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OMB #: 0938-1066Expires August 31, 2023HOME HEALTH CARE CAHPS SURVEY2020
3.SURVEY INSTRUCTIONS Answer all the questions by checking thebox to the left of your answer. You are sometimes told to skip oversome questions in this survey. When thishappens you will see an arrow with anote that tells you what question toanswer next, like this:Yes4.If Yes, go to Q1 on Page 1.NoYOUR HOME HEALTH CARE1.According to our records, you got carefrom the home health agency,[AGENCY NAME]. Is that right?As you answer the questions in thissurvey, think only about yourexperience with this agency.2.1Yes2No5.If No, please stop andreturn the survey in theenvelope provided.When you first started getting homehealth care from this agency, didsomeone from the agency tell youwhat care and services you would get?1Yes2No3Do not remember1When you first started getting homehealth care from this agency, didsomeone from the agency talk withyou about how to set up your home soyou can move around safely?1Yes2No3Do not rememberWhen you started getting home healthcare from this agency, did someonefrom the agency talk with you aboutall the prescription and over-thecounter medicines you were taking?1Yes2No3Do not rememberWhen you started getting home healthcare from this agency, did someonefrom the agency ask to see all theprescription and over-the-countermedicines you were taking?1Yes2No3Do not remember
9.YOUR CARE FROM HOMEHEALTH PROVIDERS IN THELAST 2 MONTHSThese next questions are about all thedifferent staff from [AGENCY NAME]who gave you care in the last 2 months. Donot include care you got from staff fromanother home health care agency. Do notinclude care you got from family or friends.6.7.8.In the last 2 months of care, was oneof your home health providers fromthis agency a nurse?1Yes2No10.In the last 2 months of care, was oneof your home health providers fromthis agency a physical, occupational,or speech therapist?1Yes2No11.In the last 2 months of care, was oneof your home health providers fromthis agency a home health or personalcare aide?1Yes2No12.2In the last 2 months of care, how oftendid home health providers from thisagency seem informed and up-to-dateabout all the care or treatment you gotat home?1Never2Sometimes3Usually4Always5I only had one provider in thelast 2 months of careIn the last 2 months of care, did youand a home health provider from thisagency talk about pain?1Yes2NoIn the last 2 months of care, did youtake any new prescription medicine orchange any of the medicines you weretaking?1Yes2NoIf No, go to Q15.In the last 2 months of care, did homehealth providers from this agency talkwith you about the purpose for takingyour new or changed prescriptionmedicines?1Yes2No3I did not take any newprescription medicines orchange any medicines
13.14.15.16.17.In the last 2 months of care, did homehealth providers from this agency talkwith you about when to take thesemedicines?In the last 2 months of care, how oftendid home health providers from thisagency explain things in a way thatwas easy to understand?1Yes1Never2No2Sometimes3I did not take any newprescription medicines orchange any medicines3Usually4Always18.In the last 2 months of care, did homehealth providers from this agency talkwith you about the side effects ofthese medicines?In the last 2 months of care, how oftendid home health providers from thisagency listen carefully to you?1Never1Yes2Sometimes2No3Usually3I did not take any newprescription medicines orchange any medicines4Always19.In the last 2 months of care, how oftendid home health providers from thisagency keep you informed about whenthey would arrive at your home?1Never2Sometimes3Usually4AlwaysIn the last 2 months of care, how oftendid home health providers from thisagency treat you as gently as possible?1Never2Sometimes3Usually4Always3In the last 2 months of care, how oftendid home health providers from thisagency treat you with courtesy andrespect?1Never2Sometimes3Usually4Always
20.22.We want to know your rating of yourcare from this agency’s home healthproviders.Using any number from 0 to 10, where0 is the worst home health carepossible and 10 is the best homehealth care possible, what numberwould you use to rate your care fromthis agency’s home health providers?23.0 Worst home health carepossible1Yes2No3I did not contact this agencyIf No, go to Q24.When you contacted this agency’soffice, how long did it take for you toget the help or advice you needed?11Same day221 to 5 days36 to 14 days4More than 14 days5I did not contact this agency345624.78In the last 2 months of care, did youhave any problems with the care yougot through this agency?91Yes10 Best home health care possible2No25.YOUR HOME HEALTH AGENCYThe next questions are about the office of[AGENCY NAME].21.In the last 2 months of care, when youcontacted this agency’s office did youget the help or advice you needed?In the last 2 months of care, did youcontact this agency’s office to get helpor advice?1Yes2NoIf No, go to Q24.4Would you recommend this agency toyour family or friends if they neededhome health care?1Definitely no2Probably no3Probably yes4Definitely yes
30.ABOUT YOU26.27.28.29.In general, how would you rate youroverall health?31.Are you Hispanic or Latino/Latina?1Yes2NoWhat is your race? Please select oneor more.1Excellent2Very good13GoodWhite24FairBlack or African-American35PoorAsian4Native Hawaiian or other PacificIslander5American Indian or AlaskaNativeIn general, how would you rate youroverall mental or emotional health?1Excellent2Very good3Good4Fair5Poor32.What language do you mainly speak athome?1English2Spanish3Some other language:Do you live alone?1Yes2No(Please print.)33.What is the highest grade or level ofschool that you have completed?18th grade or less2Some high school, but did notgraduate3High school graduate or GED4Some college or 2-year degree54-year college graduate6More than 4-year college degree5Did someone help you complete thissurvey?1Yes2NoIf No, please return thecompleted survey in thepostage-paid envelope.
34.How did that person help you? Checkall that apply.1Read the questions to me2Wrote down the answers I gave3Answered the questions for me4Translated the questions into mylanguage5Helped in some other way:(Please print.)6No one helped me complete thissurveyThank you!Please return the completed surveyin the postage-paid envelope.6
another home health care agency. Do not include care you got from family or friends. 6. In the last 2 months of care, was one of your home health providers from this agency a nurse? 1 Yes 2 No 7. In the last 2 months of care, was one of your home health providers from this agency a physical, occupational, or speech therapist? 1 Yes 2 No 8.
