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VA Form 10-1465-6 SHEP Patient Centered Medical Homes (PCMH) Long Form 10-
ICR 201601-2900-013 · OMB 2900-0712 · Object 61564101.
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OMB Number 2900-0712 Est. Burden: 21 minutes Exp. Date 03/31/2017 VA Form 10-1465-6 SURVEY OF HEALTHCARE EXPERIENCES OF PATIENTS AMBULATORY CARE 2016 In order for the VA to carry out its mission to provide the best possible medical care and services to all veterans, it is extremely important that you complete and return this survey booklet. Your answers will help ensure that all veterans receive the high-quality care they have earned and so richly deserve. Please read each question and check the box that best describes your experience. Please be sure to read all pages of this survey booklet. The check-box responses you provide to the survey questions will not be connected with you personally but combined with the opinions of other veterans and shared with the VA facility providing your care. However, any additional information which you provide including comments written in the margins, letters, and other enclosures will be shared with the Medical Center Director or appropriate staff at your facility if it is the best way to address your concerns, unless you instruct us not to. Participation is voluntary and your answers to the survey will not affect the healthcare you receive or your eligibility for VA benefits. If you have a specific question or need help with your VA care, you may contact the VA as described at the end of this survey booklet. Thank you very much! The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 21 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Customer satisfaction surveys are used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this survey will lead to improvements in the quality of service delivery by helping to shape the direction and focus of specific programs and services. Disclosure of information involves release of statistical data and other non-identifying data for the improvement of services within the VA healthcare system and associated administrative purposes. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled. Version: 45 – 0416 SURVEY INSTRUCTIONS • 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: Yes If Yes, go to #1 No YOUR PROVIDER 1. Our records show that you got care from the provider named below in the last 6 months. [PROVIDER NAME] Is that right? YOUR CARE FROM THIS PROVIDER IN THE LAST 6 MONTHS These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits. 4. Yes NoIf No, go to #59 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. Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt? 3. Yes 5. No How long have you been going to this provider? At least 1 year but less than 3 years At least 3 years but less than 5 years 5 years or more 6. None If None, go to #44 1 time 2 3 4 5 to 9 10 or more times In the last 6 months, did you contact this provider’s office to get an appointment for an illness, injury or condition that needed care right away? Less than 6 months At least 6 months but less than 1 year In the last 6 months, how many times did you visit this provider to get care for yourself? Yes NoIf No, go to #8 In the last 6 months, when you contacted 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 7. In the last 6 months, how many days did you usually have to wait for an appointment when you needed care right away? 8. 1 day 2 to 3 days 4 to 7 days More than 7 days In the last 6 months, did you make any appointments for a check-up or routine care with this provider? 9. Same day Yes No If No, go to #10 In the last 6 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed? Never Sometimes Usually Always 10. Did this provider’s office give you information about what to do if you needed care during evenings, weekends, or holidays? Yes No 11. In the last 6 months, did you need care for yourself during evenings, weekends, or holidays? Yes No If No, go to #13 12. In the last 6 months, how often were you able to get the care you needed from this provider’s office during evenings, weekends, or holidays? Never Sometimes Usually Always 13. In the last 6 months, did you contact this provider’s office with a medical question during regular office hours? Yes No If No, go to #15 14. In the last 6 months, when you contacted 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 15. In the last 6 months, did you contact this provider’s office with a medical question after regular office hours? Yes No If No, go to #17 16. In the last 6 months, when you contacted 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 17. Some offices remind patients between visits about tests, treatment or appointments. In the last 6 months, did you get any reminders from this provider’s office between visits? Yes No 18. Wait time includes time spent in the waiting room and exam room. In the last 6 months, how often did you see this provider within 15 minutes of your appointment time? Never Sometimes Usually Always 19. In the last 6 months, how often did this provider explain things in a way that was easy to understand? Never Sometimes Usually Always 20. In the last 6 months, how often did this provider listen carefully to you? Never Sometimes Usually Always 21. In the last 6 months, did you talk with this provider about any health questions or concerns? Yes No If No, go to #23 22. In the last 6 months, how often did this provider give you easy to understand information about these health questions or concerns? Never Sometimes Usually Always 23. In the last 6 months, how often did this provider seem to know the important information about your medical history? Never Sometimes Usually Always 24. In the last 6 months, how often did this provider show respect for what you had to say? Never Sometimes Usually Always 25. In the last 6 months, how often did this provider spend enough time with you? Never Sometimes Usually Always 26. In the last 6 months, did this provider order a blood test, x-ray, or other test for you? Yes No If No, go to #28 27. In the last 6 months, when this provider ordered 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 28. In the last 6 months, did you and this provider talk about starting or stopping a prescription medicine? Yes No If No, go to #32 29. 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 30. When you talked about starting or stopping a prescription medicine, how much did this provider talk about the reasons you might not want to take a medicine? Not at all A little Some A lot 31. When you talked about starting or stopping a prescription medicine, did this provider ask you what you thought was best for you? Yes No 32. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider? 0 Worst provider possible 1 2 3 4 5 6 7 8 9 10 Best provider possible 33. In the last 6 months, did you take any prescription medicine? Yes No If No, go to #35 34. In the last 6 months, how often did you and someone from this provider’s office talk about all the prescription medicines you were taking? Never Sometimes Usually Always 35. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 6 months, did you see a specialist for a particular health problem? Yes No If No, go to #37 36. In the last 6 months, how often did the provider named in Question 1 seem informed and up-to-date about the care you got from specialists? Never Sometimes Usually Always Please answer these questions about the provider named in Question 1 of the survey. 37. In the last 6 months, did anyone in this provider’s office talk with you about specific goals for your health? Yes No 38. In the last 6 months, did anyone in this provider’s office ask you if there are things that make it hard for you to take care of your health? Yes No 39. In the last 6 months, did anyone in this provider’s office ask you if there was a period of time when you felt sad, empty or depressed? Yes No 40. In the last 6 months, did you and anyone in this provider’s office talk about things in your life that worry you or cause you stress? Yes No 41. In the last 6 months, did you and anyone in this provider’s office talk about a personal problem, family problem, alcohol use, drug use, or a mental or emotional illness? Yes No CLERKS AND RECEPTIONISTS AT THIS PROVIDER’S OFFICE 42. In the last 6 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be? Never Sometimes Usually Always 43. In the last 6 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect? Never Sometimes Usually Always YOUR CARE FROM SPECIALISTS IN THE LAST 6 MONTHS These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits. 44. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 6 months, did you try to make any appointments with a VA specialist? Yes No If No, go to #46 45. In the last 6 months, how often was it easy to get appointments with VA specialists? Never Sometimes Usually Always 46. In the last 6 months, did you try to make any appointments with a Non-VA specialist paid for by VA? Yes No If No, go to #48 47. In the last 6 months, how often was it easy to get appointments with Non-VA specialist paid for by VA? Never Sometimes Usually Always 48. Please think about your most recent visit within the last 6 months to either a VA specialist or Non-VA specialist. Was this specialist: A VA specialist A non-VA specialist paid for by VA A non-VA specialist seen on my own Did not see a specialist in the last 6 months Go to #51 49. During your most recent visit with the specialist, did the specialist know important information about your medical history? Yes, definitely Yes, somewhat No 50. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate this specialist? 0 Worst specialist possible 1 2 3 4 5 6 7 8 9 10 Best specialist possible USING THE VA PHARMACY 51. During the past 3 months, when you were seen at [FACILITY NAME], did you visit the pharmacy outpatient window to get your prescription(s) filled? Yes No If No, go to #54 No pharmacy outpatient window at this facility If No outpatient window, go to #54 52. For each part of your VA pharmacy visit, please tell us the amount of improvement needed, if any: No Improvement Needed Slight Improvement Needed Some Improvement Needed A lot of Improvement Needed Does Not Apply a. The length of time you waited at the VA pharmacy b. Questions were answered to your satisfaction by pharmacy staff c. The courtesy of the VA pharmacy staff d. Personal privacy in the VA pharmacy waiting room e. VA pharmacy waiting room comfort & cleanliness f. Contacting the VA pharmacy by phone when you have questions about your medication g. Contacting your VA healthcare provider when you have questions about your medication 53. Overall, how satisfied were you with pharmacy services provided at the [FACILITY NAME] pharmacy outpatient window during the past three months? Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied 54. During the past 3 months, did you receive medications or supplies from the VA pharmacy in the mail? Yes No If No, go to #57 55. Please tell us about the medications or supplies you received from the VA pharmacy in the mail. How often did these things happen to you? a. I received the wrong medication or supplies b. The medication or supplies were for another person c. The amount of medication or supplies received was too small d. The amount of medication or supplies received was too large e. The package had no medication or supplies f. The package was damaged g. The medication in the package was too hot h. The medication in the package was too cold i. There was an unexplained change to the medication or supplies I received 56. Overall, how satisfied were you with VA pharmacy services provided through the mail during the past 3 months? Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied ABOUT COMMUNICATING WITH THE VA 57. In the last 6 months, did you have a complaint about how you were treated (medically or personally) during your recent healthcare visit? Yes No 58. In the last 6 months, how often did you have a hard time speaking with or understanding your VA doctor or nurse because you spoke different languages? Never Sometimes Usually Always Never Sometimes Usually Always YOUR OVERALL EXPERIENCE WITH THE DEPARTMENT OF VETERANS AFFAIRS Now think about your experiences with all the services provided by the Department of Veterans Affairs (which include healthcare, benefits programs, or memorial services). Please tell us how you feel about the following statements: 59. I got the service I needed. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 60. It was easy to get the service I needed. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 61. I felt like a valued customer. Strongly disagree Disagree Neither agree nor disagree Strongly agree Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree ABOUT YOU 63. In general, how would you rate your overall health? Excellent Very Good Good Fair Poor 64. In general, how would you rate your overall mental or emotional health? Excellent Very Good Good Fair Poor 65. Have you had either a flu shot or flu spray in the nose since July 1, 2015? Was told I was not eligible to get the flu vaccine this year because of the shortage Flu vaccine not available and I didn't get it elsewhere Medical advice not to get a flu shot (such as allergy, illness) No time/Didn't get around to it Agree 62. I trust VA to fulfill our country’s commitment to veterans. 66. If you did not get a flu vaccine in July 2015 or later, why not? Mark the MAIN reason: Yes No Don’t know Inconvenient to get it at the VA Don't like needles/injections I believe it might make me sick Don't believe in it/Prefer other methods of prevention Did not think I needed a flu shot Did not want a flu vaccine I plan to get my flu vaccine at a later date Other 67. Where did you get your flu vaccine? At the VA (such as a hospital, clinic, outreach mobile unit) Vet Center Non-VA hospital, clinic, doctor's office, visiting nurse or Health Department Community source (drug store, church, grocery store, etc.) Other Do not remember 68. Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine. Yes No Don’t know 69. Do you now smoke cigarettes or use tobacco every day, some days, or not at all? Every day Some days Not at all If Not at all, Go to #73 Don’t know If Don’t know, Go to #73 70. In the last 6 months, how often were you advised to quit smoking or using tobacco by a VA doctor or other VA health provider? Never Sometimes Usually Always 71. In the last 6 months, how often was medication recommended or discussed by a VA doctor or VA health provider to assist you with quitting smoking or using tobacco? Examples of medication are: nicotine gum, patch, nasal spray, inhaler, or prescription medication. Never Sometimes Usually Always 72. In the last 6 months, how often did your VA doctor or VA health provider discuss or provide methods and strategies other than medication to assist you with quitting smoking or using tobacco? Examples of methods and strategies are: telephone helpline, individual or group counseling, or cessation program. Never Yes Sometimes Usually Always 73. Do you take aspirin daily or every other day? No Don’t know 74. Do you have a health problem or take medication that makes taking aspirin unsafe for you? Yes No Don’t know 75. Has a VA doctor or VA health provider ever discussed with you the risks and benefits of aspirin to prevent heart attack or stroke? Yes No 76. Are you aware that you have any of the following conditions? Check all that apply. High cholesterol High blood pressure Parent or sibling with heart attack before the age of 60 77. Has a VA doctor ever told you that you have any of the following conditions? Check all that apply. A heart attack Angina or coronary heart disease A stroke Any kind of diabetes or high blood sugar 78. What is the highest grade or level of school that you have completed? 8th grade or less Some high school, but did not graduate High school graduate or GED Some college or 2-year degree 4-year college graduate More than 4-year college degree 79. Are you of Hispanic or Latino origin or descent? Yes, Hispanic or Latino No, Not Hispanic or Latino 80. What is your race? Mark one or more. 82. Did someone help you complete this survey? White Black or African-American Asian No Native Hawaiian or other Pacific Islander Thank you. Please return the completed survey in the postage-paid envelope. 83. How did that person help you? Mark one or more. American Indian or Alaska Native 81. What language do you mainly speak at home? Yes English Spanish Chinese Russian 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 Vietnamese Portuguese Some other language (please print): __________________________ THANK YOU Please return the completed survey in the postage-paid envelope. If you have a specific question or need help with your VA care, you may contact the VA: 1. By telephone: a. VA Benefits: 1-800-827-1000 b. Health Care Benefits: 1-877-222-8387 c. Telecommunications Device for the Deaf (TDD): 1-800-829-4833 2. Information on a broad range of veterans' benefits is available on our home page at http://www.va.gov 3. At your local VA medical center, either contact the department that you think can help you or ask for the Patient Advocate. Your answers are important to help us improve VA care. Thank you for completing this questionnaire. Please place the completed questionnaire in the envelope we sent you. No stamp is required. Simply place the envelope in any mailbox and return the survey to: Department of Veterans Affairs c/o Ipsos P.O. Box 806046 Chicago, IL 60680
| File Type | application/pdf |
| File Title | Microsoft Word - SHEP_PCMH_Survey_FY16T04_Long_Flu_Eng_12.22.2015_rev03a.docx |
| Author | ARober01 |
| File Modified | 2016-01-19 |
| File Created | 2016-01-15 |