Home Health and Hospice Survey and Interviews

Form Approved

OMB No. 0990-0391

Exp. Date 11/30/2021

Attachment B: ASPR TRACIE Home Health Care and Hospice Survey

Consent

The US Department of Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE) is conducting research on the role of home health care and hospice agencies in supporting the health and medical response to disasters or emergencies.

ASPR TRACIE recognizes your agency complies with the Centers for Medicare & Medicaid Services (CMS) Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule. The purpose of this survey is to better understand your agency’s capacity, preparedness, and impediments in disaster response beyond those requirements.

Your participation in this survey is completely voluntary. You may choose not to participate or to end the survey at any time. We will keep your responses confidential, and unless you wish to participate in a follow-up phone interview, we will not ask for any personal information such as your name or email address.

If you have any questions about the survey, please contact: [email protected].

Please indicate whether or not you consent to participate in this survey:

• Consent [proceed to question 1]

• Do not consent [ineligible]

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 0990-0391. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

1. Are you affiliated with a Medicare-certified home health care or hospice provider? (select one)

• Yes

• No (screen out)

2. Which of the following services do you provide? (select all that apply)

• Home Health Care

• Routine Home Hospice Care – in a private residence

• Routine Home Hospice Care – in a residential facility

• Other Hospice Care – in a private residence (i.e., Continuous Home Care)

• Other Hospice Care – in a hospice inpatient facility, hospital, or nursing facility (i.e., Inpatient Respite Care, General Inpatient Care)

3. Which of the following best represents your role? (select one)

• Clinical Manager

• Clinician

• Emergency Preparedness Lead

• Other (please provide)

4. Where are you located?

• Dropdown list of states, DC, and territories

5. What percentage of your staff work for other agencies?

• _______ (insert %)

6. What percentage of your staff are per diem?

• _______ (insert %)

7. What percentage of your staff are independent contractors?

• _______ (insert %)

8. Is your agency part of an integrated healthcare system? (select one)

• Yes

• No

8.A. If yes to 8, did someone from your agency participate in the development of the integrated healthcare system’s emergency preparedness program? (select one)

• Yes

• No

9. Which of the following are most challenging? (select all that apply)

• Developing/maintaining emergency plan

• Developing/implementing emergency preparedness policies and procedures

• Developing emergency preparedness plans for your patients

• Developing/maintaining an emergency preparedness communication plan

• Developing/maintaining a training program

• Collaborating and engaging with other community response partners

• Conducting/participating in exercises

10. What barriers contribute to these challenges? (select all that apply)

• Unsure how to access technical assistance to improve understanding of CMS Final Rule requirements

• Lack of staff expertise in emergency management

• Not enough time to devote to preparedness given other competing responsibilities/priorities

• Unsure of role/not engaged in community planning for emergency response

• Continually changing patient population/care setting

• Other (please describe)

Scenarios

For the remaining questions, please consider the two different scenarios presented below:

An infectious disease outbreak is affecting your entire geographic region. Over an extended period of time, the number of infections will gradually increase, reach a peak, and begin to decrease. There will be high demands on the overall healthcare system, which will deal with patients infected with the disease and the worried well on top of the normal range of healthcare services. There may be high demand and low availability of healthcare personnel, supplies, and other resources at varying points in time during the outbreak.

A natural disaster such as a hurricane or wildfire occurs in your community and results in large numbers of injuries with limited or no warning. The healthcare system will absorb an immediate influx of patients with injuries of varying severity on top of its existing load of patients with chronic and acute illnesses and injuries. There may be infrastructure damage, security requirements, or communications breakdowns that challenge your response to the incident for an unpredictable amount of time due to electrical outages, telecommunications and IT system failure, supply chain disruptions, unnavigable transportation systems, and reduced staffing availability.

Please select one answer for each scenario.

	Infectious Disease Outbreak		Natural Disaster
Based on your existing emergency plan and/or community partnerships, would your agency have a role in addressing healthcare needs caused by either of these scenarios?	Yes	No	Yes	No

12. Does your agency receive notifications about emergencies in your area from your local or state emergency management or public safety agency? (select one)

• Yes

• No

13. Does your agency receive health alerts from your local or state health department? (select one)

• Yes

• No

14. Does your agency participate in coordinated emergency preparedness activities with any of the following? (select one response for each row)

	Yes	No
Healthcare coalition
Health department
Emergency management agency Hospital(s) in your community
Nursing or long-term care facility(ies) in your community
Non-profit organizations serving in your community
Other (describe)

15. Do you have a communication plan with your staff, patients, and their loved ones to communicate critical information in the event of an emergency? (select one)

• Yes

• No

16. Has your agency tested the ability to implement the following either through an exercise or real-life incident? (select all that apply)

	Yes – through an exercise	Yes – through a real-life emergency
Contact staff during off hours
Contact patients during off hours
Receive/send notifications to other preparedness/response partners
Maintain patient records (i.e., paper-based) if electronic health record is inaccessible
Procedures to shut down operations
Procedures to restart operations
Financial preparedness (e.g., maintaining cash reserves, planning for business operations and losses, insurance policies)
Establish incident command
Evacuate staff and patients

17. Have you developed any policies, procedures, or resources that you would be willing to share with other agencies? (select one)

• Yes

• No

18. Has your agency been involved in the response to an emergency or disaster? (select one)

• Yes

• No

18A. If yes to 18, would you be willing to share additional information about your experience? (select one)

• Yes

• No

19. Would you be willing to participate in a follow-up discussion, scheduled at your convenience, to elaborate on some of your survey responses? (select one)

• Yes

• No

19A. If yes to 19, please provide your first name and email address: __________________

20. Do you operate an inpatient hospice facility? (select one)

• Yes

• No

21. Do you provide hospice care in a private residence? (select one)

• Yes

• No

22. Do you provide hospice care in a nursing home or other residential facility? (select one)

• Yes

• No

For those who answered yes to question 21 or 22 or selected Home Health Care in question 2:

23. How many staff members make home visits on a typical day? ______

24. How many visits per day do staff members make on average? ______

25. Approximately what percentage on average of visits occur within the following travel ranges for your staff members? (insert value for each to equal 100)

Within 5 miles _____

6-10 miles _____

11-20 miles _____

21-50 miles _____

More than 50 miles _____

26. Please estimate how your average number of daily patient visits may change during an infectious disease outbreak or natural disaster in your community. (select one in each column)

	Infectious Disease Outbreak	Natural Disaster
Average number of home visits would decrease
Average number of home visits would stay the same
Average number home visits could increase by up to 10%
Average number of home visits could increase by 11-20%
Average number of home visits could increase by more than 20%

For those who answered yes to question 20:

27. What is your average patient census? _____ insert number

28. Have you encountered any obstacles in developing your facility operations plan? (select one)

• Yes

• No

29. Do you have a plan to evacuate or shelter in place with your patients in the event of an emergency? (select one)

• Yes

• No

30. In the event of an emergency in your community, would you be able to provide medical care to patients outside of your normal patient population? (select one)

• Yes

• No

30A. If yes to 30, what types of medical care would you be able to provide to non-hospice patients in either an infectious disease outbreak or natural disaster in your community? (select all that apply in each column)

	Infectious Disease Outbreak	Natural Disaster
Medical care for low acuity patients
Patient triage
Prophylaxis/vaccination
Behavioral health support/treatment for patients
Behavioral health support/treatment for staff
Other (please describe)