Cms-p-0015a Mcbs

Institutional Utilization (IUQ)
Variable Name
MR Screen Name
IUPROBE
IU1

Question type
yes/no

Question text/description
SHOW CARD IU1
[Since (REFERENCE DATE/UTILDATE), [have you/has (SP)] been/Between (REFERENCE DATE) and (DATE OF
DEATH/ENDUTILD), was (SP)/Other than the current institutional stay that started on (DATE OF
INSTITUTIONALIZATION), between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION) was (SP)] a
patient in (a/another) nursing home or any similar place that provides long-term care -- such as the places
shown on this card?

Code list
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

LONG-TERM CARE PLACES INCLUDE SKILLED NURSING HOMES, INTERMEDIATE CARE FACILITIES, BOARD AND
CARE HOMES, NURSING HOME UNITS IN HOSPITALS, FACILITIES FOR THE MENTALLY RETARDED, PSYCHIATRIC
FACILITIES AND GROUP HOMES.

PROVIDER_IU

IU2

roster

[ENTER A STAY AT A DRUG AND REHABILITATION CENTER AS AN IP EVENT, NOT AN IU EVENT.]
Where [were you/was (SP)] a patient -- in which nursing home?
SELECT OR ADD ONLY ONE FACILITY.
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE INSTITUTION.]

[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME
FOR ALL PROVIDERS WHERE PROVNUM>02.
(01) continuous answer

PROVNAME

IU2

verbatim

ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.
[PROVE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE HOSPITAL]
NAME:
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]

GROUPNAM

IU2
BOX IU1

routing

GROUP:
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 IU3 - VAPLACE.
ELSE TO IU4 - EVBEGMM.

VAPLACE

IU3

yes/no

Is (FACILITY NAME) a Department of Veterans Affairs, or V.A., facility?

EVBEGMM

IU4

date

When [were you/was (SP)] admitted to and discharged from (FACILITY NAME)?

EVBEGDD

IU4

date

Admission Date:
When [were you/was (SP)] admitted to and discharged from (FACILITY NAME)?

EVBEGYY

IU4

date

When [were you/was (SP)] admitted to and discharged from (FACILITY NAME)?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused

Institutional Utilization (IUQ)
Variable Name
MR Screen Name
EVENDMM
IU4

Question type
date

Question text/description
When [were you/was (SP)] admitted to and discharged from (FACILITY NAME)?

EVENDDD

IU4

date

Discharge Date:
When [were you/was (SP)] admitted to and discharged from (FACILITY NAME)?

EVENDYY

IU4

date

When [were you/was (SP)] admitted to and discharged from (FACILITY NAME)?

IPADD

IU4B

choose one

HAVE ALL DATES BEEN ENTERED?

NAVIGATOR

IU4_IN

instance navigator

IUMORE

IU7

yes/no

BOX IU3

routing

Code list
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) ADD ANOTHER
(02) ALL DONE

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
YOU HAVE ENTERED DATES FOR THE FOLLOWING EVENTS. SELECT AN EVENT TO DISCUSS WITH SP OR PRESS (01) EVENT1
[PREVIOUS] TO GO BACK AND ADD MORE EVENTS.
(02) EVENT2
…
[DISPLAY ALL EVENTS ADDED AT IP4]
(N) EVENT N
[EVENT DATE, PROVIDER]
(N+1) CONTINUE INTERVIEW
IF RESPONDENT HAS ALREADY MENTIONED ANOTHER STAY AT A NURSING HOME, ENTER “YES” WITHOUT
(01) YES
ASKING. OTHERWISE, ASK:
(02) NO
(-8) Don't know
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(-9) Refused
INSTITUTIONALIZATION/ENDUTILD)], [have you had/has (SP) had/did (SP) have] any other stays in this or any
other nursing home or similar place that provides long-term care?
[ENTER A STAY AT A DRUG AND REHABILITATION CENTER AS AN IP EVENT, NOT AN IU EVENT.]
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