Form 10-21034G Survey of Veteran Enrollees w/VE Questions

Survey of Veteran Enrollees’ Health

and Use of Health Care

Mail Survey

^{OMB Control Number: 2900-0609}

^{Estimated Burden: 21 minutes}

Expiration Date: XX/XX/XXXX

Survey of Veteran Enrollees’ Health

and Use of Health Care

Welcome to the 2016 Survey of Veteran Enrollees’ Health and Use of Health Care. This annual VA survey asks about how Veterans use VA services and what types of services they do or do not use. Even if you are not a current user of VA health care, your answers to the survey questions are important. This survey takes about 21 minutes to complete.

If you require assistance from another person to complete this survey, it is all right to ask another person to fill the survey out on your behalf as long as they are able to answer questions about your health care, health benefits, and health status.

PAPERWORK REDUCTION ACT INFORMATION: This information is collected according to the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. No persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 2900-0609. The time required to complete this information collection is estimated to average 21 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. The information requested on this survey will be used to help VA assess the health status of Veterans and plan health care services. A response to this survey is voluntary.

VETERANS HEALTH ADMINISTRATION

SECTION 1. Introduction

Your participation is voluntary, but we hope you will decide to participate. If you decide not to participate or to answer some of the questions, it will not affect your VA benefits or any other benefits to which you may be entitled. VA will protect your identity and answers to the full extent allowed under the law. Also, no information you provide will be released to the general public in a way that can be traced back to you. If you are completing the survey for the Veteran who received the survey invitation, these rights and protections also apply.

Survey Instructions

• Please use a black or blue pen to complete this form.

• Mark to indicate your answer.

• If you want to change your answer, darken the box and mark the correct answer.

• You will sometimes see an arrow and instructions to skip questions that do not apply to you: ( GO TO QUESTION X or GO TO SECTION X). In these cases, simply skip to the indicated question or section.

1. Please indicate who is completing this survey. In other words, will you complete the survey yourself or will you ask someone to assist you?

I am the Veteran named in the cover letter and will be answering questions about myself.

GO TO SECTION 2

I am not the Veteran named in the cover letter, but can answer questions about that person’s health care, health benefits, and health status.

2. How would you describe your relationship to the Veteran?

Spouse

Domestic Partner

Parent

Sibling

Child

_{Some other relative}

Friend

Caregiver

Guardian or Attorney

Social Worker or Case Worker

Some other relation

SECTION 2. Health Benefits

The following questions ask about your health benefits. (If you are responding on behalf of the Veteran named in the cover letter, please answer the questions for that person.)

3. Are you enrolled in VA health care?

Enrolled Veterans are those who applied for the VA Medical Benefits Package and received confirmation that they are eligible to use VA health care services. You can be enrolled but not currently using the services.

Yes

No  GO TO QUESTION 5

I don’t remember enrolling  GO TO QUESTION 5

4. What is the primary reason that you enrolled?

Select only one

You were recently discharged from the military.

You needed health care services for a disability, injury, illness, hearing loss, or other physical or mental health problems.

You had a loss or reduction in other health insurance benefits.

Other economic circumstances led you to enroll.

You moved closer to a VA facility.

A VA facility opened close to you.

You were already using VA in 1999 when enrollment began

Some other reason (Please specify): __________________________________________________

5. Are you covered by Medicare?

Yes

No GO TO QUESTION 11

6. There are two types of Medicare options. The first option is the Original Medicare Plan, with Parts A and B. It is administered by the federal government, and you can choose any doctor or hospital that accepts Medicare. A second option is a Medicare Advantage Plan. It provides benefits through a private insurance company where you use doctors and hospitals in the plan’s networks.

Do you receive your Medicare coverage a Medicare Advantage Plan as described above?

Yes  GO TO QUESTION 10

No

7. Does your Medicare coverage pay for care if you are hospitalized?

This type of Medicare is also sometimes called "Part A"; if you have it, there is generally no monthly fee or premium because you or your spouse paid for it through payroll taxes while working.

Yes

No

8. Does your Medicare coverage pay for doctor's office visits?

This type of Medicare is also sometimes called "Part B"; if you have it, you generally pay a monthly fee or premium which may be directly deducted from your Social Security check.

Yes

No

9. Do you purchase any private health care coverage to supplement Medicare—that is, to pay for services Medicare does NOT pay for?

Types of private insurance a person can purchase to supplement Medicare include Medigap or Medicare supplement. It does not include Medicare Advantage, Medicare + Choice, or the Department of Defense TRICARE for Life Plan for Medicare Eligible Military Retirees.

Yes

No

10. Do you have Medicare prescription drug coverage, "Part D”?

Yes

No

11. Are you currently covered by Medicaid (sometimes referred to as “Medical Assistance”) for any of your health care?

Medicaid is a program that pays for Medical Assistance for certain individuals with low incomes and resources and is provided by your State government’s social services department.

Yes

No

12. Are you currently covered by the Department of Defense TRICARE or TRICARE for Life health care programs?

Yes

No

13. Are you currently covered by any other individual or group health plan that you, your current or former employer, your spouse’s or domestic partner’s employer, your union, or someone else obtains for you?

Please do not count Private Medigap, Medicare Supplement, Medicare Advantage, or Medicare + Choice plans.

Please do count any private retiree health insurance plan.

Yes

No  GO TO SECTION 3

14. Does this other health plan coverage include prescription drug coverage?

Yes

No

15. Do you have a long-term care policy that covers nursing home care, assisted living, or long-term care services in the home? Exclude any Medicare Supplement Policy.

Yes

No

SECTION 3. Medication Use and Benefits

The following questions ask about medications. (If you are responding on behalf of the Veteran named in the cover letter, please answer the questions for that person.)

16. How many different prescription medications did you use in the last 30 days? Include both VA and non-VA prescriptions. Your best guess is fine.

|__|__| Prescriptions

None  GO TO SECTION 4

17. Of these prescription medications, how many did you obtain from VA? Your best guess is fine.

|__|__| Prescriptions

None

18. On a monthly basis, on average, how much do you spend out-of-pocket for all your over-the-counter and prescription medications? Do not include any health insurance premiums you may pay. Your best guess is fine.

$ I I I,I__I I I.00 Per month

SECTION 4. Your Views About Health Care and Reasons for Using or Not Using VA’s Health Care System

Next, we ask about your use of medical health services in 2015 from both Non-VA and VA sources. (If you are responding on behalf of the Veteran named in the cover letter, please answer the following questions for that person.)

19. For the following questions, think about outpatient visits or trips you made to a doctor, hospital, or clinic for medical care from October through December 2015:

1. Care at VA or non-VA facility paid fully or partly by VA

How many such outpatient visits or trips did you make from October through December 2015? Your best guess is fine.

_______Visits or trips

2. Care at Non-VA facility for which the VA did not pay for any of the care. Please do not count dental, mental health, or substance abuse visits.

How many such outpatient visits or trips did you make from October through December 2015? Your best guess is fine.

_______Visits or trips

The following questions ask for your views about VA health care services and reasons you choose your health care providers. (If you are responding on behalf of the Veteran named in the cover letter, please answer the questions for that person.)

20. Have you used ANY VA health care services on or after January 2015? Services could either have been at a VA facility or at a community provider that was paid by the VA.

 Yes

 No  Go to Question 23

The next questions are about your recent use of VA health care.

20. In your experience with using VA services, either at the VA or with a community provider paid for by the VA, after January 1, 2015, about how often did the following happen?

	Always or nearly always	Most of the time	About half the time	Some of the time	Rarely or never
Appointments within a reasonable time were easy to get.					
Appointments were available at convenient hours/days for you.					
Appointments took place as scheduled (not canceled by VA).					
Getting to the local VA facility or VA-approved facility was easy.					
Wait times were short after arriving for an appointment.					
Getting around the facility was easy.					
Personnel were welcoming and helpful.					

20. Thinking about the health care you have received at a VA facility or that the VA paid for since January 2015, how satisfied have you been with:

	Very satisfied	Moderately satisfied	Somewhat satisfied	Not at all satisfied	Does not apply
The respect shown to you by your health care professionals?					
How clearly your health care providers explained your health problem(s)?					
How clearly your health care providers explained options and choices about your care with you?					
Opportunities for you to participate in decisions about your care?					
The way your providers listened to you?					
The manner in which your providers accepted you for who you are?					
The way your privacy was respected?					
Your ability to get referrals for specialist care or special equipment?					

20. Do you ever use health care services other than those provided or paid for by VA?

Yes, for all of my health care

Yes, for some of my health care

No  GO TO QUESTION 26

20. Please tell us if any of the following reasons are why you use other health care services for some or all of your health care:

	Yes	No
You have access to care in the community that you think is better quality than what VA provides?		
You have a provider outside of VA that you really like and trust?		
You have access to care in the community that is easier to get to than the VA?		
You have a provider that offers appointments at more convenient times than you can get at VA?		
You had prior experiences with VA care that you were dissatisfied with?		
You need information on which VA services you are eligible to receive?		
You do not believe you are eligible to receive the service you need at VA?		

20. Which of the following factors do you consider when selecting a health care provider:

	Yes	No
Cost Paid by You		
Convenient Location		
Easy parking or availability of transportation		
Travel Time or Distance		
Hours of Operation		
Physical Appearance of Location		
Professionalism of Health Care Providers		
Professionalism of Office Staff		
Insurance Coverage for the health service that you need		

26. Below is a list of possible ways you could use VA for your health care in the future. Please read them all, and then choose the one that best describes the primary way you plan to use VA health care in the future. You plan to use VA:

Choose all that apply:

As your primary source of health care

For a service-related disability or health condition, either mental or physical

For care of a specific health condition such as hearing or vision loss, diabetes, cancer, etc.

For prescriptions

As a “safety net” to use only if needed

Some other way (Please specify):___________________________________________

No plans to use VA for health care

27. Please complete the following statement: I use VA services to meet . . .

Select only one

All of my health care needs

Most of my health care needs

Some of my health care needs

None of my health care needs

I have no health care needs

28. Which of the following is your primary source for VA benefits information?

Select only one

Friends or acquaintances

VA mailings (such as the patient handbook)

VA Outreach Events

Other community forums sponsored by Non-VA organizations

A Veterans Service Organization such as VFW, AMVETS, etc.

My local Veterans Service Officer

Internet

Some other source

SECTION 5. Current Health and Caregiver Assistance

The following questions are about your current health and possible need for assistance that allows you to live safely in your home and community. (If you are responding on behalf of the Veteran named in the cover letter, please answer the questions for that person.)

29. Compared with other people your age, would you say your health is . . .

Excellent

Very Good

Good

Fair

Poor

30. In a typical week, how much assistance from family, friends, neighbors, or others do you need for the following daily activities or situations? Please mark any needs you have for assistance, whether or not you are currently receiving assistance for them.

	No assistance needed	Some assistance needed	Completely dependent on assistance	I do not do this activity/have this situation
a. Bathing
b. Eating
c. Transferring from bed or a chair
d. Using the toilet
e. Walking around the home
f. Dressing
g. Preparing meals
h. Managing money
i. Doing household chores
j. Using the telephone
k. Taking medications properly
l. Getting to places in the community
m. Scheduling medical services
n. Coping with stressful situations
o. Driving or using public transportation
p. Avoiding triggers of anxiety
q. Coping with memory loss

31. Are you currently receiving assistance from family, friends, neighbors, or others for the activities or situations listed in question 30?

Yes, for all or most of the needs I marked

Yes, for some of the needs I marked

No, I am not currently receiving such assistance for any needs I marked  Go to Question 36

Does not apply—I currently do not have any needs for assistance  Go to question 37

31. Who is providing the assistance you need for daily living activities?

Mark all that apply

Spouse

Domestic partner

Parent

Brother or sister

Adult son or daughter (18 years or older)

Minor son or daughter (less than 18 years old)

_Grandparent

Step-family member

Another family member

Friend or neighbor

Home health aide

I live in an Assisted Living Facility

Someone else (Please specify): __________________________________

31. In a typical week, how much time do family members, friends, neighbors, or others spend providing assistance to you?

10 hours or less

11-20 hours

21-30 hours

31-40 hours

More than 40 hours

31. Does the person assisting you the most hours per week (your primary caregiver) live in your home?

Yes

No

Does not apply – I do not currently live in a home setting

31. The VA is interested in knowing if your primary caregiver is receiving any VA or non-VA caregiver support services. Which one of the following best applies? Your primary caregiver . . .

Select only one

Is an approved primary family caregiver in VA’s Program of Comprehensive Assistance for Family Caregivers.

Is not an “approved family caregiver,” but does receive services through VA’s Caregiver Support Program.

Receives caregiver support services from another VA program.

Receives caregiver support services from a non-VA program.

Does not receive support services from any program.

I don’t know if my primary caregiver is receiving any support services from a VA or non-VA program.

31. Is your need for the assistance of family, friends, neighbors, or others related to any of the following:

	Yes	No
You experienced a serious injury or mental disorder, including traumatic brain injury, psychological trauma, or other mental disorder related to your active duty service?
You were diagnosed by a health care professional with an illness or disease related to your active duty service?
You have physical or mental problems or were diagnosed with an illness or disease unrelated to your active duty service?

VA, as well as other health care systems, has strived to provide assistance to those who wish to stop smoking. The next few questions ask about your cigarette smoking habits and any attempts you may have made to quit.

31. . Have you smoked at least 100 cigarettes in your entire life?

Yes

No  GO TO SECTION 6

31. Do you now smoke cigarettes every day, some days, or not at all?

Every day

Some days

Not at all Go to question 40

31. During the past 12 months, have you stopped smoking for more than one day because you were trying to quit smoking?

Yes GO TO SECTION 6

No GO TO SECTION 6

31. How long has it been since you last smoked cigarettes regularly?

Less than 1 month

1 month

2 to 3 months

4 to 6 months

6 months to less than 1 year

1-4 years

5 years

6-9 years

10 years or more

Never smoked regularly

SECTION 6. Digital Access

Health care systems throughout the country are taking advantage of new technologies to provide easier access to health care. The next few questions ask you about your use of desktop and laptop computers, cell phone, tablets, and other mobile devices. They also ask about your ability to access the Internet

31. Do you use the Internet, at least occasionally?

 Yes

 No  GO TO SECTION 7

31. Do you use the Internet to do the following:

    	Yes	No
    Look up health information?		
    Send e-mails?		
    Pay bills online?		
    Purchase household goods or services?		
    Make medical appointments?		
    Track the delivery of purchases?		
    Read weather reports?		
    Take online courses?		
    Access personal information in an electronic health record?		
    Get travel directions?		
    Make airline, hotel, or restaurant reservations?		

32. Where do you go on-line to use the Internet?

Mark ALL that apply

 Home

 Work

School

 Public library

 Community center

 Someone else’s house

 Many places with my cell phone, tablet, or other mobile device

 Some other place

31. During a typical week, how often do you use the following to access the Internet?

	Do not have this device	Every day	4 to 6 days a week	1 to 3 days a week	Less than once a week
Desktop or laptop computer					
Cell phone					
Tablet					
Other mobile device					

31. Do you currently use the following type(s) of service to access the Internet?

Mark ALL that apply

 Dial-up service

 DSL service

 Cable modem service

 Fiber optic service (FIOS)

 Satellite Internet service

 Cell phone plan

 Tablet plan

 Wi-Fi hot spot service when away from home

 Some other service

 I don’t know which type(s) of service I use

31. Does your Internet service for your mobile device use a 4G LTE network (currently provides the highest download speeds and reliability for mobile devices in the United States)?

 Yes

 No

 Don’t know

 Does not apply – do not use a mobile device to access the Internet

31. Do you send or receive text messages on your cell phone?

 Yes

 No

 Does not apply – do not use a cell phone with Internet access

31. Think about any computer or mobile device available to you at home or elsewhere that has access to the Internet. How willing would you be to do the following on at least one of those computers or mobile devices?

	Very willing	Somewhat willing	Not willing at this time	This activity does not apply to me
Obtain information on VA benefits?				
Fill out VA health-related forms?				
Look for health information on a VA web site?*				
Reorder VA medical prescriptions?*				
Watch educational health videos?				
Join an online support group for VA enrollees sharing similar medical challenges?				
Communicate securely with VA physicians or other clinicians?				
Complete an online self-assessment for stress or anxiety?				
Schedule VA medical appointments?*				
Access your VA Personal Health Record?*				
Access VA lab test results?*
Use VA apps to track your health care status (e.g., blood pressure, weight)				
Communicate with your VA healthcare providers via secure text messages on mobile devices?				
Communicate with your VA healthcare providers via secure email?*				

31. Are you aware of the MyHealtheVet Web site?

Yes

No  GO TO SECTION 7

31. Do you use the MyHealtheVet Web site?

Yes

No  GO TO SECTION 7

31. Do you use the MyHealtheVet Web site for the following purposes? Answer Yes or No for each purpose.

	Yes	No
a. To look for health information?
b. To communicate with your healthcare provider via secure email?
c. To see laboratory or other test result?
d. To see my health record, including my doctor’s or nurse’s notes?
e. To see my VA appointments?
f. To order a medication prescription?
g. For enter information into my personal health record?
h. Some other way

SECTION 7. About You

In this section, we would like to obtain information on your active duty military history. (If you are responding on behalf of the Veteran named in the cover letter, please answer the following questions for that person.)

31. Did you serve on active duty in the U.S. Armed Forces during the following time frames?

Please answer Yes or No for each period; answer Yes, even if you served for just part of the time indicated.

	Yes	No
a. September 2001 or later?
b. August 1990 to August 2001 (includes Persian Gulf War)?
c. May 1975 to July 1990?
d. Vietnam era (August 1964 to April 1975)?
e. February 1955 to July 1964?
f. Korean War (July 1950 to January 1955)?
g. January 1947 to June 1950?
h. World War II (December 1941 to December 1946)?
i. November 1941 or earlier?

53. Did you ever serve in a combat or war zone? Note: Persons serving in a combat or war zone usually receive combat zone tax exclusion, imminent danger pay, or hostile fire pay.

Yes

NoS

54. Which of the following best describes your current marital status?

Now married

Widowed

Divorced

Separated

Never married

A member of an unmarried couple

55. Not including yourself, how many dependents, such as a spouse or dependent children, do you currently have? A “Dependent” is anyone who relies on you for at least half of their financial support.

I have no dependents  GO TO QUESTION 58

|__|__| Dependents

56. How many of these dependents are under the age of 18 (0 to 17 years of age)?

I I__I Dependents

57. How many of these dependents are between the ages of 18 and 26?

I I__I Dependents

58. How would you best characterize your employment status?

Select only one

Employed full-time (include self-employment)

Employed part-time (include self-employment)

Unemployed, looking for work, or laid off

Currently not employed (For example: retired, a homemaker, a student, on disability)

59. Would you describe yourself as Spanish, Hispanic, or Latino(a)? (a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race)

Yes

No

60. What is your race?

Note: For the purposes of this survey, Spanish, Hispanic, or Latino(a) origins are not considered race.

Choose one or more of the following:

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

61. This annual income information is critical for VA planning purposes. Please indicate the range that best describes your 2015 total annual household income below.

Was it . . .

Less than $10,000

$10,000 – $14,999

$15,000 -$19,999

$20,000 - $24,999

$25,000 - $34,999

$35,000 - $49,999

$50,000 - $74,999

$75,000 or more

SECTION 8. Awareness of the Veterans Choice Act

In August of 2014, The Veterans Choice and Accountability Act (Veterans Choice Act) was signed into law. This law expanded the options by which VA can provide care for Veterans, primarily allowing Veterans residing more than 40 miles from a VA facility to see a community provider closer to them. The next few questions ask about your understanding of the Veterans Choice Act and how you think it might impact your use of VA.

62. How well do you understand the Veterans Choice Act?

Answer Yes or No to each of the following statements.

	Yes	No
a. I’ve followed this issue closely.
b. I rely on others for information about the Act.
c. The Veterans Choice Act directly affects me.
d. I understand this Act.

63. How do you think the Veterans Choice Act will change your planned use of the VA health care system?

I will definitely increase my use of the VA health care system

I will probably increase my use of the VA health care system

I will not change my use

I will probably decrease my use of the VA health care system

_{I will definitely decrease my use of the VA health care system}

SECTION 9. Trust in VA

64. Please tell us how you feel about the following statement:

“I trust VA to fulfill our country’s commitment to Veterans”

Strongly Agree

Somewhat Agree

Neither Agree nor Disagree

Somewhat Disagree

_{Strongly Disagree}

Thank you! You have completed the survey.

The information you have provided will help VA to better serve all Veterans in the future.

_{Please return this survey in the postage-paid envelope provided.}