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VA Form 10-1465-6
VA form 10-1465-7
SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
HOME HEALTH CARE SURVEY
In order for the VA to carry out its mission to provide the best possible medical care and
services to all veterans, it is extremely important that you complete and return this survey
booklet. Your answers will help ensure that all veterans receive the high-quality care they
have earned and so richly deserve.
Please read each question and check the box that best describes your experience. Please be
sure to read all pages of this survey booklet.
We want to remind you that all information is strictly anonymous. It will not be shared with
your doctor or affect your VA care.
Your Privacy is Protected. All information that would let someone identify you or your family will be
kept private. Synovate will not share your personal information with anyone without your OK. Your
responses to this survey are also completely confidential.
Your Participation is Voluntary. You may choose to answer this survey or not. If you choose not to,
this will not affect the health care you get.
If you have a specific question or need help with your VA care, you may contact the VA as
described at the end of this survey booklet.
Thank you very much!
The Paperwork Reduction Act of 1995: This information is collected in accordance with section
3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you
are not required to respond to, a collection of information unless it displays a valid OMB number. We
anticipate that the time expended by all individuals who complete this survey will average 1 minutes.
This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
Customer satisfaction surveys are used to gauge customer perceptions of VA services as well as
customer expectations and desires. The results of this survey will lead to improvements in the quality
of service delivery by helping to shape the direction and focus of specific programs and services.
Disclosure of information involves release of statistical data and other non-identifying data for the
improvement of services within the VA healthcare system and associated administrative purposes.
Submission of this form is voluntary and failure to respond will have no impact on benefits to which
you may be entitled.
Version: 43 – 071
3.
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
4.
If Yes, go to Q1 on Page 1.
No
YOUR HOME HEALTH CARE
1.
According to our records, you got care
from the home health agency,
[AGENCY NAME]. Is that right?
As you answer the questions in this
survey, think only about your
experience with this agency.
2.
1
Yes
2
No
5.
If No, please stop and
return the survey in the
envelope provided.
When you first started getting home
health care from this agency, did
someone from the agency tell you
what care and services you would get?
1
Yes
2
No
3
Do not remember
1
When you first started getting home
health care from this agency, did
someone from the agency talk with
you about how to set up your home so
you can move around safely?
1
Yes
2
No
3
Do not remember
When you started getting home health
care from this agency, did someone
from the agency talk with you about
all the prescription and over-thecounter medicines you were taking?
1
Yes
2
No
3
Do not remember
When you started getting home health
care from this agency, did someone
from the agency ask to see all the
prescription and over-the-counter
medicines you were taking?
1
Yes
2
No
3
Do not remember
9.
YOUR CARE FROM HOME
HEALTH PROVIDERS IN THE
LAST 2 MONTHS
These next questions are about all the
different staff from [AGENCY NAME]
who gave you care in the last 2 months. Do
not include care you got from staff from
another home health care agency. Do not
include care you got from family or friends.
6.
7.
8.
In the last 2 months of care, was one
of your home health providers from
this agency a nurse?
1
Yes
2
No
10.
In the last 2 months of care, was one
of your home health providers from
this agency a physical, occupational,
or speech therapist?
1
Yes
2
No
11.
In the last 2 months of care, was one
of your home health providers from
this agency a home health or personal
care aide?
1
Yes
2
No
12.
2
In the last 2 months of care, how often
did home health providers from this
agency seem informed and up-to-date
about all the care or treatment you got
at home?
1
Never
2
Sometimes
3
Usually
4
Always
5
I only had one provider in the
last 2 months of care
In the last 2 months of care, did you
and a home health provider from this
agency talk about pain?
1
Yes
2
No
In the last 2 months of care, did you
take any new prescription medicine or
change any of the medicines you were
taking?
1
Yes
2
No
If No, go to Q15.
In the last 2 months of care, did home
health providers from this agency talk
with you about the purpose for taking
your new or changed prescription
medicines?
1
Yes
2
No
3
I did not take any new
prescription medicines or
change any medicines
13.
14.
In the last 2 months of care, did home
health providers from this agency talk
with you about when to take these
medicines?
17.
1
Yes
1
Never
2
No
2
Sometimes
3
I did not take any new
prescription medicines or
change any medicines
3
Usually
4
Always
18.
In the last 2 months of care, did home
health providers from this agency talk
with you about the side effects of
these medicines?
16.
In the last 2 months of care, how often
did home health providers from this
agency listen carefully to you?
1
Never
1
Yes
2
Sometimes
2
No
3
Usually
3
I did not take any new
prescription medicines or
change any medicines
4
Always
19.
15.
In the last 2 months of care, how often
did home health providers from this
agency explain things in a way that
was easy to understand?
In the last 2 months of care, how often
did home health providers from this
agency keep you informed about when
they would arrive at your home?
1
Never
2
Sometimes
3
Usually
4
Always
In the last 2 months of care, how often
did home health providers from this
agency treat you as gently as possible?
1
Never
2
Sometimes
3
Usually
4
Always
3
In the last 2 months of care, how often
did home health providers from this
agency treat you with courtesy and
respect?
1
Never
2
Sometimes
3
Usually
4
Always
20.
We want to know your rating of your
care from this agency’s home health
providers.
22.
Using any number from 0 to 10, where
0 is the worst home health care
possible and 10 is the best home
health care possible, what number
would you use to rate your care from
this agency’s home health providers?
23.
0 Worst home health care
possible
1
2
3
4
5
In the last 2 months of care, when you
contacted this agency’s office did you
get the help or advice you needed?
1
Yes
2
No
3
I did not contact this agency
If No, go to Q24.
When you contacted this agency’s
office, how long did it take for you to
get the help or advice you needed?
1
Same day
2
1 to 5 days
3
6 to 14 days
4
More than 14 days
5
I did not contact this agency
6
24.
7
8
9
1
Yes
10 Best home health care possible
2
No
25.
YOUR HOME HEALTH AGENCY
The next questions are about the office of
[AGENCY NAME].
21.
In the last 2 months of care, did you
have any problems with the care you
got through this agency?
In the last 2 months of care, did you
contact this agency’s office to get help
or advice?
1
Yes
2
No
If No, go to Q24.
4
Would you recommend this agency to
your family or friends if they needed
home health care?
1
Definitely no
2
Probably no
3
Probably yes
4
Definitely yes
S31. In the last 2 months of care, did you
contact this agency's office about any
problems?
S26. Did this home health care start as soon as
you thought you needed?
1
2
Yes
No
1
2
S27. Did your care from this agency follow a
stay in a hospital, nursing home, or
rehabilitation center?
1
2
3
S32. In the last 2 months of care, did this
agency solve your problem as soon as you
needed?
Yes
No
1
S28. In the last 2 months of care, how often did
you have a hard time speaking with or
understanding home health providers from
this agency because you spoke different
languages?
1
2
3
4
2
3
4
Never
Sometimes
Usually
Always
1
2
4
S29. In the last 2 months of care, how often did
home health providers from this agency
behave in a professional manner?
2
3
4
Never
Sometimes
Usually
Always
5
S30. In the last 2 months of care, how often did
you feel that home health providers from
this agency really cared about you?
7
8
9
2
3
4
Yes
No
I am still waiting
I did not call (Go to s9)
S34. Using any number from 0 to 10, where 0
is the worst home health agency possible
and 10 is the best home health agency
possible, what number would you use to
rate this home health agency?
6
1
Yes
No
I am still waiting
I did not call (Go to S9)
S33. Are you satisfied with how this agency
solved your problem?
3
1
Yes
No
Did not have problems
10
Never
Sometimes
Usually
Always
11
12
13
14
15
1
0 Worst home health agency possible
1
2
3
4
5
6
7
8
9
10 Best home health agency possible
28. I felt like a valued customer.
YOUR OVERALL EXPERIENCE WITH
THE DEPARTMENT OF VETERANS
AFFAIRS
Now think about your experiences with all
the services provided by the Department of
Veterans Affairs (which include healthcare,
benefits programs, or memorial services).
Please tell us how you feel about the
following statements:
Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
27. It was easy to get the service I needed.
Disagree
Neither agree nor disagree
Agree
Strongly agree
29. I trust VA to fulfill our country’s
commitment to veterans.
26. I got the service I needed.
Strongly Disagree
Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
2
Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
35.
ABOUT YOU
30.
2
31.
32.
33.
White
2
Black or African-American
Excellent
3
Asian
Very good
4
Native Hawaiian or other Pacific
Islander
5
American Indian or Alaska Native
3
Good
4
Fair
5
Poor
36.
In general, how would you rate your
overall mental or emotional health?
What language do you mainly speak at
home?
1
English
1
Excellent
2
Spanish
2
Very good
3
Some other language:
3
Good
4
Fair
5
Poor
37.
Do you live alone?
1
Yes
2
No
What is the highest grade or level of
school that you have completed?
38.
Did someone help you complete this
survey?
1
Yes
2
No
If No, please return the
completed survey in the
postage-paid envelope.
How did that person help you? Check all
that apply.
1
8th grade or less
1
Read the questions to me
2
Some high school, but did not
graduate
2
Wrote down the answers I gave
3
Answered the questions for me
4
Translated the questions into my
language
5
Helped in some other way:
6
No one helped me complete this
survey
3
34.
1
In general, how would you rate your
overall health?
1
What is your race? Please select one or
more.
High school graduate or GED
4
Some college or 2-year degree
5
4-year college graduate
6
More than 4-year college degree
Are you Hispanic or Latino/Latina?
1
Yes
2
No
Thank you!
Please return the completed survey
in the postage-paid envelope.
3
| File Type | application/pdf |
| File Title | Microsoft Word - SHEP_HHCAHPS Long Form 10-1465-7a.docx |
| Author | ARober01 |
| File Modified | 2016-01-19 |
| File Created | 2016-01-15 |