CMS-10784 Home Health Care CAHPS Web Survey

WEB INTERVIEW SCREENSHOTS FOR THE HOME HEALTH CARE CAHPS SURVEY
(HHCAHPS®)

OMB #: TBD
Expires: TBD
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OTHERWISE, ALLOW RESPONDENT TO LEAVE ITEM/QUESTION BLANK AND CLICK
“NEXT” TO PROCEED TO THE NEXT SCREEN. NO SOFT CHECK (ONSCREEN
OR IN POP-UP) NEEDED.
HHCAHPS Landing Page*

Home Health Survey / Encuesta sobre la salud en el hogar

Please input your Survey Access code.
Por favor ingrese su código de acceso.

Take the Survey / Responder la encuesta

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INTRO1

Home Health Survey
Patient Name:
Welcome to the Home Health Survey!
Click the “Next” button below to begin the survey.
(Para completar esta encuesta en español, seleccione “Español” de la opción desplegable
del idioma en la esquina superior derecha de esta pantalla.)

Next>
Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.
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 information collection is TBD. The
expiration date for OMB control number TBD is TBD. The time required to complete this information collection is
estimated to average 10 minutes per response, including the time to review instructions, search existing data sources,
gather the data needed, and complete and review the information collection. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: Centers for Medicare & Medicaid
Services, 7500 Security Boulevard, Mail Stop C1-25-05, Baltimore, Maryland 21244-1850.

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INTRO2

Home Health Survey
[AGENCY NAME] is participating in a national survey about the quality of health care
delivered to people in their homes. Your feedback helps us monitor quality of care.
Your participation in this survey is voluntary and will not affect any health care or
benefits you receive. All information you give is confidential. No one can connect your
name to your answers.

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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INTRO3

Home Health Survey
If you are answering on behalf of someone who received home health care, please try
to answer the questions from his or her point-of-view.

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q1

LOGIC AFTER Q1; IF Q1=NO, GO TO Q_INELIG. IF Q1=YES OR BLANK, GO TO
Q2.

Home Health Survey
YOUR HOME HEALTH CARE
According to our records, you got care from the home health agency, [AGENCY NAME]. Is
that right?
 Yes
 No

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q2

Home Health Survey
YOUR HOME HEALTH CARE
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?
 Yes
 No
 Not sure

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q3_INTRO

Home Health Survey
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.

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q3

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
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.
 Yes
 No
 I don’t know
 I did not need help with home safety

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q4

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
Has someone from the agency ever reviewed the prescribed and over-the-counter
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.
 Yes
 No
 I don’t know
 I don’t take any medicines

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q5

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
In the last 2 months, did home health staff from this agency talk with you about any
side effects of your medicines?
 Yes
 No
 I don’t know
 I don’t take any medicines

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q6

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
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?
 Never
 Sometimes
 Usually
 Always

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q7

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
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?
 Never
 Sometimes
 Usually
 Always

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q8

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
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?
 Never
 Sometimes
 Usually
 Always

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q9

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
In the last 2 months, how often did home health staff from this agency explain things
in a way that was easy to understand?
 Never
 Sometimes
 Usually
 Always

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q10

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
In the last 2 months, how often did home health staff from this agency listen carefully
to you?
 Never
 Sometimes
 Usually
 Always

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q11

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
In the last 2 months, how often did home health staff from this agency treat you with
courtesy and respect?
 Never
 Sometimes
 Usually
 Always

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q12

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
In the last 2 months, how often did you feel that home health staff from the agency
cared about you as a person?
 Never
 Sometimes
 Usually
 Always

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q13

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
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?
 Yes
 No
 I don’t know
 I did not want or need this

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q14

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
In the last 2 months, have the services you received from this agency helped you take
care of your health?
 Never
 Sometimes
 Usually
 Always

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q15

Home Health Survey
YOUR CARE FROM HOME HEALTH STAFF
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 Worst home health care possible
 1
 2
 3
 4
 5
 6
 7
 8
 9
 10 Best home health care possible

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q16

LOGIC AFTER Q16: IF Q16=NO OR BLANK, GO TO Q18.

Home Health Survey
YOUR HOME HEALTH AGENCY
The next questions are about the office of [AGENCY NAME].
Have you contacted this agency’s office for help or advice?
 Yes
 No

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q17

Home Health Survey
YOUR HOME HEALTH AGENCY
When you contacted this agency’s office, did you get the help or advice you needed?
 Yes
 No

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q18

Home Health Survey
YOUR HOME HEALTH AGENCY
Would you recommend this agency to someone who needed home health care?
 Definitely no
 Probably no
 Probably yes
 Definitely yes

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q19_INTRO

Home Health Survey
ABOUT YOU
There are only a few questions left.
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.

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q19

Home Health Survey
ABOUT YOU
In general, how would you rate your overall health?
 Excellent
 Very good
 Good
 Fair
 Poor

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q20

Home Health Survey
ABOUT YOU
In general, how would you rate your overall mental or emotional health?
 Excellent
 Very good
 Good
 Fair
 Poor

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q21

Home Health Survey
ABOUT YOU
Do you live alone?
 Yes
 No

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q22

Home Health Survey
ABOUT YOU
What is the highest grade or level of school that you have completed?
 8th grade or less
 Some high school, but did not graduate
 High school graduate or GED
 Some college or 2-year degree
 4-year college graduate
 More than 4-year college degree

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q23

Home Health Survey
ABOUT YOU
Are you Hispanic or Latino/Latina?
 Yes
 No

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q24

Home Health Survey
ABOUT YOU
What is your race? Please select all that apply.







Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q25

Home Health Survey
ABOUT YOU
What language do you mainly speak at home?
 English
 Spanish
 Some other language (Please specify):

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q26

LOGIC AFTER: IF Q26 = NO OR BLANK, THEN GO TO Q_END

Home Health Survey
ABOUT YOU
Did someone help you complete this survey?
 Yes
 No

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q27

Home Health Survey
ABOUT YOU
How did that person help you? Please select all that apply.







Read the questions to me



No one helped me complete this survey

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

Q_END

Home Health Survey
You have completed the Home Health Survey. Thank you for your time.
Please click the “Submit” button to close the survey.

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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Q_INELIG

Home Health Survey
Those are all the questions we have for you. Thank you for your time.
Please click the “End” button to close the survey.

Questions? Contact the HHCAHPS Survey Coordination Team at [email protected] or call 1-866-662-8174.

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