Form CMS-10784 Home Health Care CAHPS Mail Survey

HOME HEALTH CARE CAHPS®
SURVEY

OMB #: TBD
Expires: TBD

SURVEY INSTRUCTIONS
•

Answer all the questions by checking the box to the left of your answer.

•

If you are answering for someone who received home health care, please try to answer
questions from his or her point of view.

•

Sometimes you can skip some questions in this survey. When this happens, you will see an arrow
with a note that tells you what question to answer next, like this:
Yes
No

If No, skip to Q1.

1

4

YOUR HOME HEALTH CARE
1

2

According to our records, you got care
from the home health agency, [AGENCY
NAME]. Is that right?
1

Yes

2

No If No, please stop and return
the survey in the envelope
provided.

As you answer the rest of the questions in
this survey, think only about your
experience with [AGENCY NAME].
When you first started getting home health
care from this agency, did you get the
information you needed about what care
and services you would get?
1

Yes

2

No

3

Not sure

5

6

YOUR CARE FROM HOME HEALTH
STAFF
These next questions are about all the different
staff from [AGENCY NAME]. Do not include
care you got from staff from another home
health care agency.
3

When you first started getting home health
care from this agency, did someone from
the agency talk about ways to help make
your home safer? For example, they may
have suggested adding grab bars in the
shower or removing tripping hazards.
1

Yes

2

No

3

I don’t know

4

I did not need help with home safety

7

2

Has someone from the agency ever
reviewed the prescribed and over-thecounter medicines you were taking? For
example, they might have asked you to
show them your medicines and talked with
you about how and when to take each one.
1

Yes

2

No

3

I don’t know

4

I don’t take any medicines

In the last 2 months, did home health staff
from this agency talk with you about any
side effects of your medicines?
1

Yes

2

No

3

I don’t know

4

I don’t take any medicines

In the last 2 months, how often did home
health staff from this agency keep you
informed about when they would arrive
at your home?
1

Never

2

Sometimes

3

Usually

4

Always

In the last 2 months, how often did home
health staff from this agency seem to be
aware of all the care or treatment you
were getting at home?
1

Never

2

Sometimes

3

Usually

4

Always

8

9

10

11

12

In the last 2 months, how often did home
health staff from this agency treat you
with care – for example, when moving
you around or changing a bandage?

In the last 2 months, how often did you
feel that home health staff from the agency
cared about you as a person?
1

Never

Never

2

2

Sometimes

Sometimes

3

3

Usually

Usually

4

4

Always

Always

1

13

In the last 2 months, how often did home
health staff from this agency explain
things in a way that was easy to
understand?

In the last 2 months, did home health staff
from this agency provide your family or
friends with information or instructions
about your care as much as you wanted?
1

Never

Yes

2

2

Sometimes

No

3

3

Usually

I don’t know

4

4

Always

I did not want or need this

1

14

In the last 2 months, how often did home
health staff from this agency listen
carefully to you?

In the last 2 months, have the services you
received from this agency helped you
take care of your health?
1

Never

Never

2

2

Sometimes

Sometimes

3

3

Usually

Usually

4

4

Always

Always

1

In the last 2 months, how often did home
health staff from this agency treat you
with courtesy and respect?
1

Never

2

Sometimes

3

Usually

4

Always

3

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18

We want to know your rating of your care
from this agency’s home health staff.
Using any number from 0 to 10, where 0 is
the worst home health care possible and
10 is the best home health care possible,
what number would you use to rate your
care from this agency’s home health staff?
0
1
2
3
4
5
6
7
8
9
10

17

2

No

Yes

2

No

Probably no

3

Probably yes

4

Definitely yes

If you are answering on behalf of a family
member or friend who received home health
care: these questions are about that person, not
yourself.
19

Best home health care possible

20
If No, skip to Q18.

When you contacted this agency’s office,
did you get the help or advice you needed?
1

2

There are only a few questions left.

Have you contacted this agency’s office
for help or advice?
Yes

Definitely no

ABOUT YOU

The next questions are about the office of
[AGENCY NAME].

1

1

Worst home health care possible

YOUR HOME HEALTH AGENCY

16

Would you recommend this agency to
someone who needed home health care?

21

4

In general, how would you rate your
overall health?
1

Excellent

2

Very good

3

Good

4

Fair

5

Poor

In general, how would you rate your
overall mental or emotional health?
1

Excellent

2

Very good

3

Good

4

Fair

5

Poor

Do you live alone?
1

Yes

2

No

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23

25

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

What language do you mainly speak at
home?

1

8th grade or less

1

English

2

Some high school, but did not
graduate

2

Spanish

3

Some other language: (Please print.)

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

_____________________________
26

Are you Hispanic or Latino/Latina?
1

Yes

2

No

24

27

What is your race? Please choose one or
more.

Did someone help you complete this
survey?
1

Yes

2

No If No, please return your
completed survey in the postagepaid envelope.

How did that person help you? Check all
that apply.
1

Read the questions to me

Black or African American

2

Wrote down the answers I gave

3

Asian

3

4

Answered the questions for me

Native Hawaiian or other Pacific
Islander

4

5

American Indian or Alaska Native

Translated the questions into my
language

1

White

2

5

print.)

Helped in some other way: (Please
_____________________________

6

No one helped me complete this
survey

Thank you!
Please return the completed survey
in the postage-paid envelope.

5