CMS-P-0015A Institutional Utilization

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

IUQ - INSTITUTIONAL UTILIZATION

Question Type

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, 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?
SELECT OR ADD ONLY ONE FACILITY.
PROVIDER_IU

IU2

roster

[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE INSTITUTION.]
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING AN
EVENT WITH THAT PROVIDER

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.

(01-N) BOX IU1
(N+1) IU2-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX
IU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO IU2PROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPLCHNGSPL.

(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

YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
NAME:
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
GROUPNAM

IU2

GROUP:

BOX IU1

roster

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND SELECT 2. [PROVIDER 2]
"ADD ANOTHER."
…
N. [PROVIDER N]
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF YOU
ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO SELECT OR ADD DISPLAY PROVIDER NAME, SPECIALITY, GROUP
THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.

CRCTSPL-CRCTSPL

verbatim

WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND SELECT
(01) [Continuous Answer]
"ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

BOX IU1

WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CRCTSPL

CHNGSPL

CRCTSPL

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2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

BOX IU1

IUQ - INSTITUTIONAL UTILIZATION

Question Type

routing

Question Text/Description

Code List

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.

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

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

VAPLACE

IU3

yes/no

EVBEGMM

IU4

date

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

EVBEGYY

IU4

date

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

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

IU4 - EVENDMM

EVENDMM

IU4

date

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

IU4 - EVENDDD

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

IU4 - STLLINST

STLLINST

IU4

date

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

(01) SP IS STILL IN FACILITY
(-7) Empty

IU4B-IUADD

IUADD

IU4B

choose one

(01) ADD ANOTHER
(02) ALL DONE

(01) IU4-EVBEGMM
(02) IU7-IUMORE

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

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

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

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

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF RESPONDENT HAS ALREADY MENTIONED ANOTHER STAY AT A NURSING HOME, ENTER “YES” WITHOUT
ASKING. OTHERWISE, ASK:

IUMORE

IU7

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you had/has (SP) had/did (SP) have] any other stays in this or any other
nursing home or similar place that provides long-term care?

IU4 - EVBEGMM

IU4 - EVBEGDD

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

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