CMS-10549.GenIC#3 Questionnaire

MATERIALS NEEDED FOR INTERVIEW

• INTERVIEWER PROTOCOL BOOKLET (THIS BOOKLET) AND SHOWCARD

• INFORMED CONSENT (TWO COPIES)

• ONE ENVELOPE WITH $40 CASH IN IT

• ONE PAYMENT RECEIPT

• DIGITAL RECORDER AND EXTRA BATTERIES

• PENS AND PENCILS

STEP 1: INFORMED CONSENT

PROVIDE RESPONDENT WITH A COPY OF THE INFORMED CONSENT. ANSWER ANY QUESTIONS THE BENEFICIARY MAY HAVE.

• COPY OF INFORMED CONSENT GIVEN TO BENEFICIARY

• IF THE BENEFICIARY HAS CONSENTED TO RECORDING, START THE RECORDER.

STEP 2: COMPLETION OF THE QUESTIONNAIRE

The Medicare Current Beneficiary Survey (MCBS) asks Medicare beneficiaries about their health status, sources of health care, satisfaction with care, and health care expenditures. In today’s interview I will be asking you about your recent health care and some of your medical conditions.

After we have finished the survey, I would like to talk with you about some of the questions in the survey. Getting your feedback on the questions can help make the questions better.

[INTERVIEWER: EACH TEST QUESTION IN THE PROTOCOL IS IMMEDIATELY FOLLOWED BY A SET OF EXAMPLE PROBES AND INTERVIEWER NOTES DESIGNED TO AID THE DEBRIEFING PROCESS; WHILE SPECIFIC PROBES WILL VARY, THE EXAMPLES PROVIDED IN THE PROTOCOL ARE MEANT TO BE A STARTING POINT FOR DIALOG WITH THE RESPONDENT. ALTHOUGH THESE PROBES APPEAR ADJACENT TO THE QUESTIONS THEMSELVES, IT IS GENERAL PRACTICE TO ADMINISTER THE QUESTIONNAIRE IN FULL BEFORE USING THE EXAMPLE PROBES AND INTERVIEWER NOTES TO DEBRIEF THE RESPONDENT. REMIND THE RESPONDENT OF THE QUESTION AND HIS/HER RESPONSE IN ADVANCE OF USING PROBES.

IN ADDITION, THIS INTERVIEW WILL ASK THE RESPONDENT ABOUT TWO CHRONIC CONDITIONS, IF APPLICABLE. NOTE THAT MANY OF THE PROBES ARE REPEATED ALONG WITH QUESTIONS IN THE PROTOCOL FOR THE SECOND CHRONIC CONDITION. THESE PROBES MAY OR MAY NOT BE APPLICABLE AS YOU ASK THE RESPONDENT ABOUT HIS/HER SECOND CHRONIC CONDITION.]

STEP 3: DEBRIEFING

Now I would like to talk with you about some of the survey questions you just answered.

GENERAL PROBES: Suggested general neutral probing for issues that arise.

• How did you decide on that answer?

• Can you tell me more about that?

• Can you give me an example of that?

• Tell me what you are thinking.

• What did you think about when I asked that question?

• What did you think about in deciding on your answer?

• What doctors did you include when you answered this question?

• What does [QUESTION/TERM] mean to you?

OPTIONAL VS REQUIRED PROBES:

• Probes with a regular round bullet point are optional

• Probes with an arrow bullet point are required.

Var Name	MR Screen Name	Question text/description	Code list	Routing
DUINT	DUINTRO	The first questions are about health care services you may have used between January 1, 2018 and today. First we’ll talk about dental care.	(01) CONTINUE	Next question
Observations:
DUPROBE	DU1	Since January 1, 2018, have you gone to a dentist or any other person for dental care? [Dental providers include dentists, dental surgeons, endodontists, periodontists, and dental hygienists.]	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
ERPROBE	ER1	Since January 1, 2018, did you go to, have you gone to a hospital emergency room for medical care?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
MPPRMDOC	MP1	Since January 1, 2018 have you seen any medical doctors? INCLUDE ANY VISITS FOR TESTS/X-RAYS. [DO NOT INCLUDE MEDICAL DOCTORS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCHBP	HFJ2	Has a doctor or other health professional ever told you that you have hypertension, sometimes called high blood pressure?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCCHD	HFJ6	Has a doctor or other health professional ever told you that you had angina pectoris or coronary heart disease?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCCFAIL	HFJ8	Has a doctor or other health professional ever told you that you had congestive heart failure?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCSTROKE	HFJ16	Has a doctor or other health professional ever told you that you had a stroke, a brain hemorrhage, or a cerebrovascular accident?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCCHOLES	HFJ17A	Has a doctor or other health professional ever told you that you had high cholesterol?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCCANCER	HFJ20	Has a doctor or other health professional ever told you that you had any kind of cancer, malignancy, or tumor other than skin cancer?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCARTHRH	HFJ24	Has a doctor or other health professional ever told you that you had rheumatoid arthritis?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCOSARTH	HFJ24B	Has a doctor or other health professional ever told you that you had osteoarthritis?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCARTH	HFJ25	Has a doctor or other health professional ever told you that you had arthritis, other than rheumatoid or osteoarthritis?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCALZMER	HFJ29A	Has a doctor or other health professional ever told you that you had Alzheimer's disease?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCDEMENT	HFJ29B	Has a doctor or other health professional ever told you that you had any type of dementia other than Alzheimer's disease?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCDEPRSS	HFJ30AA	Has a doctor or other health professional ever told you that you had depression?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCOSTEOP	HFJ32	Has a doctor or other health professional ever told you that you had osteoporosis, sometimes called fragile or soft bones?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCEMPHYS	HFJ36	Has a doctor or other health professional ever told you that you had emphysema, asthma, or COPD?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
OCBETES	HFJ41A	Has a doctor or other health professional ever told you that you had any type of diabetes, including: sugar diabetes, high blood sugar, borderline diabetes, pre-diabetes, or pregnancy-related diabetes/borderline diabetes, or pre-diabetes?	(01) YES (02) NO (-8) Don't Know (-9) Refused	(01) HFJ41B - OCDTYPE (02) Q1A (-8) Q1A (-9) Q1A
Observations:
OCDTYPE	HFJ41B	SHOW CARD HF5 Looking at this card, please tell me which type of diabetes the doctor or other health professional said that you have. [IF THE RESPONDENT REPORTS MORE THAN ONE TYPE OF DIABETES, PROBE FOR THE MOST RECENT TYPE OF DIABETES THE DOCTOR TOLD THE RESPONDENT HE/SHE HAS.]	(01) TYPE 1 (02) TYPE 2 (03) BORDERLINE (04) PRE-DIABETES (05) GESTATIONAL (PREGNANCY-RELATED) (91) SOME OTHER TYPE (-8) Don't Know (-9) Refused	Next question
Observations:
	Q1A	Now I would like to talk to you about your chronic conditions. Earlier, you said that you have (TEXT FILL ALL CHRONIC CONDITIONS IDENTIFIED DURING INTERVIEW). READ IF NECESSARY: AT THIS TIME WE ARE INTERESTED IN ONLY THE CONDITIONS WE ASKED ABOUT EARLIER IN THIS INTERVIEW.	(01) CONTINUE	Next question
Observations:
	BOX A	If R has more than one chronic condition go to Q1B, else go to Q2.
Observations:
	Q1B	Which of these conditions concerns you most? LIST CONDITIONS IDENTIFIED DURING THE INTERVIEW.	(01) CONTINUOUS ANSWER	Next question
Observations: Example probes: Please tell me in your own words what you think this question is asking. What did you think about when answering this question? How did you decide on your answer? Interviewer notes: PROBE ONLY IF RESPONDENT EXPRESSES CONFUSION OR UNCERTAINTY ABOUT THE QUESTION. How does the respondent conceptualize “concern”? Did he/she use any specific criteria to determine which condition was most concerning?
	Q2	In the last 3 months, do you feel your (CONDITION #1) has gotten better, worse, or stayed the same?	(A) BETTER (B) WORSE (C) STAYED THE SAME (D) DON’T KNOW (E) REFUSED	A. Q3 B. Q3 C. Q3 D. BOX X E. BOX X
Observations: Example probes: When I asked if you feel that your CONDITION has gotten better, worse, or stayed the same in the last 3 months, you responded [ANSWER]. Please tell me in your own words what you think this question is asking. What factors did you consider when answering this question? How easily were you able to think about whether your CONDITION [got better/got worse/stayed the same] in the last 3 months? How did your condition change in the last 3 months? What about changes that took place more than 3 months ago? Please think about the last year. In the last year, has your condition gotten better, worse, or stayed the same? What changed? What about changes that took place less than 3 months ago? Please think about the last 3-4 weeks. In the last 3-4 weeks, has your condition gotten better, worse, or stayed the same? What changed? Interviewer notes: If the respondent is confused about how to answer this question or asks whether we want them to think about what their doctor says versus some other criteria, repeat the question emphasizing “do you feel” to indicate that we are focused on perception.
	Q3	Given that your (CONDITION #1) has (gotten better/stayed the same/gotten worse), have you changed anything about how you manage it?	(A) YES (B) NO (C) DON’T KNOW (D) REFUSED	A. Q4 B. BOX X C. BOX X D. BOX X
Observations: Example probes: Please tell me in your own words what you think this question is asking. What did you think about when answering this question? What factors did you consider?
	Q4	What have you changed about how you manage your (CONDITION #1)? [PROBE: Anything else?]	(01) CONTINUOUS ANSWER	BOX X
Observations: Example probes: When I asked you what you have changed about how you manage your CONDITION, you answered [ANSWER]. Please tell me in your own words what you think this question is asking. How did you come up with your answer? When did you start making (this change/these changes)? (Is this change/Are these changes) something you usually make when your CONDITION (gets better/gets worse/stays the same)? How easy or difficult was it for you to think about changes you have made in the last 3 months, as opposed to changes you may have made earlier?
	BOX X	If CONDITION #1 is diabetes or R reports taking a class at Q4, go to BOX Y. Else, go to Q5.
Observations:
	Q5	Do you know of any courses or classes in your community to help people manage (CONDITION #1)? [READ IF NECESSARY: Examples of courses and classes include exercise classes, workshops and seminars for people with (CONDITION #1), or anything else that you think could help with (CONDITION #1).]	(A) YES (B) NO (C) DON’T KNOW (D) REFUSED	Q6
Observations: Example probes: When I asked about your knowledge of courses and classes, you answered [ANSWER]. What did you think about when answering this question? How did you decide on your answer to this question? We’re interested in how you think about what “counts” as a course or class. When I asked you what you thought about when answering this question, you said [ANSWER]. Can you tell me more about what you think does count as a course or class versus what does not count as a course or class? IF R DOES NOT MENTION THE ITEMS BELOW, PROBE ABOUT EACH. Do you think [BULLETS BELOW] also count? Why or why not? Exercise classes for older adults Seminars to learn about the signs and symptoms of certain conditions Diabetes (or other condition) Health and Wellness Fair Support groups targeting people affected by certain conditions Workshops that help you learn how to manage your CONDITION Interviewer notes: Please indicate whether you read the READ IF NECESSARY help text at this item. Also indicate whether the help text clarified the meaning of the item for the respondent. Did R request guidance or clarification on the types of things we are interested in? Did R restrict his/her thinking to formalized trainings and classes, or did they also mention things like yoga, Pilates, and other exercise groups?
	Q6	Have you ever participated in a course or class on how you can manage your (CONDITION #1)?	(A) YES (B) NO (C) DON’T KNOW (D) REFUSED	A. BOX Y B. Q7 C. BOX Y D. BOX Y
Observations: Example probes: When I asked you whether you have ever participated in a course or class on how you can manage your condition you answered [ANSWER]. Please tell me about the course or class you took. What kind of course or class was it? Where did you take it? When was that? How did you decide on your answer to this question?
	Q7	There are many reasons people do not participate in a course or class to help them manage their (CONDITION #1). Why have you not attended a course or class to help you manage that condition? [PROBE: Anything else?]	(01) CONTINUOUS ANSWER	BOX Y
Observations: Example probes: How did you decide what information to share with me? When I asked you this question, did you feel any pressure to respond in a particular way? Did you think I might make a judgment about your response?
	BOX Y	If R has exactly two chronic conditions, go to Q9. Else if R has more than two chronic conditions, go to Q8. Else, go to BOX YY.
Observations:
	Q8	Earlier you told me that you have (TEXT FILL ALL CHRONIC CONDITIONS), and you told me that your (CONDITION #1) concerns you most. After your (CONDITION #1), which of your other conditions concerns you most? LIST CONDITIONS IDENTIFIED DURING THE INTERVIEW, EXCLUDING CONDITION #1.	(01) CONTINUOUS ANSWER	Next question
Observations: Example probes: Please tell me in your own words what you think this question is asking. What did you think about when answering this question? How did you decide on your answer? Interviewer notes: PROBE ONLY IF RESPONDENT EXPRESSES CONFUSION OR UNCERTAINTY ABOUT THE QUESTION. How does the respondent conceptualize “concern”? Did he/she use any specific criteria to determine which condition was most concerning?
	Q9	In the last 3 months, do you feel your (CONDITION #2, IDENTIFIED IN Q8) has gotten better, worse, or stayed the same?	(A) BETTER (B) WORSE (C) STAYED THE SAME (D) DON’T KNOW (E) REFUSED	A. Q10 B. Q10 C. Q10 D. BOX XX E. BOX XX
Observations: Example probes: When I asked if you feel that your CONDITION has gotten better, worse, or stayed the same in the last 3 months, you responded [ANSWER]. Please tell me in your own words what you think this question is asking. What factors did you consider when answering this question? How easily were you able to think about whether your CONDITION [got better/got worse/stayed the same] in the last 3 months? How did your condition change in the last 3 months? What about changes that took place more than 3 months ago? Please think about the last year. In the last year, has your condition gotten better, worse, or stayed the same? What changed? What about changes that took place less than 3 months ago? Please think about the last 3-4 weeks. In the last 3-4 weeks, has your condition gotten better, worse, or stayed the same? What changed? Interviewer notes: If the respondent is confused about how to answer this question or asks whether we want them to think about what their doctor says versus some other criteria, repeat the question emphasizing “do you feel” to indicate that we are focused on perception.
	Q10	Given that your (CONDITION #2) has (gotten better/stayed the same/gotten worse), have you changed anything about how you manage it?	(A) YES (B) NO (C) DON’T KNOW (D) REFUSED	A. Q11 B. BOX XX C. BOX XX D. BOX XX
Observations: Example probes: Please tell me in your own words what you think this question is asking. What did you think about when answering this question? What factors did you consider?
	Q11	What have you changed about how you manage your (CONDITION #2)? [PROBE: Anything else?]	(01) CONTINUOUS ANSWER	BOX XX
Observations: Example probes: When I asked you what you have changed about how you manage your CONDITION, you answered [ANSWER]. Please tell me in your own words what you think this question is asking. How did you come up with your answer? When did you start making (this change/these changes)? (Is this change/Are these changes) something you usually make when your CONDITION (gets better/gets worse/stays the same)? How easy or difficult was it for you to think about changes you have made in the last 3 months, as opposed to changes you may have made earlier?
	BOX XX	If CONDITION #2 is diabetes or R reports taking a class at Q11, go to BOX YY. Else, go to Q12.
Observations:
	Q12	Do you know of any courses or classes in your community to help people manage (CONDITION #2)? [READ IF NECESSARY: Examples of courses and classes include exercise classes, workshops and seminars for people with (CONDITION #2), or anything else that you think could help with (CONDITION #2).]	(A) YES (B) NO (C) DON’T KNOW (D) REFUSED	Q13
Observations: Example probes: When I asked about your knowledge of courses and classes, you answered [ANSWER]. What did you think about when answering this question? How did you decide on your answer to this question? We’re interested in how you think about what “counts” as a course or class. When I asked you what you thought about when answering this question, you said [ANSWER]. Can you tell me more about what you think does count as a course or class versus what does not count as a course or class? IF R DOES NOT MENTION THE ITEMS BELOW, PROBE ABOUT EACH. Do you think [BULLETS BELOW] also count? Why or why not? Exercise classes for older adults Seminars to learn about the signs and symptoms of certain conditions Diabetes (or other condition) Health and Wellness Fair Support groups targeting people affected by certain conditions Workshops that help you learn how to manage your CONDITION Interviewer notes: Please indicate whether you read the READ IF NECESSARY help text at this item. Also indicate whether the help text clarified the meaning of the item for the respondent. Did R request guidance or clarification on the types of things we are interested in? Did R restrict his/her thinking to formalized trainings and classes, or did they also mention things like yoga, Pilates, and other exercise groups?
	Q13	Have you ever participated in a course or class on how you can manage your (CONDITION #2)?	(A) YES (B) NO (C) DON’T KNOW (D) REFUSED	A. BOX YY B. Q14 C. BOX YY D. BOX YY
Observations: Example probes: When I asked you whether you have ever participated in a course or class on how you can manage your condition you answered [ANSWER]. Please tell me about the course or class you took. What kind of course or class was it? Where did you take it? When was that? How did you decide on your answer to this question?
	Q14	There are many reasons people do not participate in a course or class to help them manage their (CONDITION #2). Why have you not attended a course or class to help you manage that condition? [PROBE: Anything else?]	(01) CONTINUOUS ANSWER	BOX YY
Observations: Example probes: How did you decide what information to share with me? When I asked you this question, did you feel any pressure to respond in a particular way? Did you think I might make a judgment about your response?
	BOX YY	If R has a diabetes other than gestational diabetes go to HFP4-DIAINSUL. Else, go to END.
Observations:
DIAINSUL	HFP4	Please tell me whether you use any of the following ways to manage your diabetes. Do you… take insulin?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
DIAMEDS	HFP4	Please tell me whether you use any of the following ways to manage your diabetes. Do you… take prescription diabetes pills or oral diabetes medicine?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
DIATEST	HFP4	Please tell me whether you use any of the following ways to manage your diabetes. Do you… test your blood for sugar or glucose?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
DIASORES	HFP4	Please tell me whether you use any of the following ways to manage your diabetes. Do you… check for sores or irritations on your feet?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
DIAPRESS	HFP4	Please tell me whether you use any of the following ways to manage your diabetes. Do you… measure your blood pressure at home?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
DIAASPRN	HFP4	Please tell me whether you use any of the following ways to manage your diabetes. Do you… take aspirin regularly for your diabetes?	(01) YES (02) NO (-8) Don't Know (-9) Refused	Next question
Observations:
	NEWVAR1	Do you know of any courses or classes in your community to help people manage diabetes? [READ IF NECESSARY: Examples of courses and classes include exercise classes, workshops and seminars for people with diabetes, or anything else that you think could help with diabetes.]	(A) YES (B) NO (C) DON’T KNOW (D) REFUSED	Q16
Observations:
	NEWVAR2	Have you ever participated in a course or class on how you can manage your diabetes?	(A) YES (B) NO (C) DON’T KNOW (D) REFUSED	A. HFP18-DIATRAIN B. Q17 C. HFP19-DIAKNOW D. HFP19-DIAKNOW
Observations:
	NEWVAR3	There are many reasons people do not participate in a course or class to help them manage their diabetes. Why have you not attended a course or class to help you manage that condition? [PROBE: Anything else?]	(01) CONTINUOUS ANSWER	HFP19-DIAKNOW
Observations:
	NEWVAR4	When was the most recent time that you participated in a diabetes self-management course or class or received special training on how you can manage your diabetes? [IF THE RESPONDENT HAS GONE TO MORE THAN ONE COURSE OR TRAINING, PROBE FOR THE MOST RECENT TIME.]	(01) LESS THAN 1 YEAR AGO (02) 1 YEAR TO LESS THAN 2 YEARS AGO (03) 2 YEARS TO LESS THAN 3 YEARS AGO (04) 3 YEARS TO LESS THAN 5 YEARS AGO (05) 5 OR MORE YEARS AGO (-8) Don't Know (-9) Refused	Next question
Observations:

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 0938-1275 (expires 05/31/2021). The time required to complete this information collection is estimated to average 70 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact [email protected].

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