CMS-P-0015A Institutional Utilization

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

IUQ-INSTITUTIONAL UTILIZATION

Question Type

Question Text/Description

Code List

Routing

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
(01) YES
(SP)] a patient in (a/another) nursing home or any similar place that provides long-term care -- such as the
(02) NO
places shown on this card?
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
LONG-TERM CARE PLACES INCLUDE SKILLED NURSING HOMES, INTERMEDIATE CARE FACILITIES, (-9) Refused
BOARD AND CARE HOMES, NURSING HOME UNITS IN HOSPITALS, FACILITIES FOR THE
INTELLECTUALLY DISABLED, PSYCHIATRIC FACILITIES AND GROUP HOMES.

(01) IU2 - PROVIDER_IU
(02) BOX IU3
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX IU3
(-9) BOX IU3

[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

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2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

IUQ-INSTITUTIONAL UTILIZATION

Question Type

Question Text/Description

Code List

Routing

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 2. [PROVIDER 2]
…
SELECT "ADD ANOTHER."
N. [PROVIDER N]
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO
NAME FOR ALL PROVIDERS WHERE
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
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
(01) [Continuous Answer]
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

BOX IU1

WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CRCTSPL

CHNGSPL

CRCTSPL

BOX IU1

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.

VAPLACE

IU3

yes/no

EVBEGMM

IU4

date

EVBEGDD

IU4

date

EVBEGYY

IU4

date

EVENDMM

IU4

date

EVENDDD

IU4

date

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

IU4 - EVBEGMM

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

IU4 - EVBEGDD

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

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

IU4 - EVBEGYY

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

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

IU4 - EVENDMM

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

IU4 - EVENDDD

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

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

IU4 - EVENDYY

IU4 - STLLINST

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

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:

EVENDYY

IU4

date

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

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

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

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?
[ENTER A STAY AT A DRUG AND REHABILITATION CENTER AS AN IP EVENT, NOT AN IU EVENT.]

BOX IU3

routing

GO TO HHQ.

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