Form CMS-10537 Hospice Experience of Care Survey - Mail

OMB Control Number: 0938-1257
Expiration Date: XX/XXXX

CAHPS® Hospice Survey
Please answer the survey questions about the care the patient received from this
hospice:

[NAME OF HOSPICE]

All of the questions in this survey will ask about the experiences with this
hospice.

If you want to know more about this survey, please call [TOLL FREE NUMBER]. All
calls to that number are free.

December 2016

1

CAHPS® Hospice Survey
SURVEY INSTRUCTIONS


Please give this survey to the person in your household who knows the most about
the hospice care received by the person listed on the survey cover letter.



Use a dark colored pen to fill out the survey.



Place an X directly inside the square indicating a response, like in the sample below.
Yes
No



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  If Yes, Go to Question 1
No
_____________________________________________________________________

THE HOSPICE PATIENT
1. How are you related to the person
listed on the survey cover letter?



3

1
2



6

7

8

9

4
5

2

My spouse or partner
My parent
My mother-in-law or father-inlaw
My grandparent
My aunt or uncle
My sister or brother
My child
My friend
Other (please print):

2. For this survey, the phrase "family
member" refers to the person
listed on the survey cover letter.
In what locations did your family
member receive care from this
hospice? Please choose one or
more.



3

4

5

6

1
2

Home
Assisted living facility
Nursing home
Hospital
Hospice facility/hospice house
Other (please print):

December 2016

YOUR ROLE
3. While your family member was in
hospice care, how often did you
take part in or oversee care for
him or her?



1



4

2
3

Never  If Never, go to
Question 41
Sometimes
Usually
Always

YOUR FAMILY MEMBER’S
HOSPICE CARE
As you answer the rest of the
questions in this survey, please think
only about your family member's
experience with the hospice named
on the survey cover.
4. For this survey, the hospice team
includes all the nurses, doctors,
social workers, chaplains and
other people who provided
hospice care to your family
member. While your family
member was in hospice care, did
you need to contact the hospice
team during evenings, weekends,
or holidays for questions or help
with your family member’s care?




1
2

Yes
No  If No, go to Question 6

5. How often did you get the help
you needed from the hospice
team during evenings, weekends,
or holidays?



3

4

1
2

Never
Sometimes
Usually
Always

December 2016

6. While your family member was in
hospice care, how often did the
hospice team keep you informed
about when they would arrive to
care for your family member?



3

4

1
2

Never
Sometimes
Usually
Always

7. While your family member was in
hospice care, when you or your
family member asked for help
from the hospice team, how often
did you get help as soon as you
needed it?



3

4

1
2

Never
Sometimes
Usually
Always

8. While your family member was in
hospice care, how often did the
hospice team explain things in a
way that was easy to understand?

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
3

4

1
2

Never
Sometimes
Usually
Always

9. While your family member was in
hospice care, how often did the
hospice team keep you informed
about your family member’s
condition?



3

4

1
2

Never
Sometimes
Usually
Always

3

10. While your family member was in
hospice care, how often did
anyone from the hospice team
give you confusing or
contradictory information about
your family member’s condition or
care?



3

4

1
2

Never
Sometimes
Usually
Always

11. While your family member was in
hospice care, how often did the
hospice team treat your family
member with dignity and respect?



3

4

1
2

Never
Sometimes
Usually
Always

14. How often did the hospice team
listen carefully to you when you
talked with them about problems
with your family member’s
hospice care?



3

4

1
2

15. While your family member was in
hospice care, did he or she have
any pain?




1
2



3

4

1
2

Never
Sometimes
Usually
Always

13. While your family member was in
hospice care, did you talk with the
hospice team about any problems
with your family member’s
hospice care?


2

1

4

Yes
No  If No, go to Question 15

Yes
No  If No, go to Question 17

16. Did your family member get as
much help with pain as he or she
needed?



3

1
2

12. While your family member was in
hospice care, how often did you
feel that the hospice team really
cared about your family member?

Never
Sometimes
Usually
Always

Yes, definitely
Yes, somewhat
No

17. While your family member was in
hospice care, did he or she
receive any pain medicine?




1
2

Yes
No  If No, go to Question 21

18. Side effects of pain medicine
include things like sleepiness. Did
any member of the hospice team
discuss side effects of pain
medicine with you or your family
member?



3

1
2

Yes, definitely
Yes, somewhat
No

December 2016

19. Did the hospice team give you the
training you needed about what
side effects to watch for from pain
medicine?


2

3

1

Yes, definitely
Yes, somewhat
No

20. Did the hospice team give you the
training you needed about if and
when to give more pain medicine
to your family member?


2

3

4

1

Yes, definitely
Yes, somewhat
No
I did not need to give pain
medicine to my family member

21. While your family member was in
hospice care, did your family
member ever have trouble
breathing or receive treatment for
trouble breathing?




1
2

Yes
No  If No, go to Question 24

22. How often did your family member
get the help he or she needed for
trouble breathing?



3

4

1
2

Never
Sometimes
Usually
Always

December 2016

23. Did the hospice team give you the
training you needed about how to
help your family member if he or
she had trouble breathing?



3

4

1
2

Yes, definitely
Yes, somewhat
No
I did not need to help my family
member with trouble breathing

24. While your family member was in
hospice care, did your family
member ever have trouble with
constipation?




1
2

Yes
No  If No, go to Question 26

25. How often did your family member
get the help he or she needed for
trouble with constipation?



3

4

1
2

Never
Sometimes
Usually
Always

26. While your family member was in
hospice care, did he or she show
any feelings of anxiety or
sadness?




1
2

Yes
No  If No, go to Question 28

5

27. How often did your family member
get the help he or she needed
from the hospice team for feelings
of anxiety or sadness?


2

3

4

1

Never
Sometimes
Usually
Always

28. While your family member was in
hospice care, did he or she ever
become restless or agitated?


2

1

Yes
No  If No, go to Question 30

29. Did the hospice team give you the
training you needed about what to
do if your family member became
restless or agitated?



3

1
2

Yes, definitely
Yes, somewhat
No

30. Moving your family member
includes things like helping him or
her turn over in bed, or get in and
out of bed or a wheelchair. Did
the hospice team give you the
training you needed about how to
safely move your family member?


2

3

4

1

6

31. Did the hospice team give you as
much information as you wanted
about what to expect while your
family member was dying?



3

1
2

Yes, definitely
Yes, somewhat
No

HOSPICE CARE RECEIVED IN A
NURSING HOME
32. Some people receive hospice care
while they are living in a nursing
home. Did your family member
receive care from this hospice
while he or she was living in a
nursing home?




1
2

Yes
No  If No, go to Question 35

33. While your family member was in
hospice care, how often did the
nursing home staff and hospice
team work well together to care
for your family member?



3

4

1
2

Never
Sometimes
Usually
Always

Yes, definitely
Yes, somewhat
No
I did not need to move my
family member

December 2016

34. While your family member was in
hospice care, how often was the
information you were given about
your family member by the
nursing home staff different from
the information you were given by
the hospice team?



3

4

1
2

Never
Sometimes
Usually
Always

YOUR OWN EXPERIENCE WITH
HOSPICE
35. While your family member was in
hospice care, how often did the
hospice team listen carefully to
you?



3

4

1
2

37. While your family member was in
hospice care, how much
emotional support did you get
from the hospice team?



3

1
2

Too little
Right amount
Too much

38. In the weeks after your family
member died, how much
emotional support did you get
from the hospice team?


2

3

1

Too little
Right amount
Too much

Never
Sometimes
Usually
Always

36. Support for religious or spiritual
beliefs includes talking, praying,
quiet time, or other ways of
meeting your religious or spiritual
needs. While your family member
was in hospice care, how much
support for your religious and
spiritual beliefs did you get from
the hospice team?



3

1
2

Too little
Right amount
Too much

December 2016

7

OVERALL RATING OF HOSPICE
CARE
39. Please answer the following
questions about your family
member’s care from the hospice
named on the survey cover. Do
not include care from other
hospices in your answers.

ABOUT YOUR FAMILY MEMBER
41. What is the highest grade or level
of school that your family member
completed?


2

1



5

6

3

Using any number from 0 to 10,
where 0 is the worst hospice care
possible and 10 is the best
hospice care possible, what
number would you use to rate
your family member’s hospice
care?

 0
1
 1
2
 2
3
 3
4
 4
5
 5
6
 6
7
 7
8
 8
9
 9
10
 10
0

Worst hospice care possible



3

4

2

8



7

42. Was your family member of
Hispanic, Latino, or Spanish
origin or descent?


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3

1
2




4
5

Best hospice care possible

40. Would you recommend this
hospice to your friends and
family?
1

4

Definitely no
Probably no
Probably yes
Definitely yes

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
Don’t know

No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Mexican, Mexican
American, Chicano/a
Yes, Cuban
Yes, Other Spanish/Hispanic/
Latino

43. What was your family member’s
race? Please choose one or more.



3

4

1
2



5

White
Black or African American
Asian
Native Hawaiian or other Pacific
Islander
American Indian or Alaska
Native

December 2016

ABOUT YOU
44. What is your age?


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3

4

5

6

7

8

1
2


2


18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 84
85 or older

1



5

6

3
4

45. Are you male or female?




1
2

Male
Female

46. 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

47. What language do you mainly
speak at home?



3

4

5

6

7

8

9

1
2

English
Spanish
Chinese
Russian
Portuguese
Vietnamese
Polish
Korean
Some other language (please
print):

THANK YOU
Please return the completed survey in the postage-paid envelope.

[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]

December 2016

9

PRA Disclosure Statement:
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 0938-1257. The time required to complete this information collection is estimated
to average 11 minutes for questions 1 – 40, the “About Your Family Member” questions and the “About
You” questions on the survey, including the time to review instructions, search existing data resources,
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, C1-25-05, Baltimore, MD
21244-1850.

10

December 2016