Form CMS-10694 GenIC 1 CMS-10694 GenIC 1 CAHPS® Hospice Survey

CAHPS^® Hospice Survey

Please answer the survey questions about the care the patient listed on the survey cover letter received from this hospice:

[NAME OF HOSPICE]

All of the questions in this survey will ask about experiences with this hospice.

If you want to know more about this survey, please call [TOLL FREE NUMBER]. All calls to this number are free.

CAHPS^® Hospice Survey

Who Should Fill Out the Survey?

• The person in your household who knows the most about the hospice care received by the patient listed on the survey cover letter.

How to Fill Out the Survey

• Please use a dark colored pen.

• Please put an X inside the square by your answer, like this:

Yes

No

• At times you will be asked to skip some questions. When this happens you will see an arrow with a note that tells you where to go next, like this:

Yes  If Yes, Go to Question 1

No

_____________________________________________________________________

The Hospice Patient

1. How are you related to the patient listed on the survey cover letter?

¹ My spouse or partner

² My parent

³ My mother-in-law or father-in-law

⁴ My grandparent

⁵ My aunt or uncle

⁶ My sister or brother

⁷ My child

⁸ My friend

⁹ Other (please print):

2. For this survey, the phrase "family member" refers to the patient listed on the survey cover letter.

In what locations did your family member receive care from this hospice? Please choose one or more.

¹ Home

² Assisted living facility

³ Nursing home

⁴ Hospital

⁵ Hospice facility/hospice house

⁶ Other (please print):

Your Role

3. While your family member was in hospice care, how often did you take part in or oversee care for him or her?

¹ Never  If Never, go to Question 37

² Sometimes

³ Usually

⁴ Always

Your Family Member’s Hospice Care

For the rest of the questions, please think only about your family member's experience with the hospice listed on the survey cover.

4. For this survey, the hospice team means all the nurses, doctors, social workers, chaplains and others who gave hospice care to your family member.

While your family member was in hospice care, did you need to contact anyone on the hospice team during evenings, weekends, or holidays for questions or help?

¹ Yes

² No  If No, go to Question 6

5. How often did you get the help you needed from the hospice team during evenings, weekends, or holidays?

¹ Never

² Sometimes

³ Usually

⁴ Always

6. How often did the hospice team let you know when they would arrive to care for your family member?

¹ Never

² Sometimes

³ Usually

⁴ Always

7. When you or your family member asked for help from the hospice team, how often did you get help as soon as you needed it?

¹ Never

² Sometimes

³ Usually

⁴ Always

8. How often did the hospice team explain things in a way that was easy to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

9. How often did the hospice team keep you informed about your family member’s condition?

¹ Never

² Sometimes

³ Usually

⁴ Always

10. How often did the hospice team treat your family member with dignity and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

11. How often did you feel that the hospice team really cared about your family member?

¹ Never

² Sometimes

³ Usually

⁴ Always

12. Did you talk with the hospice team about any problems with your family member’s hospice care?

¹ Yes

² No  If No, go to Question 14

13. How often did the hospice team listen carefully to you when you talked with them about problems with your family member’s hospice care?

¹ Never

² Sometimes

³ Usually

⁴ Always

14. While your family member was in hospice care, did he or she have any pain?

¹ Yes

² No  If No, go to Question 16

15. Did your family member get as much help with pain as he or she needed?

¹ Yes, definitely

² Yes, somewhat

³ No

16. While your family member was in hospice care, did he or she ever have trouble breathing or receive treatment for trouble breathing?

¹ Yes

² No  If No, go to Question 18

17. How often did your family member get the help he or she needed for trouble breathing?

¹ Never

² Sometimes

³ Usually

⁴ Always

18. While your family member was in hospice care, did he or she ever have trouble with constipation?

¹ Yes

² No  If No, go to Question 20

19. How often did your family member get the help he or she needed for trouble with constipation?

¹ Never

² Sometimes

³ Usually

⁴ Always

20. While your family member was in hospice care, did he or she show any feelings of anxiety or sadness?

¹ Yes

² No  If No, go to Question 22

21. How often did your family member get the help he or she needed from the hospice team for feelings of anxiety or sadness?

¹ Never

² Sometimes

³ Usually

⁴ Always

Your Own Experience with Hospice

22. Hospice teams may teach you how to care for family members who need pain medicine, have trouble breathing, are restless or agitated, or have other care needs.

Did the hospice team teach you how to care for your family member?

¹ Yes, definitely

² Yes, somewhat

³ No

⁴ I did not need this teaching

23. While your family member was in hospice care, how often did the hospice team listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

24. Did the hospice team give you as much information as you wanted about what to expect while your family member was dying?

¹ Yes, definitely

² Yes, somewhat

³ No

25. Support for religious or spiritual beliefs includes talking, praying, quiet time, or other ways of meeting your religious or spiritual needs.

While your family member was in hospice care, how much support for your religious and spiritual beliefs did you get from the hospice team?

¹ Too little

² Right amount

³ Too much

26. While your family member was in hospice care, how much emotional support did you get from the hospice team?

¹ Too little

² Right amount

³ Too much

27. In the weeks after your family member died, how much emotional support did you get from the hospice team?

¹ Too little

² Right amount

³ Too much

Overall Rating of Hospice Care

28. Please answer the following questions about the hospice named on the survey cover. Do not include care from other hospices in your answers.

Using any number from 0 to 10, where 0 is the worst hospice care possible and 10 is the best hospice care possible, what number would you use to rate your family member’s hospice care?

⁰ 0 Worst hospice care possible

¹ 1

² 2

³ 3

⁴ 4

⁵ 5

⁶ 6

⁷ 7

⁸ 8

⁹ 9

¹⁰ 10 Best hospice care possible

29. Would you recommend this hospice to your friends and family?

¹ Definitely no

² Probably no

³ Probably yes

⁴ Definitely yes

Additional Questions About Hospice Care

This next set of questions will give the hospice additional feedback about your family member’s hospice care.

30. Did the hospice team make an effort to listen to the things that matter most to you or your family member?

¹ Yes, definitely

² Yes, somewhat

³ No

31. Did the hospice team ever talk with you or your family member about what was important in his or her care?

¹ Yes, definitely

² Yes, somewhat

³ No

32. Did the hospice team provide care that respected your family member's wishes?

¹ Yes, definitely

² Yes, somewhat

³ No

33. Did the hospice team do anything that went against your family member's wishes?

¹ Yes, definitely

² Yes, somewhat

³ No

34. How often did the hospice team treat your family member’s loved ones with respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

35. Cultural traditions include holidays, festivals, foods, languages, and other practices shared by a group of people.

Did the hospice team respect you or your family member’s cultural traditions?

¹ Yes, definitely

² Yes, somewhat

³ No

⁴ This was not needed

36. How often was your family member treated unfairly by the hospice team because of their race or ethnicity?

¹ Never

² Sometimes

³ Usually

⁴ Always

About Your Family Member

37. What is the highest grade or level of school that your family member completed?

¹ 8^th grade or less

² Some high school but did not graduate

³ High school graduate or GED

⁴ Some college or 2-year degree

⁵ 4-year college graduate

⁶ More than 4-year college degree

⁷ Don’t know

37. Was your family member of Hispanic, Latino, or Spanish origin or descent?

¹ No, not Spanish/Hispanic/Latino

² Yes, Puerto Rican

³ Yes, Mexican, Mexican American, Chicano/a

⁴ Yes, Cuban

⁵ Yes, Other Spanish/Hispanic/ Latino

37. What was your family member’s race? Please choose one or more.

¹ White

² Black or African American

³ Asian

⁴ Native Hawaiian or other Pacific Islander

⁵ American Indian or Alaska Native

About You

37. What is your age?

¹ 18 to 24

² 25 to 34

³ 35 to 44

⁴ 45 to 54

⁵ 55 to 64

⁶ 65 to 74

⁷ 75 to 84

⁸ 85 or older

37. Are you male or female?

¹ Male

² Female

37. What is the highest grade or level of school that you have completed?

¹ 8^th grade or less

² Some high school but did not graduate

³ High school graduate or GED

⁴ Some college or 2-year degree

⁵ 4-year college graduate

⁶ More than 4-year college degree

37. What language do you mainly speak at home?

¹ English

² Spanish

³ Chinese

⁴ Russian

⁵ Portuguese

⁶ Vietnamese

⁷ Polish

⁸ Korean

⁹ Some other language (please print):

37. This question allows you to say more about your family member's hospice care.

In thinking about your experiences with the hospice, was there anything that went well or that you wish had gone differently? Please explain what happened, how it happened, and how it felt to you.

THANK YOU

Please return the completed survey in the postage-paid envelope.

[NAME OF SURVEY VENDOR]

[RETURN ADDRESS OF SURVEY VENDOR]

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