CAHPS Adult 12-Month Survey with the Patient-Centered Medical Home (PCMH) Items
OMH/CAHPS Survey06/05/12
The Summary Scoring Report uses the following scoring methodology:
Overall – An average of all questions with a 4 point (Always to Never) range.
Timeliness – Questions: 5, 6, 8, 10 and 11.
Thoroughness – Questions: 12, 13, 14, 15, 20, 22, 26 and 29.
Communications – Questions: 18, 21 and 24
Friendliness – Questions: 30, 31, 32, and 33.
The category for each question is also noted below.
OMH Patient Survey Version 3.doc11/01/2012
OMH/CAHPS SurveyVersion 3
Your Provider
1.Our records show that you got care from the provider named below in the last 12 months.
Name of provider label goes here
Is that right?
1Yes
2No If No, go to #35 on page 7
The questions in this survey will refer to the provider named in Question 1 as “this provider.” Please think of that person as you answer the survey.
2.How long have you been going to this provider?
Less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 3 years
At least 3 years but less than 5 years
5 years or more
Your Care From This Provider in the Last 12 Months
These questions ask about your care at the hematology/oncology provider’ office listed in question 1. Donot include care you got when you stayed overnight in a hospital or at any other provider’s office..
3.In the last 12 months, how many times did you visit this provider to get care for yourself?
None If None, go to #35 on page7
1 time
2
3
4
5 to 9
10 or more times
4.In the last 12 months, did you phone this provider’s office to get an appointment for an illness, injury or condition that needed care right away?
Yes
No If No, go to #7
5.Timeliness I n the last 12 months, when you phoned this provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?
Never
Sometimes
Usually
Always
6.TimelinessIn the last 12 months, how many days did you usually have to wait for an appointment when you neededcare right away?
Same day
1 day
2 to 3 days
4 to 7 days
More than 7 days
7. In the last 12 months, did you phone this provider’s office with a medical question during regular office hours?
Yes
No If No, go to #9
8. TimelinessIn the last 12 months, when you phoned this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?
Never
Sometimes
Usually
Always
9. In the last 12 months, did you phone this provider’s office with a medical question after regular office hours?
Yes
No If No, go to #11
10. TimelinessIn the last 12 months, when you phoned this provider’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed?
Never
Sometimes
Usually
Always
11. TimelinessWait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see this providerwithin 15 minutes of your appointment time?
Never
Sometimes
Usually
Always
12. Thoroughness In the last 12 months, how often did this provider give you all the information you wanted about your health?
Never
Sometimes
Usually
Always
13. Thoroughness In the last 12 months, how often did this provider show interest in your questions and concerns?
Never
Sometimes
Usually
Always
14. Thoroughness In the last 12 months, how often did this provider give you easy to understand instructions about what to do to take care of this illness or health condition?
Never
Sometimes
Usually
Always
15. Thoroughness Sometimes providers give instructions that are hard to follow. In the last 12 months, how often did this provider ask you whether you would have any problems doing what you need to do to take care of this illness or health condition?
Never
Sometimes
Usually
Always
16. In the last 12 months, did this provider explain the possible side effects of your medicines?
Yes
No
17. Communications In the last 12 months, how often was the written information you were given easy to understand?
Never
Sometimes
Usually
Always
18. Communications In the last 12 months, during any of your visits, did this provider:Circle applicable as Yes, No or Does Not Apply.
a) Listen to your reasons for the
visit? Yes No Does Not Apply123
b) Show concern for your
physical comfort? Yes No Does Not Apply123
c) Describe his or her
physical findings? Yes No Does Not Apply123
d) Explain the reason for any
additional tests? Yes No Does Not Apply123
e) Describe the next steps
for your care or treatment?Yes No Does Not Apply
19. Communications In the last 12 months, did this provider give you complete and accurate information about: Circle applicable as Yes, No or Does Not Apply.
a) Tests? Yes No Does Not Apply123
b) Choices for your care? Yes No Does Not Apply123
c) Treatment? Yes No Does Not Apply123
d) Plan for your care? Yes No Does Not Apply123
e) Medications? Yes No Does Not Apply123
f) Follow-up care? Yes No Does Not Apply123
20. Thoroughness In the last 12 months, how often did this providerseem to know the important information about your medical history?
Never
Sometimes
Usually
Always
21. Communications In the last 12 months, did you feel that this provider always told you the truth about your health, even if there was bad news?
Yes, definitely
Yes, somewhat
No
22. Thoroughness In the last 12 months, how often did this providerspend enough time with you?
Never
Sometimes
Usually
Always
23. In the last 12 months, did this providerorder a blood test, x-ray, or other test for you?
Yes
No If No, go to #25
24. Communications In the last 12 months, when this providerordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?
Never
Sometimes
Usually
Always
25. In the last 12 months, did you and this provider talk about starting or stopping a prescription medicine?
Yes
NoIf No, go to #28
26.Thoroughness When you talked about starting or stopping a prescription medicine, how much did this provider talk about the reasons you might want to take a medicine?
Not at all
A little
Some
A lot
27. When you talked about starting or stopping a prescription medicine, did this provider ask you what you thought was best for you?
Yes
No
28. Your hematology/oncology provider works closely with your primary care physician and other specialist in the coordination and delivery of your care. In the last 12 months, did you see your primary care physician or other specialist for a particular health problem?
Yes
No If No, go to #30
29. Thoroughness In the last 12 months, did your primary care physician or other specialist seem informed and up-to-date about the care you got from your hematology/oncology provider?
Never
Sometimes
Usually
Always
Clerical and Clinical Staff at your Hematology/Oncology Provider’s Office
30. Friendliness In the last 12 months, how often were clerks and receptionists at your hematology/oncology provider’s office as helpful as you thought they should be?
Never
Sometimes
Usually
Always
31. Friendliness In the last 12 months, how often did clerks and receptionists at your hematology/oncology provider’s office treat you with courtesy and respect?
Never
Sometimes
Usually
Always
32. Friendliness In the last 12 months, how often was the clinical staff at your hematology/oncology provider’s office as helpful as you thought they should be?
Never
Sometimes
Usually
Always
33. Friendliness In the last 12 months, how often did was the clinical staff at your hematology/oncology provider’s office treat you with courtesy and respect?
Never
Sometimes
Usually
Always
About You
34. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
35. In general, how would you rate your overall mental or emotionalhealth?
Excellent
Very good
Good
Fair
Poor
36. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
37. Are you male or female?
Male
Female
38. Did someone help you complete this survey?
Yes
No Thank you.
Please return the completed survey in the postage-paid envelope.
39. How did that person help you? Mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
Please print: ______
OMH Patient Survey Version 3.doc11/01/2012
12-Month Survey with the Patient-Centered
CAHPS Clinician & Group SurveysMedical Home (PCMH) Item Set
Thank you
Please return the completed survey in the postage-paid envelope.
OMH Patient Survey Version 3.doc11/01/2012