CMS-10543 EDPEC Discharged to Community

Attachment 4—Discharged to Community Instrument

EDPEC Survey 3.0—Discharged to
Community for Mode Experiment 4c
SURVEY INSTRUCTIONS
Answer all the questions by checking 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:
Yes
No If No, Go to Question 1

All of the questions in the survey will ask about this emergency room visit.

Attachment 3—Discharged to Community Instrument
GOING TO THE EMERGENCY ROOM
1. Thinking about this visit, what was the main reason why you went to the emergency
room?
An accident or injury
A new health problem
An ongoing health condition or concern
2. For this visit, did you go to the emergency room in an ambulance?
Yes
No
3. When you first arrived at the emergency room, how long was it before someone
talked to you about the reason why you were there?
Less than 5 minutes
5 to 15 minutes
More than 15 minutes
4. Using any number from 0 to 10, where 0 is not at all important and 10 is extremely
important, when you first arrived at the emergency room, how important was it for you
to get care right away?
0 – Not at all important
1
2
3
4
5
6
7
8
9
10 – Extremely important

Attachment 3—Discharged to Community Instrument
DURING YOUR EMERGENCY ROOM VISIT
5. During this emergency room visit, did you get care within 30 minutes of getting to the
emergency room?
Yes
No
6. During this emergency room visit, did the doctors or nurses ask about all of the
medicines you were taking?
Yes, definitely
Yes, somewhat
No
7. During this emergency room visit, were you given any medicine that you had not
taken before?
Yes
Don’t Know
No → If No, Go to Question 10
8. Before giving you any new medicine, did the doctors or nurses tell you what the
medicine was for?
Yes, definitely
Yes, somewhat
No
9. Before giving you any new medicine, did the doctors or nurses describe possible side
effects to you in a way you could understand?
Yes, definitely
Yes, somewhat
No
10. During this emergency room visit, did you have any pain?
Yes, definitely
Yes, somewhat
No →If No, Go to Question 14

Attachment 3—Discharged to Community Instrument
11. During this emergency room visit, did the doctors and nurses try to help reduce your
pain?
Yes, definitely
Yes, somewhat
No
12. During this emergency room visit, did you get medicine for pain?
Yes
No If No, go to Question 14
13. Before giving you pain medicine, did the doctors and nurses describe possible side
effects in a way you could understand?
Yes, definitely
Yes, somewhat
No
14. During this emergency room visit, did you have a blood test, x-ray, or any other
test?
Yes
No → If No, go to Question 16
15. During this emergency room visit, did doctors and nurses give you as much
information as you wanted about the results of these tests?
Yes, definitely
Yes, somewhat
No

Attachment 3—Discharged to Community Instrument
PEOPLE WHO TOOK CARE OF YOU
Please answer the following questions about the people who took care of you during
your emergency room visit.
16. During this emergency room visit, how often did nurses treat you with courtesy and
respect?
Never
Sometimes
Usually
Always
17. During this emergency room visit, how often did nurses listen carefully to you?
Never
Sometimes
Usually
Always
18. During this emergency room visit, how often did nurses explain things in a way you
could understand?
Never
Sometimes
Usually
Always
19. During this emergency room visit, did nurses spend enough time with you?
Yes, definitely
Yes, somewhat
No
20. During this emergency room visit, how often did doctors treat you with courtesy and
respect?
Never
Sometimes
Usually
Always

Attachment 3—Discharged to Community Instrument
21. During this emergency room visit, how often did doctors listen carefully to you?
Never
Sometimes
Usually
Always
22. During this emergency room visit, how often did doctors explain things in a way you
could understand?
Never
Sometimes
Usually
Always
23. During this emergency room visit, did doctors spend enough time with you?
Yes, definitely
Yes, somewhat
No

LEAVING THE EMERGENCY ROOM
24. Before you left the emergency room, did you understand what your main health
problem was?
Yes
No
25. Before you left the emergency room, did you understand what symptoms or health
problems to look out for when you left the emergency room?
Yes
No
26. Before you left the emergency room, did a doctor or nurse tell you that you should
take any new medicines that you had not taken before?
Yes
No →If No, Go to Question 28

Attachment 3—Discharged to Community Instrument
27. Before you left the emergency room, did a doctor or nurse tell you what the new
medicines were for?
Yes, definitely
Yes, somewhat
No
28. Before you left the emergency room, did someone discuss with you whether you
needed follow-up care?
Yes
No→If No, Go to Question 30
29. Before you left the emergency room, did someone ask if you would be able to get
this follow-up care?
Yes
No
OVERALL EXPERIENCE
Please answer the following questions about your visit to the emergency room named
on the front of the survey. Do not include any other emergency room visits in your
answers.
30. Using any number from 0 to 10, where 0 is the worst care possible and 10 is the
best care possible, what number would you use to rate your care during this
emergency room visit?
0 – Worst care possible
1
2
3
4
5
6
7
8
9
10 – Best care possible

Attachment 3—Discharged to Community Instrument
31. Would you recommend this emergency room to your friends and family?
Definitely no
Probably no
Probably yes
Definitely yes

YOUR HEALTH CARE
32. In the last 6 months, how many times have you visited any emergency room to get
care for yourself? Please include the emergency room visit you have been
answering questions about in this survey.
1 time
2 times
3 times
4 times
5 to 9 times
10 or more times
33. Not counting the emergency room, is there a doctor’s office, clinic, or other place
you usually go if you need a check-up, want advice about a health problem, or get
sick or hurt?
Yes
No →If No, Go to Question35
34. How many times in the last 6 months did you visit that doctor’s office, clinic, health
center, or other place to get care or advice about your health?
None
1 time
2 times
3 times
4 times
5 to 9 times
10 or more times

Attachment 3—Discharged to Community Instrument
ABOUT YOU
There are only a few remaining items left.
35. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
36. In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
37. What is the highest grade or level of school that you have completed?
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
38. Are you of Spanish, Hispanic or Latino origin or descent?
No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, Cuban
Yes, other Spanish/Hispanic/Latino
39. What is your race? Please choose one or more.
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native

Attachment 3—Discharged to Community Instrument

40. What language do you mainly speak at home?
English
Spanish
Chinese
Russian
Vietnamese
Portuguese
Some other language (please print): ______________________
41 Did someone help you complete this survey?
Yes
No →

Thank you.
Please return the completed survey in the postage-paid envelope.

42. How did that person help you? Mark one or more.
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
Please print: _______________________
43. Was the person who helped you with you at any time during this emergency room
visit?
Yes
No
Thank you
Please return the completed survey in the postage-paid envelope.

Attachment 3—Discharged to Community Instrument
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