CMS-P-0015A Comm2017R79IUQ

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

IUQ-Institutional Utilization

Question Text/Description

Code List

Routing

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

(01) IU2 - PROVIDER_IU
(02) BOX IU3
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX IU3
(-9) BOX IU3

INSTITUTIONAL 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
Administer after OPQ.
SHOW CARD IU1

IUPROBE

IU1

yes/no

[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?
LONG-TERM CARE PLACES INCLUDE SKILLED NURSING HOMES, INTERMEDIATE CARE FACILITIES,
BOARD AND CARE HOMES, NURSING HOME UNITS IN HOSPITALS, FACILITIES FOR THE
INTELLECTUALLY DISABLED, PSYCHIATRIC FACILITIES AND GROUP HOMES.
[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?
PROVIDER_IU

IU2

roster

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.

IF EXISTING PROVIDER SELECTED, GO TO BOX
IU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO IU2PROVNAME

(01) continuous answer

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]

PROVNAME

IU2

verbatim

YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT
YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE
GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.

IU2-GROUPNAM

NAME:
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]

GROUPNAM

IU2

BOX IU1

BOX IU1

GROUP:

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 IU3 VAPLACE.
ELSE TO IU4 - EVBEGMM.

VAPLACE

IU3

yes/no

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

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

IU4

date
Admission Date:

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

IU4 - EVBEGMM

(01) continuous answer
(-8) Don't Know
(-9) Refused

IU4 - EVBEGDD

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2017 MCBS Community Questionnaire

IUQ-Institutional Utilization

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

EVBEGDD

IU4

date

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

(01) continuous answer
(-8) Don't Know
(-9) Refused

IU4 - EVBEGYY

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

(01) continuous answer
(-8) Don't Know
(-9) Refused

IU4 - EVENDMM

(01) continuous answer
(-8) Don't Know
(-9) Refused

IU4 - EVENDDD

EVBEGYY

IU4

date

EVENDMM

IU4

date

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

EVENDDD

IU4

date

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

(01) continuous answer
(-8) Don't Know
(-9) Refused

IU4 - EVENDYY

EVENDYY

IU4

date

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

(01) continuous answer
(-8) Don't Know
(-9) Refused

IU7 - IUMORE

(01) ADD ANOTHER
(02) ALL DONE

(01) IU4-EVBEGMM
(02) IU4B-NAVIGATOR

HAVE ALL DATES BEEN ENTERED?
IPADD

IU4B

choose one
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

NAVIGATOR

IU4_IN

YOU HAVE ENTERED DATES FOR THE FOLLOWING EVENTS. SELECT AN EVENT TO DISCUSS WITH SP (01) EVENT1
OR PRESS [PREVIOUS] TO GO BACK AND ADD MORE EVENTS.
(02) EVENT2
…
instance navigator
[DISPLAY ALL EVENTS ADDED AT IP4]
(N) EVENT N
[EVENT DATE, PROVIDER]
(N+1) CONTINUE INTERVIEW

(01-N) BOX IU3
(N+1) IP16-IUMORE

IF RESPONDENT HAS ALREADY MENTIONED ANOTHER STAY AT A NURSING HOME, ENTER “YES”
WITHOUT ASKING. OTHERWISE, ASK:
IUMORE

IU7

yes/no

(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], [have you had/has (SP) had/did (SP) have] any other stays in this or any (-8) Don't know
other nursing home or similar place that provides long-term care?
(-9) Refused

(01) IU2 - PROVIDER_IU
(02) BOX IU3
(-8) BOX IU3
(-9) BOX IU3

[ENTER A STAY AT A DRUG AND REHABILITATION CENTER AS AN IP EVENT, NOT AN IU EVENT.]

BOX IU3

routing

IF INTTYPE in(C001, C004, C009), GO TO HHS.
IF INTTYPE in(C002, C005, C006, C007, C010), GO TO HHQ.

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