CMS-10275 Home Health Care CAHPS Survey (Telephone/Proxy)

Appendix C: English: Mail Survey Cover Letters, Regular and Scannable
January 2017 Questionnaires, Telephone Interview Script, Proxy Interview Script

Proxy Telephone Interview Script
for the Home Health Care CAHPS Survey

PROXY ID Is there somebody such as a family member or friend who is familiar with [SAMPLED MEMBER’S NAME]’s health care experiences?

PROBE TO FIND OUT IF PERSON IS AVAILABLE IN HOUSEHOLD TO DO INTERVIEW.

1. YES [GO TO PROXY_INTRO]

2. NO [COLLECT NAME AND TELEPHONE NUMBER OF PROXY AND SET A CALLBACK, OR IF NO PROXY EXISTS, GO TO Q_END AND CODE AS MENTALLY/PHYSICALLY INCAPABLE]

IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [ORGANIZATION]. I’d like to speak with someone who is knowledgeable about [SAMPLE MEMBER NAME]’s health and health care experiences for a study [ORGANIZATION] is conducting about health care.

PROXY_INTRO [Hello, this is {INTERVIEWER NAME} calling on behalf of {HOME HEALTH AGENCY}]. [HOME HEALTH AGENCY] is participating in a survey about the care people receive from their home health agencies. This survey is part of a national effort to measure the quality of care from home health care agencies. The survey results will be used by people when choosing a home health care agency.

[SAMPLE MEMBER NAME]’s participation in this survey is completely voluntary and will not affect [his/her] health care or any benefits [he/she] receives. The interview will take about 12 minutes to complete. This call may be monitored or recorded for quality improvement purposes.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1066 (Expires: TBD). The time required to complete this information collection is estimated to average 12 minutes per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Mail Stop C1-25-05, Baltimore, Maryland 21244-1850.

NOTE: THE LENGTH OF THE INTERVIEW WILL DEPEND ON WHETHER THE HHA ADDS SUPPLEMENTAL QUESTIONS TO ITS HOME HEALTH CARE CAHPS SURVEY.

1. According to our records, [SAMPLE MEMBER NAME] got care from the home health agency, [HOME HEALTH AGENCY]. Is that right?

1. YES [GO TO Q2_INTRO]

2. NO [GO TO Q_INELIG]

M MISSING/DK [GO TO Q_INELIG]

Q2_INTRO As you answer the questions in this survey, think only about [SAMPLE MEMBER NAME]’s experience with this agency. Please try to answer the questions as best you can from [SAMPLE MEMBER NAME]’s point-of-view. If you need to, you can answer the questions from the point-of-view of a family member or caregiver helping [SAMPLE MEMBER NAME].

2. When [SAMPLE MEMBER NAME] first started getting home health care from this agency, did someone from the agency tell [him/her] what care and services [he/she] would get?

1. YES

2. NO

3. DO NOT REMEMBER

M MISSING/DK

3. When [SAMPLE MEMBER NAME] first started getting home health care from this agency, did someone from the agency talk with [him/her] about how to set up [his/her] home so [he/she] can move around safely?

1. YES

2. NO

3. DO NOT REMEMBER

M MISSING/DK

4. When [SAMPLE MEMBER NAME] started getting home health care from this agency, did someone from the agency talk with [him/her] about all the prescription and over-the-counter medicines [he/she] was taking?

1. YES

2. NO

3. DO NOT REMEMBER

M MISSING/DK

5. When [SAMPLE MEMBER NAME] started getting home health care from this agency, did someone from the agency ask to see all the prescription and over-the-counter medicines [he/she] was taking?

1. YES

2. NO

3. DO NOT REMEMBER

M MISSING/DK

Q6_INTRO These next questions are about all the different staff from [HOME HEALTH AGENCY] who gave [SAMPLE MEMBER NAME] care in the last 2 months. Do not include care [SAMPLE MEMBER NAME] got from staff from another home health care agency. Do not include care [he/she] got from family or friends.

6. In the last 2 months of care, was one of [SAMPLE MEMBER NAME]’s home health providers from this agency a nurse?

1. YES

2. NO

M MISSING/DK

7. In the last 2 months of care, was one of [SAMPLE MEMBER NAME]’s home health providers from this agency a physical, occupational, or speech therapist?

1. YES

2. NO

M MISSING/DK

8. In the last 2 months of care, was one of [SAMPLE MEMBER NAME]’s home health providers from this agency a home health or personal care aide?

1. YES

2. NO

M MISSING/DK

9. 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 [SAMPLE MEMBER NAME] got at home? Would you say…

1. Never,

2. Sometimes,

3. Usually,

4. Always, or

5. [SAMPLE MEMBER NAME] only had one provider in the last 2 months of care?

M MISSING/DK

10. In the last 2 months of care, did [SAMPLE MEMBER NAME] and a home health provider from this agency talk about pain?

1. YES

2. NO

M MISSING/DK

11. In the last 2 months of care, did [SAMPLE MEMBER NAME] take any new prescription medicine or change any of the medicines [he/she] was taking?

1. YES

2. NO [GO TO Q15]

M MISSING/DK [GO TO Q15]

12. In the last 2 months of care, did home health providers from this agency talk with [SAMPLE MEMBER NAME] about the purpose for taking [his/her] new or changed prescription medicines?

1. YES

2. NO

M MISSING/DK

13. In the last 2 months of care, did home health providers from this agency talk with [SAMPLE MEMBER NAME] about when to take these medicines?

1. YES

2. NO

M MISSING/DK

14. In the last 2 months of care, did home health providers from this agency talk with [SAMPLE MEMBER NAME] about the side effects of these medicines?

1. YES

2. NO

M MISSING/DK

15. In the last 2 months of care, how often did home health providers from this agency keep [SAMPLE MEMBER NAME] informed about when they would arrive at [his/her] home? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

M MISSING/DK

16. In the last 2 months of care, how often did home health providers from this agency treat [SAMPLE MEMBER NAME] as gently as possible? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

M MISSING/DK

17. 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? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

M MISSING/DK

18. In the last 2 months of care, how often did home health providers from this agency listen carefully to [SAMPLE MEMBER NAME]? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

M MISSING/DK

19. In the last 2 months of care, how often did home health providers from this agency treat [SAMPLE MEMBER NAME] with courtesy and respect? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

M MISSING/DK

Q20_INTRO We want to know [SAMPLE MEMBER NAME]’s rating of [his/her] care from this agency’s home health providers. Please try to answer the questions as best you can from [SAMPLE MEMBER NAME]’s point-of-view. If you need to, you can answer the questions from the point-of-view of a family member or caregiver helping [SAMPLE MEMBER NAME].

20. 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 [SAMPLE MEMBER NAME] use to rate [his/her] care from this agency’s home health providers?

READ RESPONSE CHOICES ONLY IF NECESSARY

00 0 Worst home health care possible

01 1

02 2

03 3

04 4

05 5

06 6

07 7

08 8

09 9

10 10 Best home health care possible

M MISSING/DK

Q21_INTRO The next questions are about the office of [HOME HEALTH AGENCY].

21. In the last 2 months of care, did [SAMPLE MEMBER NAME] contact this agency’s office to get help or advice?

1. YES

2. NO [GO TO Q24]

M MISSING/DK [GO TO Q24]

22. In the last 2 months of care, when [SAMPLE MEMBER NAME] contacted this agency’s office did [he/she] get the help or advice [he/she] needed?

1. YES

2. NO [GO TO Q24]

M MISSING/DK [GO TO Q24]

23. When [SAMPLE MEMBER NAME] contacted this agency’s office, how long did it take for [him/her] to get the help or advice [he/she] needed? Would you say…

1. Same day,

2. 1 to 5 days,

3. 6 to 14 days, or

4. More than 14 days?

M MISSING/DK

24. In the last 2 months of care, did [SAMPLE MEMBER NAME] have any problems with the care [he/she] got through this agency?

1. YES

2. NO

M MISSING/DK

25. Would [SAMPLE MEMBER NAME] recommend this agency to [his/her] family or friends if they needed home health care? Would you say…

1. Definitely no,

2. Probably no,

3. Probably yes, or

4. Definitely yes?

M MISSING/DK

Q26_INTRO This last set of questions asks for information about [SAMPLE MEMBER NAME]. Please listen to all response choices before making a selection.

26. In general, how would [SAMPLE MEMBER NAME] rate [his/her] overall health? Would you say that it is…

1. Excellent,

2. Very good,

3. Good,

4. Fair, or

5. Poor?

M MISSING/DK

27. In general, how would [SAMPLE MEMBER NAME] rate [his/her] overall mental or emotional health? Would you say that it is…

1. Excellent,

2. Very good,

3. Good,

4. Fair, or

5. Poor?

M MISSING/DK

28. Does [SAMPLE MEMBER NAME] live alone?

1. YES

2. NO

M MISSING/DK

29. What is the highest grade or level of school that [SAMPLE MEMBER NAME] has completed? Would you say…

1. 8th grade or less,

2. Some high school, but did not graduate,

3. High school graduate or GED,

4. Some college or 2-year degree,

5. 4-year college graduate, or

6. More than 4-year college degree?

M MISSING/DK

30. Is [SAMPLE MEMBER NAME] Hispanic or Latino/Latina?

1. YES

2. NO

M MISSING/DK

31. What is [SAMPLE MEMBER NAME]’s race? You may choose one or more of the following. Is he/she…

1. White,

2. Black or African American,

3. Asian,

4. Native Hawaiian or other Pacific Islander, or

5. American Indian or Alaska Native?

M MISSING/DK

32. What language does [SAMPLE MEMBER NAME] mainly speak at home? Would you say…

1. English, [GO TO Q_END]

2. Spanish, or [GO TO Q_END]

3. Some other language? [GO TO Q32A]

M MISSING/DK [GO TO Q_END]

Q32A What other language does [SAMPLE MEMBER NAME] mainly speak at home? (ENTER RESPONSE BELOW).

{ALLOW UP TO 50 CHARACTERS}

M MISSING/DK

Q_END These are all the questions I have for you. Thank you for your time. Have a good (day/evening).

INELIGIBLE SCREEN:

Q_INELIG Thank you for your time. Have a good (day/evening).

REFUSAL SCREEN:

Q_REF Thank you for your time. Have a good (day/evening).

Centers for Medicare & Medicaid Services C-9

Home Health Care CAHPS Survey Protocols and Guidelines Manual