Cms-p-0015a Mcbs

Home Health Utilization (HHQ)
Variable Name
MR Screen Name

Question type

HHPRPROF

HH1

yes/no

PROVIDER_HHP

HH2

roster

BOX HH1AAA

routing

PROVSPEC

HH3

code one

PROVSPOS

HH3

text

Question text/description
SHOW CARD HH1

Code list

(01) YES
(Besides what you have already mentioned,) [(Since/since) (REFERENCE
(02) NO
DATE/UTILDATE)/(Between/between) (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(03) INDICATED YES BY DATAPREP. DO NOT DISPLAY.
INSTITUTIONALIZATION/ENDUTILD)], [have you been/has (SP) been/was (SP)] helped at home by any (other)
DATA EDITING ONLY.
health or medical professionals, such as those listed on this card?
(-8) DON'T KNOW
(-9) REFUSED
[Health professionals include nurse (visiting nurse, private duty nurse, etc.), doctor, social worker, therapist,
and hospice worker.]
What is the name of the health professional who helped [you/(SP)] at home [since (REFERENCE
DATE/UTILDATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)]?
ENTER NAME OF PERSON WHO HELPED. DO NOT ENTER THE NAME OF PLACE OR ORGANIZATION.
(01) CONTINUOUS ANSWER
[ADD OR SELECT ONLY ONE PROVIDER IF DIFFERENT PEOPLE COME FROM THE SAME ORGANIZATION, PROBE
FOR THE PERSON WHO USUALLY COMES OR WHO COMES MOST OFTEN.]
IF (HOME HEALTH PROVIDER WAS ADDED AT HH2) OR (AN EXISTING PROVIDER WAS SELECTED AT HH2 THAT
WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO HH3 - PROVSPEC.
ELSE GO TO BOX HH1BBB.

(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
What kind of health professional is (PROVIDER NAME)?
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
[SELECT THE RESPONSE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY NAMES
(15) OCCUPATIONAL THERAPIST (OT)
THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN PARENTHESES FOLLOWING THAT PROVIDER
(16) OPTOMETRIST (OD)
SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL SPECIALTY NOT LISTED BELOW, BUT LISTED ON
(17) OSTEOPATH (DO)
SHOWCARD AC1, SUCH AS ‘CARDIOLOGY,’ SELECT 'MEDICAL DOCTOR.']
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
OTHER MEDICAL PROVIDER (SPECIFY)

Home Health Utilization (HHQ)
Variable Name
MR Screen Name

Question type

Question text/description
Who does (PROVIDER NAME) work for, that is, for what place or organization?

WORKSFOR

HH4

code one
[PROBE: Or does (PROVIDER NAME) work for himself/herself?]

Code list
(01) NAME OF ORGANIZATION GIVEN
(02) WORKS FOR SELF
(-8) DON'T KNOW
(-9) REFUSED

[Who does (PROVIDER NAME) work for, that is, what place or organization?]
PROVIDER_HHPORG HH5

BOX HH1AA

roster

routing

HHPLACE

HH6

code one

HHPLACOS

HH6

text

BOX HH1BBB

routing

OTHMEALS

VAPLACE

[PROBE: Who would (you/SP) call if (PROVIDER NAME) did not show up?]
ADD OR SELECT ONLY ONE PROVIDER.
[DO NOT ADD A NEW ROSTER ENTRY IF A DIFFERENT PERSON CAME FROM AN ORGANIZATION ALREADY
LISTED ON THE ROSTER.]
IF HH4 - WORKSFOR = 1/OrganizationGiven, SET HOME HEALTH PROVIDER FOR THIS VISIT TO THE HOME
HEALTH ORGANIZATION SELECTED AT HH5, AND GO TO HH6 - HHPLACE.
ELSE SET HOME HEALTH PROVIDER FOR THIS VISIT TO THE PROVIDER SELECTED AT HH2, HH19, ST27 OR
NS27, AND GO TO BOX HH1BB.

PROVIDER NAME: (PROVIDER NAME)
What kind of place or organization is (PROVIDER NAME)?

OTHER (SPECIFY)
SET HOME HEALTH PROVIDER FOR THIS VISIT TO THE PROVIDER SELECTED AT HH2 OR HH19.
IF TYPE OF HOME HEALTH PROVIDER ORGANIZATION IS A MEAL PROGRAM, GO TO HH7 - OTHMEALS.
ELSE GO TO BOX HH1BB.

(01) CONTINUOUS ANSWER

(01) MANAGED CARE PLAN (SUCH AS HMO)
(02) MEAL PROGRAM (SUCH AS MEALS ON WHEELS)
(03) VISITING NURSE ASSOCIATION
(04) HOME HEALTH AGENCY
(05) HOSPITAL
(06) PRIVATE PHYSICIAN/GROUP PRACTICE
(07) HOSPICE
(08) REHABILITATION OR SPORTS MEDICINE THERAPY
(09) LOCAL GOVERNMENT ORGANIZATION
(10) CHURCH OR COMMUNITY ORGANIZATION
(11) ASSISTED LIVING/RETIREMENT HOME
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

yes/no

[Between (REFERENCE DATE/UTILDATE) and (today/DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did (PROVIDER NAME) provide any services to [you/(SP)] other than
delivering meals?

BOX HH1BB

routing

IF TYPE OF HOME HEALTH PROVIDER IS A MEAL PROGRAM THAT DID NOT PROVIDE ANY OTHER SERVICES
BESIDES MEALS, GO TO BOX HH3.
ELSE IF (HOME HEALTH PROVIDER IS A FRIEND OR RELATIVE) OR (TYPE OF HOME HEALTH PROVIDER IS A
LOCAL GOVERNMENT, CHURCH OR COMMUNITY ORGANIZATION), GO TO HH11 - HELPUNIT.
ELSE GO TO BOX HH1.

BOX HH1

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO HH8 - VAPLACE.
ELSE GO TO BOX HH1A.

yes/no

(01) YES
(02) NO
Is [(PROVIDER NAME) associated with/(PROVIDER NAME)] a Department of Veterans Affairs, or V.A., facility?
(-8) DON'T KNOW
(-9) REFUSED

HH7

HH8

Home Health Utilization (HHQ)
Variable Name
MR Screen Name

BOX HH1A

Question type

routing

Question text/description
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO HH10A - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO HH10B - HMOREFER.
ELSE GO TO HH11 - HELPUNIT.

HMOASSOC

HH10A

yes/no

Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

HMOREFER

HH10B

yes/no

[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]

HELPUNIT

HH11

quantity unit

[Between (REFERENCE DATE/UTILDATE) and (today/DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION/ENDUTILD)], how many times (has/did) [(PROVIDER NAME)/someone from
(PROVIDER NAME)] come to the home to help [you/(SP)]? [Remember to include all home health providers
from (PROVIDER NAME).]
[ENTER "TOTAL NUMBER OF TIMES" WHENEVER POSSIBLE.]

Code list

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) TOTAL NUMBER OF TIMES
(02) NUMBER OF TIMES PER DAY
(03) NUMBER OF TIMES PER WEEK
(04) NUMBER OF TIMES PER MONTH
(-8) DON'T KNOW
(-9) REFUSED

[DO NOT ENTER VISITS SEPARATELY FOR PEOPLE WHO WORK FOR THE SAME ORGANIZATION.]
HELPNUM

STAYUNIT

HH11

HH12

numeric

quantity unit

(Generally speaking, how long did/Generally speaking, how long does/How long did)[PROVIDER
NAME)/someone from (PROVIDER NAME)] stay with [you/(SP)]? [INCLUDE TIME SPENT SHOPPING OR
RUNNING ERRANDS.]
[PROBE: We just need to know in general.]

STAYHOUR
STAYMIN

HH12
HH12

numeric
numeric

(01) CONTINUOUS ANSWER
(01) HOURS ONLY
(02) MINUTES ONLY
(03) HOURS AND MINUTES
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER

SHOW CARD HH2

NEEDNURS

HH13

yes/no

(Generally speaking, did/Generally speaking, does/Did) [(PROVIDER NAME)/someone from (PROVIDER
NAME)] help [you/(SP)] by giving any medical or nursing treatment, such as the things shown on this card?
["MEDICAL OR NURSING TREATMENT" MEANS SUCH THINGS AS APPLYING STERILE BANDAGES OR
DRESSINGS, GIVING MEDICATIONS, TAKING BLOOD PRESSURE, GIVING SHOTS OR INJECTIONS.]

(01) YES, AT LEAST ONE
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

[PROBE: We just need to know in general.]
SHOW CARD HH3

NEEDMEAL

HH14

yes/no

(01) YES, AT LEAST ONE
(Generally speaking, did/Generally speaking, does/Did) [(PROVIDER NAME)/someone from (PROVIDER
(02) NO
NAME)] help with [your/(SP’s)] daily needs by doing things, such as the ones shown on this card? [HELP WITH
(-8) DON'T KNOW
DAILY NEEDS MEANS HELP IN USING THE TELEPHONE, DOING HOUSEWORK, PREPARING MEALS.]
(-9) REFUSED
[PROBE: We just need to know in general.]

Home Health Utilization (HHQ)
Variable Name
MR Screen Name

NEEDCARE

HH15

BOX HH3

HHPMORE

HHPOMORE

HH16

HH17

Question type

yes/no

routing

yes/no

yes/no

Question text/description
SHOW CARD HH4

Code list

(Generally speaking, did/Generally speaking, does/Did) [(PROVIDER NAME)/someone from (PROVIDER
NAME)] help with [your/(SP’s)] personal care by doing things such as those shown on this card? [HELP WITH
PERSONAL CARE MEANS HELP WITH BATHING, SHOWERING, DRESSING, EATING, WALKING, USING THE
TOILET.]

(01) YES, AT LEAST ONE
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

[PROBE: We just need to know in general.]
IF CURRENTLY ADMINISTERING ST, GO TO BOX ST31B.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS31B.
ELSE IF CURRENTLY ADMINISTERING HHS, GO TO BOX HHS5.
ELSE IF CURRENTLY ASKING ABOUT HOME HEALTH FRIENDS OR FAMILY, GO TO BOX HH6.
ELSE IF HOME HEALTH PROVIDER WORKED FOR SELF, GO TO HH16 - HHPMORE.
ELSE GO TO HH17 - HHPOMORE.
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you been/has (SP) been/was (SP)] helped at home by any other
health professionals?
Other than the persons who (have) visited [you/(SP)] from (PROVIDER NAME) [or from the other(s) we’ve
talked about], [have you been/has (SP) been/was (SP)] helped at home by any other health professionals
[since (REFERENCE DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)]?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

[DON’T INCLUDE ANY OTHER PERSONS COMING FROM THE SAME ORG/ AGENCY LISTED BELOW]
SHOW CARD HH5

HHPRFRND

HH18

yes/no

(01) YES
(02) NO
(Besides what you have already talked about, [(Since/since) (REFERENCE
(03) INDICATED YES BY DATAPREP DO NOT DISPLAY.
DATE/UTILDATE)/(Between/between) (REFERENCE DATE) and (DATE OF DEATH/DATE OF
DATA EDITING ONLY.
INSTITUTIONALIZATION/ENDUTILD)], because of health problems [have you/has (SP)/did (SP)]
(-8) DON'T KNOW
(received/receive) any personal care or help at home with daily needs from (any other) persons who (do/did)
(-9) REFUSED
not live with (you/him/her), including home health aides, homemakers, friends, neighbors, or relatives?
Who helped [you/(SP)]? What is the name of the person who helped (you/him/her)?
ENTER NAME OF PERSON WHO HELPED. DO NOT ENTER THE NAME OF THE PLACE OR ORGANIZATION.

PROVIDER_HHF

HHFTYPE

HH19

roster

BOX HH3AA

routing

HH20

code one

[SELECT OR ADD ONLY ONE PERSON. DO NOT ENTER A PERSON WHO LIVES WITH THE SP. IF DIFFERENT
PEOPLE COME FROM THE SAME ORGANIZATION, PROBE FOR THE PERSON WHO USUALLY COMES OR WHO
COMES MOST OFTEN.]
IF (HOME HEALTH PROVIDER WAS ADDED AT HH19) OR (AN EXISTING PROVIDER WAS SELECTED AT HH19
THAT WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO HH20 - HHFTYPE.
ELSE GO TO BOX HH1BBB.

Is (PROVIDER NAME) a friend or neighbor, a relative, or some other type of home health provider?

(01) CONTINUOUS ANSWER

(01) FRIEND OR NEIGHBOR
(02) RELATIVE
(03) OTHER TYPE OF HOME HEALTH PROVIDER
(-8) DON'T KNOW
(-9) REFUSED

Home Health Utilization (HHQ)
Variable Name
MR Screen Name

Question type

HHFRELAT

HH21

code one

HHFRELOS

HH21

text

BOX HH3A

routing

BOX HH6

routing

HHFMORE

HH28

yes/no

HHFOMORE

HH29

yes/no

BOX HH7

routing

Question text/description

Code list
(01) SAMPLE PERSON
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
How is (PROVIDER NAME) related to [you/(SP)]?
(13) NEPHEW
[CLASSIFY ANY “STEP” RELATIONSHIP WITH THE RELATED “NON-STEP” RELATIONSHIP (E.G., STEP-DAUGHTER
(14) NIECE
= DAUGHTER).]
(50) PARTNER/ROOMMATE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER RELATIVE
(92) OTHER NON-RELATIVE
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
IF HH20 - HHFTYPE = 3/Other, DK, OR RF, GO TO HH3 - PROVSPEC.
ELSE GO TO BOX HH1AA.
IF (HOME HEALTH PROVIDER IS A FRIEND OR RELATIVE) OR (HOME HEALTH PROVIDER WORKS FOR SELF), GO
TO HH28 - HHFMORE.
ELSE GO TO HH29 - HHFOMORE.
(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], [have you/has (SP)/did (SP)] (received/receive) personal care or help at
(-8) DON'T KNOW
home with daily needs from any other persons who (do/did) not live with (you/him/her)?
(-9) REFUSED
Other than the persons who have visited [you/(SP)] from (PROVIDER NAME) [since (REFERENCE
(01) YES
DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], [have you/has (SP)/did (SP)] (received/receive) personal care or help at
(-8) DON'T KNOW
home with daily needs from any other persons who (do/did) not live with (you/him/her)? [DON’T INCLUDE
(-9) REFUSED
ANY OTHER PERSONS COMING FROM THE SAME ORG/AGENCY LISTED BELOW.]
GO TO NEXT SECTION. (MPQ)