Form CMS-10688 HHA Survey Instrument

Attachment II — Home Health Agency Survey Instrument
[INITIAL OR SPLASH SCREEN]
[PROGRAMMING NOTE: Survey needs to allow user to move forward without
answering questions, as we assume that some users will want to review all the
questions prior to answering them.]
NATIONAL PROVIDER SURVEY OF HOME HEALTH AGENCIES
Welcome
Thank you for agreeing to complete the National Provider Survey of Home Health
Agencies. This survey asks about your home health agency’s experience implementing
the CMS quality and efficiency measures, such as clinical processes and outcomes,
patient experience with care, patient safety, resource use or cost of care, and structural
measures. The information you provide will help CMS understand the impact of the use
of these measures and to identify opportunities for program improvement.
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 collection of information is 0938-[PLACEHOLDER FOR
NEW NUMBER]. The time required to complete this information collection is estimated
to average 60 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.
Confidentiality
This survey is conducted by the [CMS CONTRACTOR(s)]. This survey is hosted on
[CMS CONTRACTOR’s] secure website. Your answers will be kept strictly confidential
and will not be shared with any persons outside this research project.
Survey Instructions
Participation in this survey is voluntary, but we encourage you to participate, as your
home health agency was chosen at random to represent the experiences of similar
agencies. As you answer the questions, please do not use your browser’s BACK and
FORWARD buttons. Only use the BACK and NEXT buttons that are located below the
questions to move backward and forward through the questionnaire.
INSERT CONTRACTOR INSTRUCTIONS FOR WEB SURVEYS, INCLUDING
CONTACT EMAIL OR PHONE NUMBER FOR TECHNICAL ASSISTANCE.

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To begin the survey, please enter the PIN provided in the letter you received.
[PROGRAMING NOTE: ADD LINK TO DOWNLOAD PDF SURVEY]
[PROGRAMMING NOTE: THESE DEFINITIONS NEED TO BE ACCESSIBLE DURING
COMPLETION OF THE WEB SURVEY]
DEFINITION OF KEY TERMS IN THIS SURVEY
CMS quality measures: CMS home health quality measures include measures of clinical
processes and outcomes, patient experience with care, patient safety, resource use or cost of
care, and structural measures (such as a home health agency’s use of EHRs). These measures
are reported by home health agencies to the Centers for Medicare & Medicaid Services (CMS)
and can be found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits/Home-Health-Quality-Measures.html. Measures come from
patient assessment data that home health agencies routinely collect on the patients at specified
time intervals during their stay as well as Medicare claims data.
Accountable care organizations (ACO): ACOs are networks of healthcare providers and
organizations (usually hospitals and ambulatory care physician groups, and possibly including
nursing homes, home health agencies, and hospice organizations) that agree to take some
financial responsibility for reducing the costs and improving the quality of care for a defined
patient population.
Clinical decision support (CDS): CDS encompasses a variety of tools to enhance decisionmaking in the clinical workflow. These tools include computerized alerts and reminders to care
providers and patients; clinical guidelines; condition-specific order sets; focused patient data
reports and summaries; documentation templates; diagnostic support; and contextually relevant
reference information, among other tools.
Culture of safety: Organizations with a positive safety culture are characterized by
communications founded on mutual trust, by shared perceptions of the importance of safety,
and by confidence in the efficacy of preventive measures. The Agency for Healthcare Research
and Quality notes the following key features: acknowledgment of the high-risk nature of an
organization's activities and the determination to achieve consistently safe operations; a blamefree environment where individuals are able to report errors or near misses without fear of
reprimand or punishment; encouragement of collaboration across ranks and disciplines to seek
solutions to patient safety problems; and organizational commitment of resources to address
safety concerns.
Integrated delivery system (IDS): An IDS is an integrated network of healthcare providers and
organizations such as nursing homes, primary and specialty care, hospitals, rehabilitation
centers, home health care agencies, and hospice services that provides or arranges to provide
a coordinated continuum of services to a defined population. It may own or be closely aligned
with an insurance product, usually a form of managed care.
Lean/Six Sigma Engineering: Redesign or re-engineering concepts that were originally
developed to increase the efficiency of production and reduction of errors within manufacturing
companies. Lean/Six Sigma has been adopted by healthcare organizations to identify problems

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or inefficiencies and take actions to address these issues. “Lean” and “Six Sigma” emphasize
focusing on customer satisfaction, problem solving, and elimination of waste and involving
employees in identifying and resolving the problem.
Learning Organization: An organization that encourages and supports continuous employee
learning, critical thinking, and risk-taking with new ideas.
Plan, Do, Study, Act Improvement Cycles (PDSA): PDSA is a tool that is used for
accelerating quality improvement that involves developing a plan to test the change (Plan),
carrying out the test (Do), observing and learning from the consequences (Study), and
determining what modifications should be made to the test (Act).
Situation Background Assessment Recommendation (SBAR): SBAR is a standardized way
of communicating that promotes patient safety by helping individuals communicate with each
other with a shared set of expectations. Staff and physicians can use SBAR to share patient
information in a concise and structured format.
Electronic Health Record (EHR) systems. An EHR is an electronic version of a patient's
medical history that is maintained by the provider over time and may include all of the key
clinical data relevant to that person's care under a particular provider, including demographics,
progress notes, problems, medications, vital signs, past medical history, immunizations,
laboratory data, and radiology reports.

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YOUR HOME HEALTH AGENCY’S EXPERIENCE WITH CMS MEASURES
In this survey, we will ask about your home health agency’s experience with CMS quality
measures, which broadly include measures of clinical processes and outcomes, patient
experience with care, patient safety, resource use or cost of care, and use of EHRs.
1. How would you describe your home health agency’s performance on CMS quality measures
in 2019 compared to 2018?
[PROGRAMMING NOTE – MARK ONE ITEM]
1
2
3
4
5

Improved across the board on all measures
More measures improved than declined
Most measures stayed about the same
More measures declined than improved
Declined across the board on all measures

2. In your opinion, how well does your home health agency’s performance on the CMS quality
measures reflect the improvements in care that your home health agency makes?
[PROGRAMMING NOTE – MARK ONE ITEM]
1
2
3

Very well
Somewhat well
Not well at all

3. Thinking about all of the CMS home health quality measures, do you think the CMS quality
measures are clinically important?
[PROGRAMMING NOTE – MARK ONE ITEM]
1
2
3
4

Yes
Mostly yes
Mostly no
No

4. Do you think home health agencies should be held responsible for performance on the CMS
quality measures?
[PROGRAMMING NOTE – MARK ONE ITEM]
1
2
3
4

Yes
Mostly yes
Mostly no
No

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5. Have you experienced difficulties with improving performance on any of the CMS quality
measures?
[PROGRAMMING NOTE – MARK ONE ITEM]
1
2
3

Yes on many of the measures
Yes on some of the measures
No [GO TO QUESTION 8]

6. Based on your home health agency’s experience, how difficult has it been for your home
health agency to improve on the following types of measures?
[PROGRAMMING NOTE – MARK ONE FOR EACH ITEM]
----

Not
Difficult

Clinical process measures (for
example: How often the home health
team made sure that their patients
have received a flu shot for the
current flu season)
Patient outcome measures (for
example: How often patients got
better at walking or moving around?)
Patient experience measures (for
example: Home Health CAHPS
Survey measure “How often the
home health team gave care in a
professional way”)
Patient safety measures (for
example: How often the home health
team checked patients’ risk of falling)
Other (please specify): [TEXT BOX
140 CHARACTERS]

Slightly
Difficult

Moderately
Difficult

Difficult

Very
Difficult

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7. Have any of the following contributed to your home health agency’s difficulties with
improving performance on the CMS measures?
[PROGRAMMING NOTE – MARK ONE FOR EACH ITEM A-N]
a. Difficulty identifying improvement strategies .................................... Yes

No

b. Difficulty implementing improvement strategies ............................... Yes

No

c. Difficulty identifying processes of care that lead to
improved patient outcomes .............................................................. Yes

No

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d. Difficulty getting front-line staff to change behavior to improve
performance .................................................................................... Yes

No

e. Insufficient staffing to implement quality improvement strategies ..... Yes

No

f.

Inadequate health information technology (IT) capabilities
(e.g., clinical decision support or longitudinal tracking of
outcomes, or electronic medication administration system) ………. Yes

No

g. Staff turnover ................................................................................... Yes

No

h. Lack of senior leadership support .................................................... Yes

No

i.

Difficulty with coding or documentation (e.g., inconsistent or
insufficient documentation by staff) .................................................. Yes

No

Lack of training on improvement processes ..................................... Yes

No

k. A difficult patient mix (e.g., low socioeconomic status,
clinically complex) ............................................................................ Yes

No

j.

l.

Your home health agency’s organizational culture not supporting
improvement efforts ......................................................................... Yes

No

m. Inability to retrieve timely data from CMS or data from other
providers such as hospitals............................................................... Yes

No

n. Other reason (please specify): [TEXT BOX 140 CHARACTERS] ..... Yes

No

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INNOVATIONS IN THE DELIVERY OF CARE
8. We are interested in understanding what changes your home health agency has made in
the way care is being delivered to improve its performance on CMS quality measures.
[PROGRAMMING NOTE: IF “YES” RESPONSE IN COLUMN (I) A RESPONSE IS
ALLOWED IN COLUMN (II). IF “NO” RESPONSE IN COLUMN (I) A RESPONSE IS NOT
ALLOWED IN COLUMN (II). IF “YES” RESPONSE IN COLUMN (II) A RESPONSE IS
ALLOWED IN COLUMN (III). IF “NO” RESPONSE IN COLUMN (II) A RESPONSE IS NOT
ALLOWED IN COLUMN (III]
(I)
(II)
(III)
Type of change or
Has your home
Was this change
Did the change
innovation
health agency
implemented to
help performance
implemented
improve
on CMS quality
this change?
performance on CMS measures?
quality measures?
Organizational Culture
a. Adopted practices to
☐ Yes →
☐ Yes, mostly →
☐ Yes, definitely
become a “learning
☐ Yes, somewhat
☐ No ↓
☐ Yes, partly →
organization” that
☐ No
☐ No ↓
encourages and
☐ Don’t know/Not
supports continuous
sure
employee learning,
critical thinking, and
risk-taking with new
ideas.
b. Implemented a “culture ☐ Yes →
of safety” characterized ☐ No ↓
by communications
founded on mutual
trust, by shared
perceptions of the
importance of safety,
and by confidence in
the efficacy of
preventive measures.
Health Information Technology
c. Implemented an
☐ Yes →
electronic health record ☐ No ↓
(EHR).

d. Implemented electronic
tools to support
frontline clinical staff,
such as clinical
decision support, or
medication
administration system.

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure
☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

7

Type of change or
innovation

e. Implemented systems
for electronically
exchanging clinical
information with
providers in the
community (e.g., other
post-acute care
providers, hospitals and
ambulatory care
providers).
Care Process Redesign
f. Implemented risk
prediction tools to
identify and manage
high-risk patients.
g. Implemented
standardized care
protocols or checklists.

h. Implemented
telemonitoring or
remote patient
monitoring
i. Adopted care
redesign/re-engineering
(e.g., Lean
Engineering; Six
Sigma; Plan, Do,
Study, Act
improvement cycles).
j. Implemented
interdisciplinary rounds,
case conferences, or
multispecialty patient
care teams.

(I)
Has your home
health agency
implemented
this change?

(II)
Was this change
implemented to
improve
performance on CMS
quality measures?
☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

(III)
Did the change
help performance
on CMS quality
measures?

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure
☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure
☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure
☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes →
☐ No ↓

8

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

Type of change or
innovation

k. Implemented or
changed
communication
protocols to support or
improve collaboration
between referring
providers and agency
staff
l. Increased coordination
with hospitals, nursing
homes, and other
providers to improve
care transitions and
reduce hospitalization
rates.
m. Increased number of
visits at beginning of
care episode (i.e.,
“frontloading”) so that
patients have greater
contact with clinicians
earlier in care episode.
n. Addition of after-hours
on-call availability to
patients.

(I)
Has your home
health agency
implemented
this change?

(II)
Was this change
implemented to
improve
performance on CMS
quality measures?
☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

(III)
Did the change
help performance
on CMS quality
measures?

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure
☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes →
☐ No ↓

Feedback and Monitoring of Performance
o. Developed a system for ☐ Yes →
tracking patient
☐ No ↓
outcomes.

p. Provided routine
feedback on your home
health agency’s
performance on CMS
measures to nurses,
physical therapists, and
other staff.

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

9

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

Type of change or
innovation

(I)
Has your home
health agency
implemented
this change?

Changing Provider Incentives
q. Used performance on
☐ Yes →
CMS measures as a
☐ No ↓
basis for determining
pay for nurses or other
frontline staff.
r. Implemented an internal
incentive or bonus
program for senior
management based on
performance on CMS
measures.
s. Gave staff awards or
other special
recognition tied to
quality performance.
Changes in Staffing
t. Increased the number of
staff dedicated to
quality improvement or
quality management.
u. Identified champions
for quality improvement
initiatives or projects
among clinical staff.

v. Implemented changes
to how clinical staff are
deployed (e.g., change
in staffing levels or
clinical roles/
responsibilities).

(II)
Was this change
implemented to
improve
performance on CMS
quality measures?

(III)
Did the change
help performance
on CMS quality
measures?

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure
☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure
☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

10

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

Type of change or
innovation

(I)
Has your home
health agency
implemented
this change?

Obtained Technical Assistance
w. Obtained technical
☐ Yes →
assistance from CMS
☐ No ↓
(e.g., via a CMS Quality
Improvement
Organization or the
CMS Home Health
Quality Improvement
initiative) to collect and
report CMS quality
measures.
x. Obtained technical
☐ Yes →
assistance from private ☐ No ↓
organizations (e.g.,
quality improvement
collaboratives,
consulting firms).
Provider Education and Training
y. Implemented quality
☐ Yes →
improvement initiatives ☐ No ↓
targeted to specific
CMS measures.
z. Provided training to
nurses, physical
therapists, and other
clinical staff on quality
improvement
strategies.
a1. Provided training to
clinical staff on
teaching patient selfmanagement
techniques.
Other Improvements
b1. Other change or
innovation. (please
specify): [TEXT BOX
140 CHARACTERS]

(II)
Was this change
implemented to
improve
performance on CMS
quality measures?

(III)
Did the change
help performance
on CMS quality
measures?

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure
☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

☐ Yes →
☐ No ↓

☐ Yes, mostly →
☐ Yes, partly →
☐ No ↓

☐ Yes, definitely
☐ Yes, somewhat
☐ No
☐ Don’t know/Not
sure

11

FACTORS ASSOCIATED WITH CHANGE IN QUALITY PERFORMANCE
9. There are many factors that influence a home health agency’s decision to invest in efforts to
improve its quality performance. Please rank the importance of the following six external
factors in your home health agency’s decision to invest in quality improvement efforts for
CMS measures.
(Please rank by order of importance where 1 is the most important and 6 is the least
important. Do not use the same rank number more than once)
[PROGRAMMING NOTE: 0–6 ITEMS IN A–F CAN HAVE ONE RESPONSE]

_____ a. Potential to receive financial incentives for improved performance (i.e., pay for
performance)
_____ b. Risk of financial penalties for low performance (e.g., nonpayment for home health
agency readmissions within 30 days or for home health agency-acquired infections)
_____ c. Public reporting of your home health agency’s performance results on the CMS
Home Health Compare website
_____ d. Participation in alternative payment models (e.g., ACOs, bundled payment
arrangements) or managed care contracts where there is an opportunity for shared
reward (savings) and shared financial risk
_____ e. State or federal regulatory requirements regarding certification/accreditation
_____ f. Addition of Quality Assessment and Performance Improvement (QAPI)
requirements to conditions of participation

10. Has your home health agency improved its performance on any of the CMS measures?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes
No [GO TO QUESTION 11]

12

10a. Many different factors may help a home health agency improve its performance. How
important are the factors below in helping your agency improve performance on CMS
measures?
[PROGRAMMING NOTE - MARK ONE FOR EACH ITEM A-I]
----

Not
Important

Slightly
Important

Moderately
Important

Important

Very
Important

Not
applicable

a. Your home
health agency’s
organizational
culture
b. Effective
relationship
between
management and
staff
c. Internal
accountability for
performance on
CMS measures
d. Having strong
data systems
e. Having a
system-wide focus
on quality and
quality
improvement
f. Networking with
other home health
agencies and
health systems to
identify elements
of high-performing
organizations
g. Investments in
patient safety

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h. Focus on
improved
documentation
i. Other (please
specify): [TEXT
BOX 140
CHARACTERS]

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13

CHALLENGES TO REPORTING THE CMS MEASURES
11. Has your agency experienced any of the following challenges in submitting and reporting
OASIS data (for CMS measures)?
[PROGRAMMING NOTE - MARK ONE OR MORE]
1
2
3
4
5
6
7

Difficulty extracting the data from the EHR or other data systems/registries for OASIS
Difficulty interpreting measure specifications
Frequency of OASIS version changes
Insufficient or inadequate staffing or other resources
Challenges with interface for transmitting OASIS data
Other reason (please specify): [TEXT BOX 140 CHARACTERS]
Has not experienced any difficulties

UNDESIRED EFFECTS OF CMS QUALITY MEASUREMENT PROGRAMS
The use of quality and efficiency measures may result in undesired effects. The next questions
ask about your home health agency’s knowledge of or experience with undesired effects of the
CMS measures and their use in public reporting and pay for performance. All of the responses
you provide are confidential and are intended to help CMS in modifying reporting programs so
as to avoid the programs’ causing undesired effects. Responses to these questions will be
aggregated across all home health agencies. CMS will not see identifiable data from any
individual home health agency. Your candid feedback is important in helping CMS improve
these programs so that they work well for providers and their patients.
12. Has your home health agency observed any undesired effects stemming from using or
reporting CMS measures?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2
3

Yes, definitely
Yes, somewhat
No

14

13. In your opinion, do you think any of the following has occurred in your home health agency
as a result of your home health agency being held accountable for performance on CMS
measures?
[PROGRAMMING NOTE - MARK ONE FOR EACH ITEM A-F]
a. Fewer resources for quality improvement in areas of clinical
care that are not the focus of CMS performance measures ............. Yes

No

b. Focus on narrow improvement for specific measures rather
than across the board improvement in care ..................................... Yes

No

c. Overtreatment of patients to ensure that a measure is met .............. Yes

No

d. Increased focus on documentation or coding of data to attain
a higher score .................................................................................. Yes

No

e. Changing coding of data or documentation to ensure that
a measure is met ............................................................................. Yes

No

f.

Avoiding sicker or more challenging patients when
providing care .................................................................................. Yes

No

14. Have the changes your home health agency has made in response to the CMS measures
resulted in broader improvements in areas of care beyond what is measured by the CMS
quality measures?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2
3

Yes
No [GO TO QUESTION 16]
Don’t know [GO TO QUESTION 16]

15. Has your home health agency measured or documented the actual improvements in the
areas of care not measured by CMS?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes
No

15

PERSPECTIVES OF YOUR HOME HEALTH AGENCY’S LEADERSHIP AND OTHER
STAKEHOLDERS
16. Does your home health agency have a board of directors?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes
No [GO TO QUESTION 20]

17. How often do meetings of your home health agency’s board of directors include a review and
discussion of the home health agency’s performance on the CMS measures?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2
3
4
5

More than four times per year
Quarterly
Twice per year
Annually
Less than once per year

18. Which of the following best describes your home health agency’s board of directors?
[PROGRAMMING NOTE - MARK ONE ITEM]
1

2

3

Board is more engaged in financial performance issues than quality performance
issues.
Board is equally engaged in financial performance issues and quality performance
issues.
Board is more engaged in quality performance issues than financial performance
issues.

19. On a scale from 0 to 10, where 0 is not at all supportive and 10 is extremely supportive, how
would you describe your home health agency’s board of directors’ support of your home
health agency’s efforts to improve performance on CMS measures? Please check a
number.
[PROGRAMMING NOTE - MARK ONE ITEM]
Not at all
supportive
0

-1

-2

-3

Somewhat
supportive
4

5

16

6

-7

-8

-9

Extremely
supportive
10

20. On a scale from 0 to 10, where 0 is not at all supportive and 10 is extremely supportive, how
would you describe the home health agency leadership’s (e.g., the C-Suite executive
management) support of your home health agency’s efforts to improve performance on
CMS measures? Please check a number.
[PROGRAMMING NOTE - MARK ONE ITEM]
Not at all
supportive
0

Somewhat
supportive
1

2

3

4

5

Extremely
supportive
6

7

8

9

10

21. On a scale from 0 to 10, where 0 is not at all supportive and 10 is extremely supportive, how
would you describe the clinical staff’s support of your home health agency’s efforts to
improve performance on CMS measures? Please check a number.
[PROGRAMMING NOTE - MARK ONE ITEM]

Not at all
supportive
0

--1

--2

--3

Somewhat
supportive
4

5

6

--7

--8

--9

Extremely
supportive
10

22. On a scale from 0 to 10, where 0 is not at all and 10 is a great deal, how much does your
home health agency leadership promote a culture of quality? Please check a number.
[PROGRAMMING NOTE - MARK ONE ITEM]
Not at all
0

Somewhat
--1

--2

--3

4

5

17

6

--7

--8

--9

Great
deal
10

USE OF HEALTH INFORMATION TECHNOLOGY
These next questions are about your home health agency’s use of, and outside providers’
access to, Health Information Technology
23. Does your home health agency have an electronic health record (EHR)?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes
No [GO TO QUESTION 29]

24. Is your home health agency able to receive physician orders using its EHR?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes
No

25. Are healthcare providers in your community (e.g., ambulatory care physicians, hospitals,
other clinicians, and post-acute providers) able to access or electronically receive key
patient clinical data from your home health agency’s EHR or health information system?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2
3

Yes, all key clinical data
Yes, some key clinical data
No [GO TO QUESTION 27]

26. Which of the following types of information are healthcare providers in your community (e.g.
ambulatory care physicians, hospitals, other clinicians, and post-acute providers) able to
access or electronically receive from your home health agency’s EHR or health information
system?
[PROGRAMMING NOTE - MARK ONE FOR EACH ITEM A-D]

a. Diagnostic/treatment summary

Yes, All

Yes, Some

No

b. Discharge instructions

Yes, All

Yes, Some

No

c. Lab tests/imaging results

Yes, All

Yes, Some

No

d. Prescribed medications

Yes, All

Yes, Some

No

18

27. Is your home health agency able to electronically access information on your patients from
other providers in your community (e.g., ambulatory care physicians, hospitals) via health
information exchange, a common EHR system, or other methods?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2
3

Yes, for all or most patients
Yes, for some patients
No

28. Does your home health agency’s EHR have an interface or other tools that help with …
[PROGRAMMING NOTE - MARK ONE FOR EACH ITEM A-G]
a. Medication tracking and reconciliation?

Yes

No

b. Evidence-based treatment or clinical decision support?

Yes

No

c. Collection of data for CMS measures
(including OASIS “scrubbing” programs)?

Yes

No

d. Software prompts or validation to improve OASIS accuracy?

Yes

No

e. Reporting of CMS measures?

Yes

No

f. Tracking or monitoring of quality of care
and/or patient outcomes?

Yes

No

g. Administration of medication?

Yes

No

h. Allowing patients access to key clinical information
and care guidance via a secure patient portal? ........................... Yes

No

29. Not including an EHR, does your home health agency use any other software or electronic
tools that help with …
[PROGRAMMING NOTE - MARK ONE FOR EACH ITEM A-B]

a. Collection of data for OASIS (including “scrubbing” programs for OASIS data)?
.............................................................................................. Yes

No

b. Reporting of CMS measures? ............................................... Yes

No

19

CHARACTERISTICS OF YOUR HOME HEALTH AGENCY
These next questions will help us to describe the home health agencies that participate in this
survey.

30. Is your home health agency freestanding (and not owned by or affiliated with a larger
system/chain, hospital, or integrated delivery system)?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes, freestanding [GO TO QUESTION 34]
No, owned by or affiliated with a larger entity

31. Is your home health agency affiliated with or owned by a home health agency system or
chain?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes
No

32. Is your home health agency owned by a hospital?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes
No

33. Is your home health agency part of an integrated delivery system?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes
No

20

34. Do you face a shortage of nurses, physical therapists, or other practicing clinicians in your
area?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes
No

35. Does your home health agency participate in any of the following types of Accountable Care
Organizations (ACOs)?
[PROGRAMMING NOTE - MARK ONE FOR EACH ITEM A-F]
a. Medicare Shared Savings Program………………………………Yes
b. Medicare Pioneer ACO .......................................................... Yes

No
No

c. Medicare’s Advanced Payment Model ACO ........................... Yes

No

d. Medicare’s Next Generation ACO Model ................................ Yes

No

e. Medicaid ACO ........................................................................ Yes

No

f. A private, commercially insured ACO arrangement
(within an HMO or PPO) ....................................................... Yes

No

36. Is your home health agency participating in any other type of alternative payment model that
may have shared savings or shared risk (e.g., global budgets, bundled payments for
selected procedures)?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes
No

37. Does your home health agency participate in other non-CMS quality and efficiency measure
reporting programs sponsored by:
[PROGRAMMING NOTE - MARK ONE FOR EACH ITEM A-D]
a. Medicaid …………………………………………………………. Yes

No

b. The state where your home health agency is located ............. Yes

No

c. Commercial insurers ............................................................. Yes

No

d. Employer or multistakeholder collaboratives .......................... Yes

No

21

38. Across your home health agency’s entire book of business, approximately what percentage
of your patients use the following forms of health insurance? (Please provide your best
estimate. Your percentages should sum to 100%.) In addition, please indicate whether you
conduct OASIS assessments on patients with each form of insurance.
[PROGRAMMING NOTE – PERCENTAGES MUST SUM TO 100]

Form of Health Insurance

Medicare only (excluding Medicare Advantage)

Are patients with this
Percentage health insurance assessed
using OASIS? (Yes/No)
of patients

Medicare Advantage
Medicaid only and dual eligible (Medicare and
Medicaid)
Commercial insurance
Veterans Health Administration
Private pay
Uninsured/self-pay patients
TOTAL

100%

N/A

RESPONDENT BACKGROUND
38. Which of the following best describes your job title or position within this home health
agency?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2
3
4
5
6
7

Chief Executive Officer
Administrator
Director of Nursing
Senior leader responsible for quality of clinical care (e.g., VP for Quality)
Clinical Manager
Member of a team responsible for measuring and reporting quality of clinical care
Some other role (please specify): [TEXT BOX 140 CHARACTERS]

39. How many years have you been in your current position within this home health agency?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2
3

Less than one year
One to three years
More than 3 years

22

40. Do you have a clinical background?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes, indicate clinical background: [TEXT BOX 140 CHARACTERS]
No

41. Has your home health agency quality team received formal training/certification on quality
improvement strategies (e.g., CMS Home Health Quality Initiative educational programs or
Institute for Healthcare Improvement training courses, which include courses for Plan-DoStudy-Act cycles)?
[PROGRAMMING NOTE - MARK ONE ITEM]

1
2

Yes, indicate strategy and certification: [TEXT BOX 140 CHARACTERS]
No

42. Did anyone else help you complete this survey?
[PROGRAMMING NOTE - MARK ONE ITEM]
1
2

Yes [GO TO QUESTION 43a]
No [GO TO END SCREEN]

43a. What is the job title or position of the person or persons who helped you complete
the survey?

[TEXT BOX 140 CHARACTERS]
[GO TO END SCREEN]

[PROGRAMMING NOTE – DISPLAY AS END SCREEN]
Thank you for taking the time to complete this survey.
PRESS ENTER TO SUBMIT YOUR ORGANIZATION’S DATA

23