CAHPS 2.0 Adult Core Questionnaire

OMB #: 0938-0926 Expiration Date: February 29, 2020

Medicare In-Center Hemodialysis Survey

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0926. The time required to complete this information collection is estimated to average 16 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Mail Stop C1-25-05, Baltimore, Maryland 21244-1850. 1. 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 2 No If No, Go to Question 25 2. Where do you get your dialysis 6. In the last 3 months, how often treatments? did your kidney doctors explain things in a way that was easy for 1 At home If At home, Go to you to understand? Question 45 2 At the dialysis center 1 Never 2 Sometimes 3 I do not currently receive 3 Usually dialysis If I do not 4 Always currently receive dialysis, Go to Question 45 7. In the last 3 months, how often did your kidney doctors show 3. How long have you been getting respect for what you had to say? dialysis at [SAMPLE FACILITY 1 Never NAME]? 2 Sometimes 1 Less than 3 months If Less 3 Usually than 3 months, Go to 4 Always Question 45 2 At least 3 months but less 8. In the last 3 months, how often than 1 year did your kidney doctors spend 3 At least 1 year but less than enough time with you? 5 years 1 Never 4 5 years or more 2 Sometimes 5 I do not currently receive 3 Usually dialysis at this dialysis center 4 If I do not currently Always receive dialysis at this dialysis center, Go to 9. In the last 3 months, how often Question 45 did you feel your kidney doctors really cared about you as a person? 4. YOUR KIDNEY DOCTORS 1 Never Your kidney doctors are the doctor or 2 Sometimes doctors most involved in your 3 Usually dialysis care now. This includes 4 Always kidney doctors that you see inside and outside the center.

5. In the last 3 months, how often did your kidney doctors listen carefully to you? 1 Never 2 Sometimes 3 Usually 4 Always

3 10. Using any number from 0 to 10, 14. In the last 3 months, how often where 0 is the worst kidney did the dialysis center staff doctors possible and 10 is the explain things in a way that was best kidney doctors possible, easy for you to understand? what number would you use to 1 Never rate the kidney doctors you have 2 Sometimes now? 3 Usually 0 0 Worst kidney doctors 4 Always possible 1 1 15. In the last 3 months, how often 2 2 did the dialysis center staff 3 3 show respect for what you had 4 4 to say? 5 5 1 6 6 Never 2 7 7 Sometimes 3 8 8 Usually 4 9 9 Always 10 10 Best kidney doctors possible 16. In the last 3 months, how often did the dialysis center staff 11. Do your kidney doctors seem spend enough time with you? informed and up-to-date about 1 Never the health care you receive from 2 Sometimes other doctors? 3 Usually 1 Yes 4 Always 2 No 17. In the last 3 months, how often 12. THE DIALYSIS CENTER STAFF did you feel the dialysis center staff really cared about you as a For the next questions, dialysis person? center staff does not include doctors. 1 Never Dialysis center staff means nurses, 2 Sometimes technicians, dietitians, and social 3 Usually workers at this dialysis center. 4 Always 13. In the last 3 months, how often did the dialysis center staff listen carefully to you? 1 Never 2 Sometimes 3 Usually 4 Always

4 18. In the last 3 months, how often 23. In the last 3 months, which one did dialysis center staff make did they use most often to you as comfortable as possible connect you to the dialysis during dialysis? machine? 1 Never 1 Graft 2 Sometimes 2 Fistula 3 Usually 3 Catheter If Catheter, Go to 4 Always Question 22 4 I don’t know If Don’t 19. In the last 3 months, did dialysis Know, Go to Question 22 center staff keep information about you and your health as 24. In the last 3 months, how often private as possible from other did dialysis center staff insert patients? your needles with as little pain as possible? 1 Yes 2 No 1 Never 2 Sometimes 3 20. In the last 3 months, did you feel Usually 4 Always comfortable asking the dialysis 5 center staff everything you I insert my own needles wanted about dialysis care? 25. In the last 3 months, how often 1 Yes did dialysis center staff check 2 No you as closely as you wanted while you were on the dialysis 21. In the last 3 months, has anyone machine?

on the dialysis center staff 1 asked you about how your Never 2 Sometimes kidney disease affects other 3 parts of your life? Usually 4 Always 1 Yes 2 No 26. In the last 3 months, did any problems occur during your 22. The dialysis center staff can dialysis? connect you to the dialysis machine through a graft, fistula, 1 Yes or catheter. Do you know how to 2 No If No, Go to take care of your graft, fistula, or Question 25 catheter? 1 Yes 2 No

5 27. In the last 3 months, how often 31. As a patient you have certain was the dialysis center staff able rights. For example, you have to manage problems during your the right to be treated with dialysis? respect and the right to privacy. 1 Never Did this dialysis center ever give 2 Sometimes you any written information 3 Usually about your rights as a patient? 1 4 Always Yes 2 No 28. In the last 3 months, how often did dialysis center staff behave 32. Did dialysis center staff at this in a professional manner? center ever review your rights as a patient with you? 1 Never 1 2 Sometimes Yes 2 3 Usually No 4 Always 33. Has dialysis center staff ever Please remember that for these told you what to do if you questions, dialysis center staff does experience a health problem at not include doctors. Dialysis center home? staff means nurses, technicians, 1 Yes dietitians, and social workers at this 2 No dialysis center. 34. Has any dialysis center staff 29. In the last 3 months, did dialysis ever told you how to get off the center staff talk to you about machine if there is an what you should eat and drink? emergency at the center? 1 Yes 1 Yes 2 No 2 No

30. In the last 3 months, how often did dialysis center staff explain blood test results in a way that was easy to understand? 1 Never 2 Sometimes 3 Usually 4 Always

6 35. Using any number from 0 to 10, 39. Using any number from 0 to 10, where 0 is the worst dialysis where 0 is the worst dialysis center staff possible and 10 is center possible and 10 is the the best dialysis center staff best dialysis center possible, possible, what number would what number would you use to you use to rate your dialysis rate this dialysis center? center staff? 0 0 Worst dialysis center 0 0 Worst dialysis center staff possible possible 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 8 8 8 8 9 9 9 9 10 10 Best dialysis center 10 10 Best dialysis center staff possible possible 40. TREATMENT 36. THE DIALYSIS CENTER The next few questions ask about your care in the last 12 months. As 37. In the last 3 months, when you you answer these questions, think arrived on time, how often did only about your experience at you get put on the dialysis [SAMPLE FACILITY NAME], even if machine within 15 minutes of you have not been receiving care your appointment or shift time? there for the entire 12 months. 1 Never 2 Sometimes 41. You can treat kidney disease 3 Usually with dialysis at a center, a 4 Always kidney transplant, or with dialysis at home. In the last 12 38. In the last 3 months, how often months, did your kidney doctors was the dialysis center as clean or dialysis center staff talk to as it could be? you as much as you wanted about which treatment is right 1 Never for you? 2 Sometimes 1 3 Usually Yes 2 No 4 Always

7 42. Are you eligible for a kidney 47. In the last 12 months, did you transplant? ever talk to someone on the dialysis center staff about this? 1 Yes If Yes, Go to Question 39 1 Yes 2 No 2 No If No, Go to 3 I don’t know If Don’t Question 45 Know, Go to Question 39 48. In the last 12 months, how often 43. In the last 12 months, has a were you satisfied with the way doctor or dialysis center staff they handled these problems? explained to you why you are 1 Never not eligible for a kidney 2 Sometimes transplant? 3 Usually 1 Yes 4 Always 2 No 49. Medicare and your State have 44. Peritoneal dialysis is dialysis special agencies that check the given through the belly and is quality of care at this dialysis usually done at home. In the last center. In the last 12 months, did 12 months, did either your you make a complaint to any of kidney doctors or dialysis center these agencies? staff talk to you about peritoneal 1 Yes dialysis? 2 No 1 Yes 2 No 50. ABOUT YOU 45. In the last 12 months, were you as involved as much as you 51. In general, how would you rate wanted in choosing the your overall health? treatment for kidney disease that 1 Excellent is right for you? 2 Very good 1 Yes 3 Good 2 No 4 Fair 5 Poor 46. In the last 12 months, were you ever unhappy with the care you 52. In general, how would you rate received at the dialysis center or your overall mental or emotional from your kidney doctors? health? 1 Yes 1 Excellent 2 2 No If No, Go to Very good 3 Question 45 Good 4 Fair 5 Poor

8 53. Are you being treated for high 60. Do you have difficulty dressing blood pressure? or bathing? 1 Yes 1 Yes 2 No 2 No

54. Are you being treated for 61. Because of a physical, mental, diabetes or high blood sugar? or emotional condition, do you 1 Yes have difficulty doing errands 2 No alone, such as visiting a doctor’s office or shopping?

1 55. Are you being treated for heart Yes 2 disease or heart problems? No 1 Yes 2 No 62. What is the highest grade or level of school that you have completed? 56. Are you deaf or do you have 1 serious difficulty hearing? No formal education 2 5th grade or less 1 Yes 3 6th, 7th, or 8th grade 2 No 4 Some high school, but did not graduate 57. Are you blind or do you have 5 High school graduate or GED serious difficulty seeing, even 6 Some college or 2-year when wearing glasses? degree 7 4-year college graduate 1 Yes 8 More than 4-year college 2 No degree

58. Because of a physical, mental, 63. What language do you mainly or emotional condition, do you speak at home? have serious difficulty concentrating, remembering, or 1 English making decisions? 2 Spanish 3 Chinese 1 Yes 4 Samoan 2 No 5 Russian 6 Vietnamese 59. Do you have serious difficulty 7 Portuguese walking or climbing stairs? 8 Some other language (please 1 Yes identify): 2 No ______

9 64. Are you of Spanish, Hispanic, or ______Latino origin or descent? 1 No, not Spanish/Hispanic/ 68. How did that person help you? Latino Check all that apply. 2 Yes, Puerto Rican 1 Read the questions to me 3 Yes, Mexican, Mexican 2 Wrote down the answers I American, Chicano gave 4 Yes, Cuban 3 Answered the questions for 5 Yes, other Spanish/Hispanic/ me Latino 4 Translated the questions into my language 65. What is your race? (One or more 5 Helped in some other way categories may be selected.) (please print): 1 White ______2 Black or African American 3 American Indian or Alaska Thank you. Please return the Native 4 Asian Indian survey in the enclosed envelope 5 Chinese to: 6 Filipino 7 Japanese VENDOR’S NAME 8 Korean STREET ADDRESS 1 9 Vietnamese STREET ADDRESS 2 10 Other Asian CITY, STATE, ZIP 11 Native Hawaiian 12 Guamanian or Chamorro 13 Samoan 14 Other Pacific Islander

66. Did someone help you complete this survey? 1 Yes 2 No Thank you. Please return the completed survey in the postage-paid envelope.

67. Who helped you complete this survey? 1 A family member 2 A friend 3 A staff member at the dialysis center 4 Someone else (please print):