RESPONDENT Cover Sheet

RESPONDENT Cover Sheet

RESPONDENT ID



[FROM PATIENT SAMPLE INFO BEFORE INTERVIEW]:

NAME:LAST ______FIRST ______MI____

GENDER:MaleFemale

 RELEASED FROM HOSPITAL TO HOME

 RELEASED FROM REHAB TO HOME

 RELEASED FROM NURSING HOME TO HOME

 STILL IN REHAB/NURSING HOME [DO NOTINTERVIEW]

PATIENT SATISFACTION FOLLOW UP SURVEY FOR BRIDGES 10-04-2013

My name is ______and I am calling on behalf of Christiana Care. We are working with Christiana Care to try to understand and improve the care that heart patients like you receive after they leave the hospital. I'd like to ask you some questions about how things went after your release from your hospitalization for cardiac care on __ / __ / ____ , how you feel about the care you have received since you left the hospital, what ideas you have about what worked well and what things might have gone better. This is a short survey and your participation is voluntary,but it is very important for helping us to improve the care that patients receive. Anything you tell us will be kept confidential and, unless you tell us about a medical problem you are having, we will not reveal your name to anyone at Christiana Care or elsewhere. Also, if there are any questions you do not want to answer we can skip over them.

[INTERVIEWEE MUST BE PATIENT ]

PATIENT INTERVIEWEDPATIENT NOT INTERVIEWED BECAUSE:



 REFUSED

NOCONTACT AFTER 4 TRIES

  CAN’T TALK ON PHONE (PHYSICALLY INCAPABLE)

  MENTALLY INCAPABLE

 OTHER ______



1. Overall, how satisfied are you with the health care you have received since you returned home about 3 monthsago?

[IF DISSATISFIED] 2. What has been your concern?

3. Do you think the amount of care and follow up you have received about your health since you got home has been:

4. In general would you say your health since you got home has been:

"Now, I would like to ask you some questions about your contact and communication with the doctors,nurses, therapists,and anyone else who ishelping you specifically with your care for your heart.

5. First, have you talked with or met with doctors about your heart problems since your return home? Yes No (SKIP TO Q9)

IF YES: 6. When was the most recent time you saw a doctor or talked to a doctor on the phone

or in person about your heart problems?

7. Overall, since you returned home, how satisfied have you been with the help you have gotten from your doctor(s)?

8. Now thinking about all your interactions with your Heart doctors since you returned home, have the services you have received improved your quality of life?[IF ASKED FOR EXAMPLES/EXPLANATIONS FOR QOL:By that I mean did their assistance make you healthier? Did it make you feel better? Help you take better care of yourself and your medical condition. Those kind of things. Would you say their efforts helped you …]

9.Now, have you talked with or met with members of the CareLinkHeart Team from Christiana,such as nurses, care managers,or social workers since your return home? Yes No (SKIP TO Q16)

IF YES: 10. When was the most recent time you saw them or talked to them on the phone?

11. Did you contact the nurse, care manager or social worker or did they contact you?

I called them They called/visited me

12. Was this for a routine check up or did you have contact with the nurse, care manageror social worker for a problem you were having?

Routine Check upHad a Problem

13. Overall, how satisfied are you with the help you have gotten from your nurse, care manager, or social workersince you returned home?

14. Now thinking about all your interactions with your Christiana CareLink Heart nurses, care managers, or social workers since you returned home,…have the services you have received improved your quality of life?[IF ASKED FOR EXAMPLES/EXPLANATIONS FOR QOL:By that I mean did their assistance make you healthier? Did it make you feel better? Help you take better care of yourself and your medical condition. Those kind of things. Would you say their efforts helped you …]

15.IF A LOT OR A LITTLE: What did they do that helped you?

IF NOT AT ALL: What could they have done to better help you?

[REQUIRED PROBE IN EITHER CASE: Anything else?]

[LIST ALL MENTIONS]

16. Next, I would like to ask you about any problems that you may have faced since you returned home. What has been the biggest barrier or problem you have faced ingetting better and taking care of yourself? [REQUIRED PROBE UNLESS R SAYS NO BARRIERS: Anything else?]

16a.Has the Christiana CareLinkHeart Team helped you with this problem? YesNo

[IF NO, GO TO QUESTION 18]

17. Now I am going to read you a list of other things that some people say have been problemsforthem taking care of themselves. Please tell me if this has been a problem for you and if the Christiana CareLink Heart Team was able to help.

A Problem CCHT helped

a. Getting in touch with other health help when I need it?YesNoYesNo

b. Taking my medications correctly?YesNoYesNo

c. Making and getting out to medical appointments?YesNoYesNo

d. Getting out for other reasons?YesNoYesNo

e. Being able to take care of myself?YesNoYesNo

f. Keeping up with my diet?YesNoYesNo

g. Getting enough exercise?YesNoYesNo

g. Feeling depressed or stressed emotionally?YesNoYesNo

h. Other problems we have not mentioned?______YesNoYesNo

i.______YesNoYesNo

j.______YesNoYesNo

18. Now, I’d like to ask you what has been the most helpful aspect of care you have received since you left the hospital? [REQUIRED PROBE UNLESS R SAYS NOTHING HELPFUL: Anything else?]

19. Finally, is there anything else you'd like to tell me about your experiences since returning home?

Thank you for your help. Your opinions will help us improve the post-release care for you and for others in the future.

Appendix

Phone script for voice mail

Hello, I am [NAME] looking for Mr/MS [Respondant’s NAME]. I’m calling on behalf of Christiana Care to help with a brief satisfaction survey on thehealthservices that you've received since[month]. I will call back at a later time to see if I can reach you. Or if you want to call us, you can do so between9am and 4pmat302 831-6107, We may be able to talk with you right then or else you can tell our staffer when would be a good time to call you back. Thank you.

Version 2.2 Date: 10/10/2014Page 1