CMS-P-0015A Institutional Utilization

2022 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

IUQ-INSTITUTIONAL UTILIZATION

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 (SP)] a (01) YES
patient in (a/another) nursing home or any similar place that provides long-term care -- such as the places shown on (02) NO
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.]

PROVIDER_IU

IU2

roster

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
Where [were you/was (SP)] a patient -- in which nursing home?
2. [PROVIDER 2]
…
SELECT OR ADD ONLY ONE FACILITY.
N. [PROVIDER N]
N+1. ADD ANOTHER
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE INSTITUTION.]
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING AN
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
EVENT WITH THAT PROVIDER
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 CHNGSPL-CHNGSPL.

(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]

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2022 MCBS Community Questionnaire

Variable Name

MR Screen Name

GROUPNAM

IU2

Question Type

IUQ-INSTITUTIONAL UTILIZATION

Question Text/Description

CHNGSPL

roster

THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."

Routing

BOX IU1

GROUP:

WHICH PROVIDER IS MISSPELLED?

CHNGSPL

Code List

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]

CRCTSPL-CRCTSPL

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
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.

CRCTSPL

CRCTSPL

BOX IU1

verbatim

routing

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 "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

(01) [Continuous Answer]

BOX IU1

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

IU4 - EVBEGMM

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

IU4 - EVBEGDD

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

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

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

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:

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2022 MCBS Community Questionnaire

IUQ-INSTITUTIONAL UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

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

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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