Table S1. Community Partners of Hospital for Special Surgery
Clinical/Academic Partners
Asian American/Asian Research Institute, City University of New York
Translational Research Institute for Pain in Later Life (TRIPLL)
Charles B. Wang Community Health Center
Chinese Community Partnership for Health, New York Downtown Hospital
Clinical & Translational Science Center, Community Engagement Core, Weill Cornell Medical College
Gouverneur Healthcare Services, New York City Health and Hospitals Corporation
Mt. Sinai Medical Center, Adolescent Health Center
Hunter College School of Social Work
NewYork-Presbyterian Morgan Stanley Children’s Hospital, Pediatric Rheumatology Service, Columbia Medical Center
NewYork-Presbyterian Hospital
University of Delaware
Weill Cornell Medical College
Community-Based Organization Partners
Arthritis Foundation—New York Chapter
Asian Health and Social Service Council
CenterLight Healthcare
Children’s Aid Society
Chinatown Senior Center
Chinese American Planning Council
Community Healthcare Network
East Side Council on the Aging (ESCOTA)
General Human Outreach in the Community, Inc. (GHO)
Lenox Hill Neighborhood House
Lupus Foundation of America
Medicare Rights Center
The Myositis Association
National Osteoporosis Foundation
New York Chinese American Association
New York Foundation for Senior Citizens
New York Road Runners Club (NYRR)
Prime Care Home Health Agency
Project Sunshine
Senior Companions at Henry Street Settlement
Senior Health Partners
Service Program for Older People
S.L.E. Lupus Foundation
Government/Public Partners
National Institute of Arthritis and Musculoskeletal and Skin Diseases
New York State Department of Health
New York City Department of Health and Mental Hygiene
New York City Public Schools
New York Public Libraries
Office of Women’s Health, Department of Health and Human Services
Table S2. Survey Questionnairea
Hospital for Special Surgery wants to hear about your needs regardingmuscle, bone, joint, and rheumatology-relatedconditions. This will help us to provide programs and services that are important to you.
We do not need your name for this survey.Completing this survey will not affect any care that HSS provides for you.
Please print clearly.Please return this survey no later than March 22, 2013 so that we can make sure your opinion counts.
Thank you for your help!
Section 1. Health Conditions and Management
This section is about the health conditions you may have. Please choose your response from the options listed. If you are unsure, please give the best answer you can.
1. / Have you ever been told by a healthcare provider that you have any of the following conditions:
a) / Osteoarthritis (OA) / Yes / No
b) / Rheumatoid arthritis (RA) / Yes / No
c) / Lupus / Yes / No
d) / Fibromyalgia / Yes / No
e) / Gout / Yes / No
f) / Some other form of arthritis / Yes / No
g) / Osteoporosis / Yes / No
Note: If you answered “No” to ALL parts of Question 1, please SKIP to Question 4 (next page).
2. / Which of the following symptoms have you experienced within the past 30 daysdue to your condition(s)?
a) / Joint/bone pain or aches / Yes / No
b) / Muscle pain or aches / Yes / No
c) / Stiffness / Yes / No
d) / Fatigue / Yes / No
e) / Weight changes / Yes / No
f) / Skin rash / Yes / No
g) / Hair loss / Yes / No
h) / Mood changes (feeling sad, irritable, etc.) / Yes / No
i) / Trouble with concentrating / Yes / No
j) / Changes in memory / Yes / No
k) / Problems with balance / Yes / No
l) / Other:
3. / Has a healthcare provider ever suggested you do any of the following to help your symptoms?
a) / Lose weight / Yes / No
b) / Gain weight / Yes / No
c) / Exercise or physical activity / Yes / No
d) / Change your diet / Yes / No
4. / Have you received the following within the past 12 months:
a) / Immunizations (for example, flu shot) / Yes / No
b) / Mammograms, Pap smears / Yes / No
5. / Have you discussed the following with any healthcare provider within the past 12 months:
a) / Pregnancy prevention / family planning / Yes / No
b) / HIV / sexually transmitted disease prevention / testing / Yes / No
c) / Decision-making regarding sexual behavior / Yes / No
6. / In general, how healthy is your overall diet? A healthy diet includes lean protein, low-fat dairy, fruits and vegetables, and whole grains.
Excellent / Very good / Good / Fair / Poor
7. / If you would like to eat healthier, what keeps you fromdoing so?
a) / Healthy foods cost too much / Yes / No
b) / I do not like the taste / Yes / No
c) / I do not have any places where I live to find healthy food / Yes / No
d) / It takes too much time and effort to prepare / Yes / No
e) / I do not know what foods to eat / Yes / No
f) / Family and friends do not eat that way / Yes / No
g) / Other:
h) / Does not apply - I already eat healthy
8. / How many times a week do you usually do 30 minutes or more of moderate-intensity physical activity that increases your heart rate or makes you breathe harder than normal? (for example, carrying light loads, bicycling at a regular pace, or tennis)
5 or more times a week / 3 – 4 times a week / 1 – 2 times a week / None
9. / How many times a week do you usually do 20 minutes or more of vigorous-intensity physical activity that makes you puff or pant? (for example, heavy lifting, digging, jogging, aerobics, or fast bicycling)
3 or more times a week / 1 – 2 times a week / None
10. / In the past year, have you fallen down?
Yes / No
Note: If you answered “No,” please SKIP to Question 13 (below).
11. / Did you break any bones as a result of your fall?
Yes / No
12. / Did you talk to your doctor or other healthcare provider about your fall(s)?
Yes / No
Section 2. Your Health and Quality of Life
These questions are about how you feel overall. Please choose your response from the options listed. If you are unsure, please give the best answer you can.
13. / Would you say that in general your health is:
Excellent / Very good / Good / Fair / Poor
14. / Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
None (0 days) / 1 – 7 days / 8 – 13 days / 14 or more days
15. / Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
None (0 days) / 1 – 7 days / 8 – 13 days / 14 or more days
16. / During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?
None (0 days) / 1 – 7 days / 8 – 13 days / 14 or more days
17. / During the past 30 days, for how many days did pain make it hard for you to do your usual activities, such as personal care, work, or hobbies?
None (0 days) / 1 – 7 days / 8 – 13 days / 14 or more days
18. / Because of any health problem, do you need the help of other people with personal care needs (such as bathing or dressing) or household chores (such as shopping or cooking)?
Yes / No
19. / Over the last 2 weeks, how often have you been bothered by these problems?
a) / Feeling nervous, anxious or on edge:
Not at all / Several days / More than half the days / Nearly every day
b) / Not being able to stop or control worrying:
Not at all / Several days / More than half the days / Nearly every day
c) / Feeling down, depressed or hopeless:
Not at all / Several days / More than half the days / Nearly every day
d) / Little interest or pleasure in doing things:
Not at all / Several days / More than half the days / Nearly every day
Section 3. Use and Access to Healthcare
These questions are about your healthcare experiences. Please choose your response from the options listed. If you are unsure, please give the best answer you can.
20. / What kind of healthcare coverage/insurance do you have, if any?
No health insurance / Medicare only / Medicaid only
Medicare and Medicaid / Medicare and supplemental insurance / Commercial / private insurance
Other:
21. / How often do you need help with understanding and using your healthcare coverage? (for example, the services covered by your health insurance, billing questions, and other related issues?)
Always / Very often / Sometimes / Never
22. / In the past 12 months, was there a time when you needed to see a doctor or other healthcare provider but could not?
Yes / No
Note: If you answered “No,” please SKIP to Question 24 (next page).
23. / What were the reasons why you could not do so?
a) / Could not afford it / Yes / No
b) / No insurance / Yes / No
c) / Service not covered by insurance / Yes / No
d) / Lack of transportation / hard to get an appointment / not sure where to go / Yes / No
e) / Family responsibilities (such as no child care available) / Yes / No
f) / Language (such as could not get healthcare in my language) / Yes / No
g) / Office not patient-friendly (such as long wait time, hours not convenient) / Yes / No
h) / Other reason:
24. / How often do you follow your doctor or other healthcare provider’s medical advice?
Always / Very often / Sometimes / Never
25. / Sometimes people don’t followtheir doctor or other healthcare provider’s medical advice. Please tell us the reasons that this may apply to you.
a) / Provider didn’t explain treatment well enough (due to lack of time, uncaring attitude, or hard to understand) / Yes / No
b) / Didn’t feel treatment would help / Yes / No
c) / Concerned about the cost of treatment / Yes / No
d) / Forgot to take medicine / go for follow-up / Yes / No
e) / Provider doesn’t understand my culture / language / Yes / No
f) / Condition not severe enough to require treatment / Yes / No
g) / Worried about side effects of treatment / Yes / No
h) / Prefer to use complementary / alternative treatment / Yes / No
i) / Did not fit my schedule / not convenient for me / Yes / No
j) / Other reason:
k) / Does not apply - I always follow the medical advice of my doctor or other healthcare provider
26. / How confident are you that you can manage symptoms of your condition so that you can do the things that you want to do?
Not at all confident / Somewhat confident / Confident / Very confident
27. / When you visit your doctor (or other healthcare provider), how often do you do the following:
a) / Prepare a list of questions for your doctor (or other healthcare provider)
Never / Almost never / Sometimes / Fairly often
Very often / Always
b) / Ask questions about the things you don’t understand about your treatment
Never / Almost never / Sometimes / Fairly often
Very often / Always
c) / Discuss any personal problems that may be related to your illness
Never / Almost never / Sometimes / Fairly often
Very often / Always
28. / How would you rate your ability to speak and understand English?
Excellent / Very good / Good / Fair / Poor
29. / What is your preferred spoken language for discussing healthcare?
English / Spanish / Chinese / Russian / Other:
30. / In what language would you prefer reading medical or healthcare instruction?
English / Spanish / Chinese / Russian / Other:
31. / How often do you need to have someone help you when you read instructions, pamphlets, or other written materials from your doctor or pharmacy?
Never / Rarely / Sometimes / Often / Always
Section 4: About You
Please tell us about you and your background so that we can learn more about the communities we serve.
32. / Gender:
Female / Male
33. / Age:
Under 20 / 20-29 / 30-39 / 40-49 / 50-59
60-69 / 70-79 / 80-89 / 90-99
34. / Which one or more of the following would you say is your race? (Check all that apply)
American Indian or Alaska Native / Black or African American / White/Caucasian
Asian, Hawaiian or Pacific Islander / Hispanic, Latino(a)
Some other race(s):
35. / What is the highest grade or year of school you completed?
Never attended school or only attended kindergarten / Grades 1 through 8 (elementary)
Grades 9 through 11 (some high school) / Grade 12 or GED (high school graduate)
College 1-3 years (some college or technical school) / College 4 years or more (college graduate)
Some graduate school / Completed graduate school
36. / Is your household annual income (from all sources):
Less than $10,000 / $10,000 – $14,999 / $15,000 – $24,999 / $25,000 – $34,999
$35,000 – $49,999 / $50,000 – $74,999 / $75,000 – $99,999 / $100,000 – $149,999
$150,000 – $199,999 / $200,000 or more
37. / Are you currently:
Single (never married) / Married / Living together as a couple
Divorced / Separated / Widowed
38. / Do you live alone?
Yes / No
39. / Where do you live?
Brooklyn / Bronx / Manhattan / Queens
Staten Island / Long Island, NassauCounty / Long Island, SuffolkCounty
Westchester / New Jersey
Other:
40. / Please use the space below to tell us of any other muscle, joint, bone, or rheumatology-related needs, that you would like Hospital for Special Surgery to know about:
Thank you for completing this survey!
Please return this survey no later than March 22, 2013 so that we can make sure your opinion counts.
Please send the completed survey back to us in one of the following ways:
- Mail using the enclosed pre-paid envelope
- Drop off at:
517 East 71st Street, NY, NY 10021 - Attn: Dana Friedman
If you have any questions or concerns about the survey, please contact Dana Friedman, Public Health Outcomes Manager, at 212-774-2185.
aThe questionnaire was developed in the Public & Patient Education Department of Hospital for Special Surgery, with input from the Department of Social Work Programs and other internal stakeholders and community partners.
The following questions are validated measures:
Q8, 9: Two-Question Physical Activity Survey
Q10, 12: Medicare Current Beneficiary Survey
Q13 – 18: CDC Healthy Days Measure (HRQoL-4). Please note that additional (non-validated) response choices were inserted for these questions to a elicit better response rate.
Q19 a – d: Patient Healthy Questiopnnaire-4 (PHQ-4)
Q25: Stanford Chronic Disease Self-Efficacy Scale
Q27 a - c: Stanford Chronic Disease Self-Management Scale
Q28 – 30: HSS Outpatient Intake Form (hospital standard per Joint Commission)
Q31: Single-Item Literacy Screener (SILS) used as part of the HSS Outpatient Intake Form
Q36: NHANES 2011