VA Form 10-1465-5 SHEP Patient Centered Medical Homes (PCMH) Short Form 10

OMB Number 2900-0712
Est. Burden: 11 minutes
VA Form 10-1465-5

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
AMBULATORY CARE 2016
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.
The check-box responses you provide to the survey questions will not be connected with you
personally but combined with the opinions of other veterans and shared with the VA facility providing
your care. However, any additional information which you provide including comments written in the
margins, letters, and other enclosures will be shared with the Medical Center Director or appropriate
staff at your facility if it is the best way to address your concerns, unless you instruct us not to.
Participation is voluntary and your answers to the survey will not affect the healthcare you receive or
your eligibility for VA benefits.
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 11 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: 44 – 0416

SURVEY INSTRUCTIONS
•

Answer each question by marking 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 If Yes, go to #1
No

YOUR PROVIDER
1.

Our records show that you got care
from the provider named below in the
last 6 months.
[PROVIDER NAME]
Is that right?




YOUR CARE FROM THIS PROVIDER
IN THE LAST 6 MONTHS
These questions ask about your own
health care. Do not include care you got
when you stayed overnight in a hospital.
Do not include the times you went for
dental care visits.
4.

Yes
NoIf No, go to #51









The questions in this survey will refer to
the provider named in Question 1 as “this
provider.” Please think of that person as
you answer the survey.
2.

Is this the provider you usually see if
you need a check-up, want advice
about a health problem, or get sick or
hurt?



3.

Yes

5.

No

How long have you been going to this
provider?





At least 1 year but less than
3 years



At least 3 years but less than
5 years



5 years or more

6.

None If None, go to #44
1 time
2
3
4
5 to 9
10 or more times

In the last 6 months, did you contact
this provider’s office to get an
appointment for an illness, injury or
condition that needed care right
away?




Less than 6 months
At least 6 months but less than
1 year

In the last 6 months, how many times
did you visit this provider to get care
for yourself?

Yes
NoIf No, go to #8

In the last 6 months, when you
contacted this provider’s office to get
an appointment for care you needed
right away, how often did you get an
appointment as soon as you needed?






Never
Sometimes
Usually
Always

7.

In the last 6 months, how many days
did you usually have to wait for an
appointment when you needed care
right away?






8.

1 day
2 to 3 days
4 to 7 days
More than 7 days

In the last 6 months, did you make any
appointments for a check-up or
routine care with this provider?



9.

Same day

Yes
No If No, go to #10

In the last 6 months, when you made
an appointment for a check-up or
routine care with this provider, how
often did you get an appointment as
soon as you needed?






Never
Sometimes
Usually
Always

10. Did this provider’s office give you
information about what to do if you
needed care during evenings,
weekends, or holidays?




Yes
No

11. In the last 6 months, did you need
care for yourself during evenings,
weekends, or holidays?




Yes
No If No, go to #13

12. In the last 6 months, how often were
you able to get the care you needed
from this provider’s office during
evenings, weekends, or holidays?






Never
Sometimes
Usually
Always

13. In the last 6 months, did you contact
this provider’s office with a medical
question during regular office hours?




Yes
No If No, go to #15

14. In the last 6 months, when you
contacted this provider’s office during
regular office hours, how often did
you get an answer to your medical
question that same day?






Never
Sometimes
Usually
Always

15. In the last 6 months, did you contact
this provider’s office with a medical
question after regular office hours?




Yes

No If No, go to #17

16. In the last 6 months, when you
contacted this provider’s office after
regular office hours, how often did
you get an answer to your medical
question as soon as you needed?






Never
Sometimes
Usually
Always

17. Some offices remind patients between
visits about tests, treatment or
appointments. In the last 6 months,
did you get any reminders from this
provider’s office between visits?




Yes
No

18. Wait time includes time spent in the
waiting room and exam room. In the
last 6 months, how often did you see
this provider within 15 minutes of your
appointment time?






Never
Sometimes
Usually
Always

19. In the last 6 months, how often did
this provider explain things in a way
that was easy to understand?






Never
Sometimes
Usually
Always

20. In the last 6 months, how often did
this provider listen carefully to you?






Never
Sometimes
Usually
Always

21. In the last 6 months, did you talk with
this provider about any health
questions or concerns?




Yes
No If No, go to #23

22. In the last 6 months, how often did
this provider give you easy to
understand information about these
health questions or concerns?






Never
Sometimes
Usually
Always

23. In the last 6 months, how often did
this provider seem to know the
important information about your
medical history?






Never
Sometimes
Usually
Always

24. In the last 6 months, how often did
this provider show respect for what
you had to say?






Never
Sometimes
Usually
Always

25. In the last 6 months, how often did
this provider spend enough time with
you?






Never
Sometimes
Usually
Always

26. In the last 6 months, did this provider
order a blood test, x-ray, or other test
for you?




Yes
No If No, go to #28

27. In the last 6 months, when this
provider ordered a blood test, x-ray, or
other test for you, how often did
someone from this provider’s office
follow up to give you those results?






Never
Sometimes
Usually
Always

28. In the last 6 months, did you and this
provider talk about starting or
stopping a prescription medicine?




Yes
No If No, go to #32

29. When you talked about starting or
stopping a prescription medicine, how
much did this provider talk about the
reasons you might want to take a
medicine?






Not at all
A little
Some
A lot

30. When you talked about starting or
stopping a prescription medicine, how
much did this provider talk about the
reasons you might not want to take a
medicine?






Not at all
A little
Some
A lot

31. When you talked about starting or
stopping a prescription medicine, did
this provider ask you what you
thought was best for you?




Yes
No

32. Using any number from 0 to 10, where
0 is the worst provider possible and
10 is the best provider possible, what
number would you use to rate this
provider?













0

Worst provider possible

1
2
3
4
5
6
7
8
9
10 Best provider possible

33. In the last 6 months, did you take any
prescription medicine?




Yes
No If No, go to #35

34. In the last 6 months, how often did
you and someone from this provider’s
office talk about all the prescription
medicines you were taking?






Never
Sometimes
Usually
Always

35. Specialists are doctors like surgeons,
heart doctors, allergy doctors, skin
doctors, and other doctors who
specialize in one area of health care.
In the last 6 months, did you see a
specialist for a particular health
problem?




Yes
No If No, go to #37

36. In the last 6 months, how often did the
provider named in Question 1 seem
informed and up-to-date about the
care you got from specialists?






Never
Sometimes
Usually
Always

Please answer these questions about the
provider named in Question 1 of the
survey.
37. In the last 6 months, did anyone in
this provider’s office talk with you
about specific goals for your health?




Yes
No

38. In the last 6 months, did anyone in
this provider’s office ask you if there
are things that make it hard for you to
take care of your health?




Yes
No

39. In the last 6 months, did anyone in
this provider’s office ask you if there
was a period of time when you felt
sad, empty or depressed?




Yes
No

40. In the last 6 months, did you and
anyone in this provider’s office talk
about things in your life that worry
you or cause you stress?




Yes

No
41. In the last 6 months, did you and
anyone in this provider’s office talk
about a personal problem, family
problem, alcohol use, drug use, or a
mental or emotional illness?




Yes
No

CLERKS AND RECEPTIONISTS AT
THIS PROVIDER’S OFFICE
42. In the last 6 months, how often were
clerks and receptionists at this
provider’s office as helpful as you
thought they should be?






Never
Sometimes
Usually
Always

43. In the last 6 months, how often did
clerks and receptionists at this
provider’s office treat you with
courtesy and respect?






Never
Sometimes
Usually
Always

YOUR CARE FROM SPECIALISTS IN
THE LAST 6 MONTHS
These questions ask about your own
health care. Do not include care you got
when you stayed overnight in a hospital.
Do not include the times you went for
dental care visits.
44. Specialists are doctors like surgeons,
heart doctors, allergy doctors, skin
doctors, and other doctors who
specialize in one area of health care.
In the last 6 months, did you try to
make any appointments with a VA
specialist?




Yes
No If No, go to #46

45. In the last 6 months, how often was it
easy to get appointments with VA
specialists?






Never
Sometimes

Usually
Always

46. In the last 6 months, did you try to
make any appointments with a NonVA specialist paid for by VA?




Yes
No If No, go to #48

47. In the last 6 months, how often was it
easy to get appointments with Non-VA
specialist paid for by VA?






Never
Sometimes
Usually
Always

48. Please think about your most recent
visit within the last 6 months to either
a VA specialist or Non-VA specialist.
Was this specialist:






A VA specialist
A non-VA specialist paid for by VA
A non-VA specialist seen on my own
Did not see a specialist in the last 6
months
Go to #51

49. During your most recent visit with the
specialist, did the specialist know
important information about your
medical history?





Yes, definitely
Yes, somewhat
No

50. Using any number from 0 to 10, where
0 is the worst specialist possible and
10 is the best specialist possible, what
number would you use to rate this
specialist?













0

Worst specialist possible

1
2
3
4
5
6
7
8
9
10

Best specialist possible

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:
51. I got the service I needed.







Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

52. It was easy to get the service I needed.







Strongly disagree
Disagree

Agree
Strongly agree

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

54. I trust VA to fulfill our country’s
commitment to veterans.







Strongly disagree
Disagree






High school graduate or GED

Strongly agree

Excellent
Very Good
Good
Fair
Poor

56. In general, how would you rate your
overall mental or emotional health?
Excellent
Very Good
Good
Fair
Poor

Some high school, but did not
graduate

Some college or 2-year degree
4-year college graduate
More than 4-year college degree

58. Are you of Hispanic or Latino origin or
descent?




Yes, Hispanic or Latino
No, Not Hispanic or Latino

59. What is your race? Mark one or more.







Agree

55. In general, how would you rate your
overall health?







8th grade or less

Neither agree nor disagree

ABOUT YOU










Neither agree nor disagree

53. I felt like a valued customer.







57. What is the highest grade or level of
school that you have completed?

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

60. What language do you mainly speak at
home?









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

__________________________

61. Did someone help you complete this
survey?




Yes
No  Thank you. Please return
the completed survey in
the postage-paid
envelope.

62. How did that person help you? Mark
one or more.







Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into
my language
Helped in some other way

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

If you have a specific question or need help with your VA care, you may contact the VA:
1. By telephone:
a. VA Benefits: 1-800-827-1000
b. Health Care Benefits: 1-877-222-8387
c. Telecommunications Device for the Deaf (TDD): 1-800-829-4833
2. Information on a broad range of veterans' benefits is available on our home page at
http://www.va.gov
3. At your local VA medical center, either contact the department that you think can help you or
ask for the Patient Advocate.

Your answers are important to help us improve VA care. Thank you for completing
this questionnaire. Please place the completed questionnaire in the envelope we
sent you. No stamp is required. Simply place the envelope in any mailbox and return
the survey to:
Department of Veterans Affairs
c/o Ipsos
P.O. Box 806046
Chicago, IL 60680