CMS-P-0015A Comm2017R79HHQ

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

HHQ-Home Health Utilization

Question Text/Description

Code List

Routing

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP. DO NOT
DISPLAY. DATA EDITING ONLY.
(-8) DON'T KNOW
(-9) REFUSED

(01) HH2 - PROVIDER_HHP
(02) HH18 - HHPRFRND
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) HH18 - HHPRFRND
(-9) HH18 - HHPRFRND

(01) CONTINUOUS ANSWER

BOX HH1AAA

HOME HEALTH UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C009, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
If INTTYPE in(C001, C004), administer after HHS.
If INTTYPE in(C002, C005, C006, C007, C009, C010) administer after IUQ.
SHOW CARD HH1

HHPRPROF

HH1

yes/no

(Besides what you have already mentioned,) [(Since/since) (REFERENCE
DATE/UTILDATE)/(Between/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 or medical professionals, such as those listed on this card?
[Health professionals include nurse (visiting nurse, private duty nurse, etc.), doctor, social worker, therapist, and
hospice worker.]

PROVIDER_HHP HH2

roster

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.
[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.]

BOX HH1AAA

routing

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.

Page 1 of 6

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

HHQ-Home Health Utilization

Question Text/Description

What kind of health professional is (PROVIDER NAME)?

PROVSPEC

HH3

code one

PROVSPOS

HH3

text

[SELECT THE RESPONSE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT
SPECIFICALLY NAMES THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN
PARENTHESES FOLLOWING THAT PROVIDER SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL
SPECIALTY NOT LISTED BELOW, BUT LISTED ON SHOWCARD AC1, SUCH AS ‘CARDIOLOGY,’ SELECT
'MEDICAL DOCTOR.']

HH4

(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)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(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
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED

OTHER MEDICAL PROVIDER (SPECIFY)
Who does (PROVIDER NAME) work for, that is, for what place or organization?

WORKSFOR

Code List

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

Routing

(01)-(34), (-8), (-9) HH4 - WORKSFOR
(91) HH3 - PROVSPOS

HH4 - WORKSFOR
(01) NAME OF ORGANIZATION GIVEN
(02) WORKS FOR SELF
(-8) DON'T KNOW
(-9) REFUSED

(01) HH5 - PROVIDER_HHPORG
(02) BOX HH1AA
(-8) BOX HH1AA
(-9) BOX HH1AA

(01) CONTINUOUS ANSWER

BOX HH1AA

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

BOX HH1AA

roster

routing

[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.

Page 2 of 6

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

HHQ-Home Health Utilization

Question Text/Description

Code List

Routing

(01) BOX HH1BB
(02) BOX HH1BBB
(03) BOX HH1BB
(04) BOX HH1BB
(05) BOX HH1BB
(06) BOX HH1BB
(07) BOX HH1BB
(08) BOX HH1BB
(09) BOX HH1BB
(10) BOX HH1BB
(11) BOX HH1BB
(91) HH6 - HHPLACOS
(-8) BOX HH1BB
(-9) BOX HH1BB

HHPLACE

HH6

code one

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

(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

HHPLACOS

HH6

text

OTHER (SPECIFY)

(01) CONTINUOUS ANSWER

BOX HH1BBB

routing

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.

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?

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.

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

routing

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.

OTHMEALS

HH7

BOX HH1BB

BOX HH1

VAPLACE

HH8

BOX HH1A

HMOASSOC

HMOREFER

HH10A

HH10B

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

yes/no

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

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

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).]

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

BOX HH1BB

BOX HH1A

(01) HH11 - HELPUNIT
(02) HH10B - HMOREFER
(-8) HH10B - HMOREFER
(-9) HH10B - HMOREFER

HH11 - HELPUNIT

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2017 MCBS Community Questionnaire

Variable Name

HELPUNIT

MR Screen Name

HH11

Question Type

quantity unit

HHQ-Home Health Utilization

Question Text/Description
[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

Routing

(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

(01) HH11 - HELPNUM
(02) HH11 - HELPNUM
(03) HH11 - HELPNUM
(04) HH11 - HELPNUM
(-8) HH12 - STAYUNIT
(-9) HH12 - STAYUNIT

(01) CONTINUOUS ANSWER

HH12 - STAYUNIT

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

(01) HH12 - STAYHOUR
(02) HH12 - STAYMIN
(03) HH12 - STAYHOUR
(-8) HH13 - NEEDNURS
(-9) HH13 - NEEDNURS

[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

HH12

numeric

(01) CONTINUOUS ANSWER

If HH12 - STAYUNIT = 1/HoursOnly, go to HH13 NEEDNURS.
Else go to HH12 - STAYMIN.

STAYMIN

HH12

numeric

(01) CONTINUOUS ANSWER

HH13 - NEEDNURS

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

HH14 - NEEDMEAL

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

HH15 - NEEDCARE

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

BOX HH3

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

(01) HH2 - PROVIDER_HHP
(02) HH18 - HHPRFRND
(-8) HH18 - HHPRFRND
(-9) HH18 - HHPRFRND

(01) HH2 - PROVIDER_HHP
(02) HH18 - HHPRFRND
(-8) HH18 - HHPRFRND
(-9) HH18 - HHPRFRND

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

NEEDMEAL

HH14

yes/no

(Generally speaking, did/Generally speaking, does/Did) [(PROVIDER NAME)/someone from (PROVIDER
NAME)] help with [your/(SP’s)] daily needs by doing things, such as the ones shown on this card? [HELP WITH
DAILY NEEDS MEANS HELP IN USING THE TELEPHONE, DOING HOUSEWORK, PREPARING MEALS.]
[PROBE: We just need to know in general.]
SHOW CARD HH4

NEEDCARE

HH15

yes/no

(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.]
[PROBE: We just need to know in general.]

BOX HH3

HHPMORE

HHPOMORE

HH16

HH17

routing

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.

yes/no

[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?

yes/no

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
(01) YES
(REFERENCE DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)]?
(-8) DON'T KNOW
(-9) REFUSED
[DON’T INCLUDE ANY OTHER PERSONS COMING FROM THE SAME ORG/ AGENCY LISTED BELOW]

Page 4 of 6

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

HHQ-Home Health Utilization

Question Text/Description

Code List

Routing

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP DO NOT
DISPLAY. DATA EDITING ONLY.
(-8) DON'T KNOW
(-9) REFUSED

(01) HH19 - PROVIDER_HHF
(02) BOX HH7
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX HH7
(-9) BOX HH7

(01) CONTINUOUS ANSWER

BOX HH3AA

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

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

(01) BOX HH3A
(02) HH21 - HHFRELAT
(03) BOX HH3A
(-8) BOX HH3A
(-9) BOX HH3A
(02) BOX HH3A
(03) BOX HH3A
(04) BOX HH3A
(05) BOX HH3A
(06) BOX HH3A
(07) BOX HH3A
(08) BOX HH3A
(09) BOX HH3A
(10) BOX HH3A
(11) BOX HH3A
(12) BOX HH3A
(13) BOX HH3A
(14) BOX HH3A
(51) BOX HH3A
(52) BOX HH3A
(53) BOX HH3A
(54) BOX HH3A
(55) BOX HH3A
(56) BOX HH3A
(57) BOX HH3A
(91) HH21 - HHFRELOS
(92) HH21 - HHFRELOS
(-8) BOX HH3A
(-9) BOX HH3A
BOX HH3A

SHOW CARD HH5

HHPRFRND

HH18

yes/no

(Besides what you have already talked about, [(Since/since) (REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], because of health problems [have you/has (SP)/did (SP)]
(received/receive) any personal care or help at home with daily needs from (any other) persons who (do/did) 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 HH19

roster
[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.]

BOX HH3AA

HHFTYPE

HH20

routing

code one

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.

HHFRELAT

HH21

code one

How is (PROVIDER NAME) related to [you/(SP)]?
[CLASSIFY ANY “STEP” RELATIONSHIP WITH THE RELATED “NON-STEP” RELATIONSHIP (E.G., STEPDAUGHTER = DAUGHTER).]

(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
(13) NEPHEW
(14) NIECE
(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

HHFRELOS

HH21

text

OTHER (SPECIFY)

(01) CONTINUOUS ANSWER

BOX HH3A

routing

IF HH20 - HHFTYPE = 3/Other, DK, OR RF, GO TO HH3 - PROVSPEC.
ELSE GO TO BOX HH1AA.

BOX HH6

routing

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.

yes/no

(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

HHFMORE

HH28

(01) HH19 - PROVIDER_HHF
(02) BOX HH7
(-8) BOX HH7
(-9) BOX HH7

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2017 MCBS Community Questionnaire

Variable Name

HHFOMORE

MR Screen Name

HHQ-Home Health Utilization

Question Type

Question Text/Description

Code List

Routing

HH29

yes/no

Other than the persons who have visited [you/(SP)] from (PROVIDER NAME) [since (REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you/has (SP)/did (SP)] (received/receive) personal care or help at
home with daily needs from any other persons who (do/did) not live with (you/him/her)? [DON’T INCLUDE ANY
OTHER PERSONS COMING FROM THE SAME ORG/AGENCY LISTED BELOW.]

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

(01) HH19 - PROVIDER_HHF
(02) BOX HH7
(-8) BOX HH7
(-9) BOX HH7

BOX HH7

routing

GO TO MPQ.

Page 6 of 6