CMS-10105 Medicare In-Center Hemodialysis Survey (English)

National Implementation of In-Center Hemodialysis CAHPS Survey (CMS-10105)

ICH-SurveyStandardEnglish2024OMB-508

In-Center Hemodialysis CAHPS Survey: National Implementation

OMB: 0938-0926

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Survey Instructions

This survey is about your experiences with dialysis care at [SAMPLE FACILITY NAME].

Answer each question by marking the box to the left of your answer.

You are sometimes told to skip over 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:

  1. Yes

    Shape2

  2. No If No, Go to Question 25

  1. Where do you get your dialysis treatments?

0 Shape3 At home or at a skilled nursing home where I live If At home or at a skilled nursing home where I live, Go to Question 45

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0 At the dialysis center

0 I do not currently receive dialysis If I do not currently receive dialysis, Go to Question 45

  1. How long have you been getting dialysis at [SAMPLE FACILITY

NAME]?

    1. Shape5 Less than 3 months If Less than 3 months, Go to Question 45

    2. At least 3 months but less than 1 year

    3. At least 1 year but less than

5 years

0 5 years or more

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5 I do not currently receive dialysis at this dialysis center

If I do not currently receive dialysis at this dialysis center, Go to Question 45

YOUR KIDNEY DOCTORS

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Your kidney doctors are the doctor or doctors most involved in your dialysis care now. This includes kidney doctors that you see inside and outside the center.

  1. In the last 3 months, how often did your kidney doctors listen carefully to you?

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    1. Never

    2. Sometimes

    3. Usually

    4. Always

  2. In the last 3 months, how often did your kidney doctors explain things in a way that was easy for you to understand?

    Shape9

    1. Never

    2. Sometimes

    3. Usually

    4. Always

  3. In the last 3 months, how often did your kidney doctors show respect for what you had to say?

    Shape10

    1. Never

    2. Sometimes

    3. Usually

    4. Always

  4. In the last 3 months, how often did your kidney doctors spend enough time with you?

    Shape11 Shape12 Shape13

  5. In the last 3 months, how often

did you feel your kidney doctors really cared about you as a person?

0 Never

0 Sometimes

    1. Usually

    2. Always

  1. Using any number from 0 to 10, where 0 is the worst kidney doctors possible and 10 is the best kidney doctors possible, what number would you use to rate the kidney doctors you have now?

    1. 0 Worst kidney doctors possible

    2. 1

0 2

0 3

Shape14 Shape15 00 4

    1. 5

    2. 6

    3. 7

    4. 8

    5. 9

00 10 Best kidney doctors possible

  1. Do your kidney doctors seem informed and up-to-date about the health care you receive from other doctors?

THE DIALYSIS CENTER STAFF

For the next questions, dialysis center staff does not include doctors. Dialysis center staff means nurses, technicians, dietitians, and social workers at this dialysis center.

  1. In the last 3 months, how often did the dialysis center staff listen carefully to you?

Shape16

1 Never

0 Sometimes

0 Usually

Shape17 00 Always

  1. In the last 3 months, how often did the dialysis center staff explain things in a way that was easy for you to understand?

0000 Never

Shape18 Shape19 Shape20 Shape21

  1. In the last 3 months, how often did you feel the dialysis center staff really cared about you as a person?

0 Never

Shape22 0 Sometimes

    1. Usually

    2. Always

  1. In the last 3 months, how often did dialysis center staff make you as comfortable as possible during dialysis?

0 Never

0 Sometimes

    1. Usually

Shape23 Shape24 00 Always

  1. In the last 3 months, did dialysis center staff keep information about you and your health as private as possible from other patients?

0 Yes

0 No

  1. In the last 3 months, did you feel comfortable asking the dialysis center staff everything you wanted about dialysis care?

  1. The dialysis center staff can connect you to the dialysis machine through a graft, fistula, or catheter. Do you know how to take care of your graft, fistula, or catheter?

    Shape25

    1. Yes

    2. No

  2. In the last 3 months, which one did they use most often to connect you to the dialysis machine?

    Shape26

    1. Graft

    2. Fistula

0 Catheter If Catheter, Go to

Question 22

0 I don’t know If Don’t

Know, Go to Question 22

  1. In the last 3 months, how often did dialysis center staff insert your needles with as little pain as possible?

    Shape27

    1. Never

    2. Sometimes

    3. Usually

Shape28 Shape29 Shape30

  1. In the last 3 months, did any problems occur during your dialysis?

0 Yes

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0 No If No, Go to Question 25

  1. In the last 3 months, how often was the dialysis center staff able to manage problems during your dialysis?

0 Never

Shape32 Shape33 0 Sometimes

    1. Usually

    2. Always

  1. In the last 3 months, how often did dialysis center staff behave in a professional manner?

0 Never

0 Sometimes

    1. Usually

    2. Always

Please remember that for these questions, dialysis center staff does not include doctors. Dialysis center staff means nurses, technicians, dietitians, and social workers at this dialysis center.

  1. In the last 3 months, did dialysis center staff talk to you about what you should eat and drink?

  2. In the last 3 months, how often did dialysis center staff explain blood test results in a way that was easy to understand?

    Shape34

    1. Never

    2. Sometimes

    3. Usually

    4. Always

  3. As a patient you have certain rights. For example, you have the right to be treated with respect and the right to privacy. Did this dialysis center ever give you any written information about your rights as a patient?

    Shape35

    1. Yes

    2. No

  4. Did dialysis center staff at this center ever review your rights as a patient with you?

    Shape36

    1. Yes

    2. No

  5. Has dialysis center staff ever told you what to do if you experience a health problem at home?

32. Using any number from 0 to 10, where 0 is the worst dialysis center staff possible and 10 is the best dialysis center staff possible, what number would you use to rate your dialysis center staff?

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0 0 Worst dialysis center staff possible

0 1

0 2

0 3

Shape38 Shape39 0 4

  1. 5

  2. 6

  3. 7

  4. 8

  5. 9

00 10 Best dialysis center staff possible

THE DIALYSIS CENTER

33. In the last 3 months, when you arrived on time, how often did you get put on the dialysis machine within 15 minutes of your appointment or shift time?

35. Using any number from 0 to 10, where 0 is the worst dialysis center possible and 10 is the best dialysis center possible, what number would you use to rate this dialysis center?

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  1. 0 Worst dialysis center possible

  2. 1

0 2

0 3

0 4

  1. 5

  2. 6

  3. 7

  4. 8

  5. 9

000 10 Best dialysis center possible

TREATMENT

The next few questions ask about your care in the last 12 months. As you answer these questions, think only about your experience at [SAMPLE FACILITY NAME], even if you have not been receiving care there for the entire 12 months.

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  1. You can treat kidney disease with dialysis at a center, a kidney transplant, or with dialysis at home. In the last 12 months, did your kidney doctors or dialysis center staff talk to you as much as you wanted about which treatment is right for you?

    Shape42 Shape43 Shape44 Shape45

  2. Are you eligible for a kidney transplant?

0 Yes If Yes, Go to Question 39

Shape46 0 No

3 I don’t know If Don’t

Know, Go to Question 39

  1. In the last 12 months, has a doctor or dialysis center staff explained to you why you are not eligible for a kidney transplant?

0 Yes

0 No

  1. Peritoneal dialysis is dialysis given through the belly and is usually done at home. In the last 12 months, did either your kidney doctors or dialysis center staff talk to you about peritoneal dialysis?

    1. Yes

    2. No

  1. In the last 12 months, were you as involved as much as you wanted in choosing the treatment for kidney disease that is right for you?

Shape47 Shape48 Shape49 Shape50 Shape51 Shape52 Shape53

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

    1. Excellent

    2. Very good

    3. Good

    4. Fair

    5. Poor

  2. Are you being treated for high blood pressure?

    1. Yes

    2. No

  3. Are you being treated for diabetes or high blood sugar?

    1. Yes

    2. No

  4. Are you being treated for heart disease or heart problems?

    1. Yes

    2. No

  5. Are you deaf or do you have serious difficulty hearing?

    1. Yes

    2. No

  6. Are you blind or do you have serious difficulty seeing, even when wearing glasses?

    1. Yes

    2. No

  7. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

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    1. Yes

    2. No

  8. Do you have serious difficulty walking or climbing stairs?

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    1. Yes

    2. No

  9. Do you have difficulty dressing or bathing?

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    1. Yes

    2. No

  10. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone, such as visiting a doctor’s office or shopping?

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    1. Yes

    2. No

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

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    1. No formal education

    2. 5th grade or less

    3. 6th, 7th, or 8th grade

    4. Some high school, but did not graduate

    5. High school graduate or GED

    6. Some college or 2-year degree

    7. 4-year college graduate

    8. More than 4-year college degree

Shape59 Shape60 Shape61 Shape62 Shape63 Shape64

  1. What language do you mainly speak at home?

    1. English

    2. Spanish 3 Chinese 4 Samoan

    1. Russian

    2. Vietnamese

    3. Portuguese

    4. Some other language (please identify):

_______________________

  1. Are you of Spanish, Hispanic, or Latino origin or descent?

    1. No, not Spanish/Hispanic/Latino

    2. Yes, Puerto Rican

    3. Yes, Mexican, Mexican American,

Chicano

    1. Yes, Cuban

    2. Yes, other Spanish/Hispanic/ Latino

  1. What is your race? (One or more categories may be selected.)

    1. American Indian or Alaska Native 2 Asian – Please Specify

      1. Asian Indian

      2. Chinese

      3. Filipino

      4. Japanese

      5. Korean

      6. Vietnamese

      7. Other Asian

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      8. Black or African American

      9. Native Hawaiian or Pacific Islander – Please Specify

      10. Guamanian or Chamorro

      11. Native Hawaiian

      12. Samoan

      13. Other Pacific Islander

      14. Shape66 White

  2. Did someone help you complete this survey?

    1. Yes

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    2. No Thank you. Please return the completed survey in the postage-paid envelope.

  3. Who helped you complete this survey?

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    1. A family member

    2. A friend

    3. A staff member at the dialysis center

    4. Someone else (please print):

________________________

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

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    1. Read the questions to me

    2. Wrote down the answers I gave

    3. Answered the questions for me

    4. Translated the questions into my language

    5. Helped in some other way (please print):

________________________

Thank you. Please return the survey in the enclosed envelope to:

VENDOR’S NAME

STREET ADDRESS 1

STREET ADDRESS 2 CITY, STATE, ZIP

0 Never

0 Sometimes

0 Usually

0 Always

0 Yes

0 No

0 Sometimes

0 Usually

0 Always

0 . In the last 3 months, how often did the dialysis center staff show respect for what you had to say?

0 Never

0 Sometimes

0 Usually

0 Always

0 . In the last 3 months, how often did the dialysis center staff spend enough time with you?

0 Never

0 Sometimes

0 Usually

0 Always

0 Yes

0 No

18. In the last 3 months, has anyone on the dialysis center staff asked you about how your kidney disease affects other parts of your life?

0 Yes

0 No

0 Always

0 I insert my own needles

22. In the last 3 months, how often did dialysis center staff check you as closely as you wanted while you were on the dialysis machine?

0 Never

0 Sometimes

0 Usually

0 Always

0 Yes

0 No

0 Yes

0 No

31. Has any dialysis center staff ever told you how to get off the machine if there is an emergency at the center?

0 Yes

0 No

0 Never

0 Sometimes

0 Usually

0 Always

34. In the last 3 months, how often was the dialysis center as clean as it could be?

0 Never

0 Sometimes

0 Usually

0 Always

0 Yes

0 No

0 Yes

0 No

41. In the last 12 months, were you ever unhappy with the care you received at the dialysis center or from your kidney doctors?

0 Yes

0 No If No, Go to

Question 45



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