months.

In the last 12 months, if you told your primary care provider or other primary care professional at
this office about special needs you had, how often did they remember these needs?
[CPC/AT/MHILV-m1.4LevelOne]
1

Never
Sometimes
3
Usually
4
Always
5
I did not tell the primary care professionals in this office about any special needs in the last 12
months.
2

42. In the last 12 months, how often did your primary care provider or other primary care professional at
this office, ask you about habits related to your health, such as smoking, diet, exercise, alcohol
consumption, and rest? [CPC/AT/RSSM-m2]
1
2
3
4

Never
Sometimes
Usually
Always

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43. In the last 12 months, how often did your primary care provider or other primary care professional in
this office talk with you about the people in your life who can help you with your health or
treatment? [CIP/AT/FCCST-F-m1.B]
1
2
3
4

44.

Never
Sometimes
Usually
Always

In the last 12 months, how often did your primary care provider or other primary care professional
in this office talk to you about any support you might need to take care of your health?
[CPC/AT/MHILV-m3.5LevelOne]
1
2
3
4

Never
Sometimes
Usually
Always

45. In the last 12 months, how often did your primary care provider or other primary care professional at
this office, ask about your goals for taking care of your health? [CPC/AT/RSSM-m1]
1
2
3
4

Never
Sometimes
Usually
Always

46. In the last 12 months, how often has your primary care provider or other primary care professional
at this office, helped you in setting goals for taking care of your health? [CPC/AT/RSSM-m4]
1
2
3
4

Never
Sometimes
Usually
Always

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Develop and execute a plan of action for your care: Collaboration on the
design of care
47.

In the last 12 months, how often did the care you received from your primary care provider or
other primary care professional at this office, consider your preferences for how you wanted to
receive your care? [CPC/AT/FCCST-F-m3.A]
1
2
3
4

48.

Never
Sometimes
Usually
Always

In the last 12 months, how often did the care you received from your primary care provider or
other primary care professional at this office, consider your preferences for where you wanted to
receive your care? [CPC/AT/FCCST-F-m3.A]
1
2
3
4

Never
Sometimes
Usually
Always

49. In the last 12 months, how often did you and your primary care provider agree on the best way to
take care of your health or health conditions? [CPC/NI/HP4-AS-mCC8]
1
2
3
4

Never
Sometimes
Usually
Always

50. In the last 12 months, if you saw any other primary care professionals in this office, how often did
you and these other primary care professionals agree about the best way to take care of your health
or health conditions? [CPC/NI/HP4-AS-mCC8]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not see any other primary care professionals in this office in the last 12 months

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51.

Choices for your treatment or health care can include choices about tests and screenings,
preventive healthcare (e.g. flu shot), medicine, surgery, or other treatment.
In the last 12 months, how often did your primary care provider or other primary care professional
in this office tell you there was more than one choice for your health care or treatment?
[CPC/AT/PACCC-mB2]
1
2
3
4

Never
Sometimes
Usually
Always

52. In the last 12 months, if you talked about different options for your health care or treatment with
your primary care provider or other primary care professional in this office, how often did they talk
about the reasons for choosing an option? [CPC/NI/HP4-AS-mH3]
1
Never
2
Sometimes
3
Usually
4
Always
5
I did not talk to my primary care provider or other primary care professional in this office
about different options for my healthcare or treatment.
53. In the last 12 months, if you talked about different options for your health care or treatment with
your primary care provider or other primary care professional in this often, how often did they talk
about the reasons for not choosing an option? [CPC/NI/HP4-AS-mH3]
1
Never
2
Sometimes
3
Usually
4
Always
5
I did not talk to my primary care provider or other primary care professional in this office
about different options for my healthcare or treatment.
54. In the last 12 months, if you talked about different choices for your healthcare or treatment with your
primary care provider or other primary care professional in this office, how often did they ask which
choice you thought was best for you? [CPC/NI/HP4-AS-mH4]
1

Never
Sometimes
3
Usually
4
Always
5
I did not talk to my primary care provider or other primary care professional in this office
about different choices for my healthcare or treatment.
2

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55.

In the last 12 months, how often did you have as much of a choice as you wanted in the care you
received from the primary care professionals in this office? [CPC/AT/MPOC-m3]
1
2
3
4

Never
Sometimes
Usually
Always

56. In the last 12 months, how often did your primary care provider or other primary care professional in
this office involve your family as much as you wanted in planning your care? [EA/AT/MHILV-3.1level four]
1
2
3
4
5
6

Never
Sometimes
Usually
Always
I do not have a family.
I do not have a family whom I wanted involved in planning my care in the last 12 months.

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Develop and execute a plan of action for your care: Creating a health care plan
of action
“Plan of action” or “care plan”: Sometimes, in order to coordinate care, the patient and/or family
creates a care plan, together with one or more health care providers. It covers the patient’s needs and
goals for health care and identifies any gaps in care coordination. The plan may set goals for the patient
and the patient’s providers. Ideally, it anticipates routine needs and tracks current progress toward a
patient’s goals. This can be called a care plan or a plan of action.
57. In the last 12 months, how often did your primary care provider or other primary care professionals
in this office help you create a plan of action that you use every day to help you take care of your
health? [CPC/ATU, F/B5AP-m7]
1
2
3
4

Never
Sometimes
Usually
Always

58. In the last 12 months, if you and a primary care professional in this office had a plan of action to take
care of your health, how often did the plan include different ways to communicate with your primary
care practice? [CPC/ATU, F/PCCPP-m1]
1
Never
2
Sometimes
3
Usually
4
Always
5
I did not have a plan of action with primary care professionals in this office in the last 12
months.
59. In the last 12 months, if you asked someone in your primary care provider’s office for a copy of your
plan of action, how often did someone in the office give you a copy? [CIF/AT/PACIC-mB9]
1

Never
Sometimes
3
Usually
4
Always
5
I did not have a plan of action with primary care professionals in this office in the last 12
months.
6
I did not ask for a copy of my plan of action in the last 12 months.
2

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60.

In the last 12 months, if you and a primary care professional in this office had a plan of action to
take care of your health, how often did the plan include specific outcomes that would tell you
when you met your goals? Outcomes can include functional goals, such as being able to walk a
flight of stairs without losing your breath, or target rates, for example, a blood pressure reading
below 120/80 mmHg? [CPC/AT, F/MPOC-m10]
1
2
3
4
5

61.

Never
Sometimes
Usually
Always
I did not have a plan of action with primary care professionals in this office in the last 12
months.

In the last 12 months, if you and a primary care professional in this office had a plan of action to
take care of your health, how often did the plan include a schedule for follow up? [CPC/ AT, F
/MPOC-m10]
1

Never
Sometimes
3
Usually
4
Always
5
I did not have a plan of action with primary care professionals in this office in the last 12
months.
2

62.

In the last 12 months, if you and a primary care professional in this office had a plan of action to
take care of your health, how often did the plan include what to do if there is a problem or a
change in your health? [CPC/ F,NI/CG2-AS-mHL16]
1

Never
Sometimes
3
Usually
4
Always
5
I did not have a plan of action with primary care professionals in this office in the last 12
months.
2

63.

In the last 12 months, how often did your primary care provider or other primary care professional
in this office help you to plan ahead so that you could take care of your health even during difficult
or stressful times? [CPC/ATU/B5AP-m8]
1
2
3
4

Never
Sometimes
Usually
Always

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Develop and execute a plan of action for your care: Following up, identifying
problems and making adjustments
64.

In the last 12 months, if you had a health problem, how often did your primary care provider or
other primary care professional in this office follow up on a health problem you had, either at the
next visit or by phone?[CPC/AT/CPCI-m13]
1
2
3
4
5

65.

In the last 12 months, how often did your primary care provider or other primary care professional
in this office ask you how your health or treatment affected your daily life? [CIP/AT/PACCCmB15]
1
2
3
4

66.

Never
Sometimes
Usually
Always

In the last 12 months, if you had treatment, how often did your primary care provider or other
primary care professional in this office follow up with you to find out what was working well with
your treatment? [CIP/AT/FCCST-F-1.B]
1
2
3
4
5

67.

Never
Sometimes
Usually
Always
I did not have a health problem in the last 12 months

Never
Sometimes
Usually
Always
I did not have treatment in the last 12 months.

In the last 12 months, how often did your primary care provider or other primary care professional
in this office discuss whether you were getting the health care you needed? [CPC/ATU/PPIC-m24]
1
2
3
4

Never
Sometimes
Usually
Always

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68.

In the last 12 months, if you had a concern that your primary care provider or other primary care
professional in this office was not caring for your health in the way you needed, how often did you
feel that someone in the primary care practice was available to listen to your concerns?
[CPC/AT/MHILV-m1.1-Level Four]
1
2
3
4
5

69.

Never
Sometimes
Usually
Always
I did not have a concern that the primary care professionals in this office were not caring for
my health the way I wanted in the last 12 months

In the last 12 months, if you had a health care plan of action, how often did your primary care
provider or other primary care professional in this office review and update your plan of action and
make any changes that were needed? [CPC/AT,F/MHFIS-m10c]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not have a plan of action in the last 12 months

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Connecting you to other sources of care
70.

In the last 12 months, if you needed a referral from your primary care provider to see another
health care professional, how often did you get one as soon as you needed it? [FAS/AT/CSHCNmC4Q07]
1
2
3
4
5

71.

Never
Sometimes
Usually
Always
I did not need a referral to another health care professional in the last 12 months

In the last 12 months, if you needed to visit another health care professional outside of your
primary care provider’s office, how often did someone in your primary care provider’s office help
you make the appointment? [FAS/AT/PPOC-m33]
1

Never
Sometimes
3
Usually
4
Always
5
I did not need to visit a health care professional outside of my primary care provider’s office in
the last 12 months
6
When I needed to visit a health care professional outside of my primary care provider’s office
in the last 12 months, I did not seek help from anyone in my primary care provider’s office.
2

72.

In the last 12 months, if your primary care provider referred you to another health care
professional, how often were you satisfied with the care you received from the professionals your
primary care provider recommended? [FAS/AT/PC-m2J]
1
2
3
4
5

Never
Sometimes
Usually
Always
My PCP did not refer me to any health care professionals in the last 12 months

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73.

In the last 12 months, how often did your primary care provider or other primary care professional
in this office give you information about available community based services to support your
health such as support groups, classes, counselors, community recreation programs, or faith-based
activities?[LCR/ATU/B5AP-m9]
1
Never
2
Sometimes
3
Usually
4
Always

74.

In the last 12 months, if your primary care provider or another primary care professional in this
office told you about resources available in the community that could help you take care of
yourself or your family, how often did someone in your primary care provider’s office follow up
with you about your use of these resources? [CPC/NI/FCCST-F-m1.E]
1
2
3
4
5

75.

Never
Sometimes
Usually
Always
Community-based services were not recommended to me in the last 12 months.

In the last 12 months, how often did your primary care provider or another primary care
professional in this office help you connect with other people with similar health issues?
[LCR/ATU/FCCST-F-m1.B]
1
2
3
4

Never
Sometimes
Usually
Always

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Helping you take care of yourself
76.

In the last 12 months, how often did your primary care provider or other primary care
professionals you saw at this office ask you how you take care of your health? [SSM/ATU/B5APm1]
1
Never
2
Sometimes
3
Usually
4
Always

77.

In the last 12 months, how often did your primary care provider or other primary care
professionals in this office explain what tests or exams you should have to manage your health or
health condition? [CPC/A/PPCCMP-m22]
1
2
3
4

78.

Some offices remind patients between visits about tests, treatment, or appointments. In the last 12
months, how often did you get reminders from your primary care provider’s office between visits?
[CIP/ATU/PCMHS2-A-mPCMH5]
1
2
3
4

79.

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

In the last 12 months, if you had an illness or injury, how often did your primary care provider or
other primary care professionals in this office ask whether you had enough services to help you
take care of this illness or injury at home? [CPC/ATU/PPIC-m38]
1
2
3
4
5

Never
Sometimes
Usually
Always
I did not have an illness or injury in the last 12 months.

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80.

In the last 12 months, if you needed help at home to manage your health, how often did someone
in your primary care provider’s office arrange services for you at home to help manage your
health condition? [SSM/ATU/PPIC-m39]
1
2
3
4
5

81.

In the last 12 months, how often did you feel like the activities primary care professionals in this
office recommended for your care took into account the responsibilities you have at work or
home? [CPC/ATU/PPCCMP-m4]
1
2
3
4

82.

Never
Sometimes
Usually
Always

In the last 12 months, how often did your primary care provider or other primary care professional
in this office teach you how to monitor your health so you can tell how you are doing?
[SSM//PCMHS-A -m22 v5.B22]
1
2
3
4

83.

Never
Sometimes
Usually
Always
I did not need help at home to manage my health in the last 12 months.

Never
Sometimes
Usually
Always

In the last 12 months, how often did a primary care professional in this office give you health
information such as booklets or videos about what you can do for your health?
[SSM/ATU/MPOC-m14]
1
2
3
4

Never
Sometimes
Usually
Always

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About You
84.

In general, how would you rate your overall physical health? [CM/HP5-AM-27]
1
2
3
4
5

85.

In general, how would you rate your overall mental or emotional health? [RC/HP5-AM-28]
1
2
3
4
5

86.

2

2

Yes
No

Do you now need or take medicine prescribed by a doctor? Do not include birth control. [RC/HP5AM-31]
1
2

89.

Yes
No  If No, go to #88

Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy or
menopause. [RC/HP5-AM-30]
1

88.

Excellent
Very good
Good
Fair
Poor

In the last 12 months, did you get health care 3 or more times for the same condition or problem?
[RC/HP5-AM-29]
1

87.

Excellent
Very good
Good
Fair
Poor

Yes
No  If No, go to #90

Is this medicine to treat a condition that has lasted for at least 3 months? Do not include pregnancy
or menopause. [RC/HP5-AM-32]
1
2

Yes
No

90. In the last 12 months, did you have to stay in the hospital for at least one night? [NI, A]
1
2

Yes
No

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91. In the last 12 months, were you admitted to or discharged from a nursing home or rehabilitation
facility? [NI,A]
1
2

Yes
No

92. In the last 12 months, did you have health insurance? [RC]
1
2

Yes
No

93. What is your age? [CM/HP5-AM-33]
1
2
3
4
5
6
7

18 to 24 years
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

94. Are you male or female? [CM/HP5-AM-33]
1
2

Male
Female

95. What is the highest grade or level of school that you have completed? [CM/HP5-AM-35]
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
More than 4-year college degree

96. Are you Hispanic, Latino/a, or Spanish origin? [RC/M-ACO-77]
1
2

Yes, Hispanic, Latino/a, or Spanish origin
No, not of Hispanic, Latino/a, or Spanish origin

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97. What is your race? Mark one or more. [RC/OMH-4032-2]
1
2
3
4
5
6
7
8
9
10
11
12
13
14

White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

98. What is your preferred language? [RC, CuC/CG2-AS-CU22]
1

English
Other
Please specify: _____________________________________________________________
2

99. How well do you speak English? [RC, CuC/OMH-4302-4]
1
2
3
4

Very well
Well
Not well
Not at all

100. Did someone help you complete this survey? [RC/HP5-AM-38]
1
2

Yes  If Yes, go to #105
No  Thank you. Please return the completed survey in the postage-paid envelope.

101. How did that person help you? Mark one or more. [RC/HP5-AM-39]
1
2
3
4
5

Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
Thank You
Please return the completed survey in the postage-paid envelope.

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102. Do you have any of the following conditions? [NI/HPQ-CCC]
Do you have any of the following
conditions?
If your answer is YES, mark whether
you never, previously, or currently
receive professional treatment.
(Professional treatment is any
treatment supervised by a health
professional.) If you are unsure if you
have a condition, please mark the NO
response option.
Arthritis?
Chronic back/neck pain?
Migraine headaches?
Other frequent or severe headaches?
Any other chronic pain?
High blood pressure or hypertension?
Congestive heart failure?
Coronary heart disease?
High blood cholesterol?
An ulcer in your stomach or intestine?
Either frequent diarrhea or frequent
constipation?
Frequent nausea, gas, or indigestion?
Chronic heartburn or GERD?
Seasonal allergies or hay fever?
Asthma?
Chronic bronchitis?
Emphysema?
Chronic Obstructive Pulmonary Disease
(COPD)?
Chronic Obstructive Airways Disease
(COAD)?
Chronic Obstructive Lung Disease
(COLD)?
Alpha one antitrypsin deficiency?
Urinary or bladder problems?
Diabetes?
Chronic sleeping problems?
Chronic fatigue or low energy?
Osteoporosis?
Multiple Sclerosis?
Skin cancer?
Any other kind of cancer?
Anxiety disorder?
Depression?
Any other emotional problem?
Substance problems (drugs or alcohol)?

NO,
I don't
have this
condition

YES,
but I
never
received
professional
treatment

YES,
I previously
received
(but don't
currently
receive)
professional
treatment

YES,
and I
currently
receive
professional
treatment

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Appendix A: CCQM-PC Survey - OMB Package Supporting Statements

Page A–36