Vital and


Health Statistics “


Developmentof the 

Series 1: 

Programs and 

No, 33 

Home and


Care Survey


Collection Procedures 

The National Home and Hospice Care Survey began operation in 1992, 

This report presents the development of the survey instruments and survey 

procedures from a feasibility study in 1990 to the first year of operation of 

the National Survey, 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES


Public Health Service


Centers for Disease Control and Prevention


National Center for Health Statistics


Hyaftsville, Ma~and


September 1994


DHHS Publication No, (PHS] 94-1309

. 

All material appearing in this report is in the public domain and maybe 

reproduced or copied without permiseiow c“tition es to source, however, is 

appreciated. 

Suggested citation 

Haupt BJ. Development of the National Home and Hospice Care Survey 

National Center for Health statistics. VIII Health Stat 1(33). 1994. 

Ubrary of Congress Ceteloglng-in-Publicetlon Data 

Haupt, 6arbara J. 

Development of the National Home and Hospice Care Survey/ 

by Barbara J. Haupt]. 

p. cm. — (Viial and health statistics. Series 1, Programs end mllection 

procedures;	 no. 33) (DHHS publication; no. (PHS) 94-1309) 

“August 1994”. 

Includes bibliographical references. 

lSBN 0-6406-0492-0 

1. National Home and Hospice Care Survey (U.S.) 2. Home care 

service9esearch-Unkd States. 3. Hospices (Terminal 

cere)-Research-United States. 4. Medical care aurveye-United States. 

L National Center for Health Statistics (U.S.) II. Ttle. Ill. Series. IV. Series 

DHHS publication; no. (PHS) 94-1309. 

RA409.U44 no. 33 

[RA645.351 

362.1’0723 e-dc20 , 

[362.1 ‘4’072073] 

94-12450 

CIP 

For sale by the U.S. Government Printing Office 

Superintendent of Documents 

Mail Stop SSOP 

Washington, DC 20402-9328 
National Center for Health Statistics 

Manning Feinleib, M.D., Dr.P.H., Director 

Jack R, Anderson, Deputy Director 

Jacob J. Feldman, Ph.D., Associate Director for Analysis, 

Epidemiology, and Health Promotion 

Gail F. Fisher, Ph.D., Associate Director for Planning and 

Extramural Programs 

Peter L. Hurley, Associate Director for Tltal and Health 

StatNics Systems 

Robert A. Israel, Associate Director for International 

Stat&tics 

Stephen E. Nieberding, Associate Director for 

Management 

Charles J. Rothwell, Associate Director for Data 

Processing and Services 

Monroe G. Sirkek, Ph.D., Associate Director for Research 

and Methodology 

Officeof Wal and HealthStatisticsSystems 

Peter L. Hurley, Associate Director 

Divisionof HealthCareStatistics 

W. Edward Bacon, Ph.D., Division Director 

Thomas McLemore, Deputy Director 

Evelyn S. Mathis, Chiej Long-Term Care Statistics Branch 

Manoochehr K Nozary, Chief Technical Services Branch 

Cooperationof the U.S.Bureau of the Census 

Under the legislation eatablfsbing the National Heafth Survey, the Fabfic 

Health SeMee is authorized to W, insofar aa possible, the aeMces or faeititiea 

of other Fedemf, State, or private agencies. 

fn aecordarrcewith apeeificationa established by the National Center for 

Heafth Statiatirs, the U.S. Bureau of the Cmaua, under a cmrtractrraf 

arrangement pardeipated in mfleding the data. 
.

Contents 

~ 

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

The National Health Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1 

Purposes of the NHHCS . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . , . . . . . . . , . . . . . . . . . . . . . . . . . . . . , . . . . , . . . . . . 1 

Feasibility of studying hospices and home health agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 

Sampling frame and sample selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 

Data collection instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 

Data collection methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 

Results of the Feasibility Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . 5 

Pretest for the National Home and Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . . . . 8 

Sampling frame and sample selection . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . 8 

Data collection instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 

Data collection methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 

Results of the Pretest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 

TheNationalHome and HospiceCareSurvey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 

Sampling frame and sample selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 

Data collection instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ’13 

Data collection methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . , . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . . 15 

Data processing and estimation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 16 

Data publication and availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 

,, 

Appendixes 

I. NCHS authorizing legislation . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 

11.	 Definitions ofcertain terrnsfor the National Home and Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 

111. Letters and data collection instruments for the Feasibility Study forthe National Home and Hospice Care Survey.. . . 23 

IV Letters, data collection instruments, and sample selection tables for the Pretest for the Natiorial Home and 

Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . ...63 

v.	 Letters, data collection instruments, and sample selection table for the National Home and 

Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 

Textfigures 

1. Data collection methods forthe Feasibili~ Stidyfor the National Home and Hospice Care Suwey . . . . . . . . . . . . . . . . . 5 

2. Second stage of sample selection for the National Home and Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 

Text tables 

A. Sample selection forthe Feasibility Stidyfor the National Home and Hospice Care Sumey . . . . . . . . . . . . . . . . . . . . . . . 3 

B. Questionnaires used and information obtained for the Feasibility Study for the National Home and 

Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., :..,.... . . . . . . . . . . 3 

c.	 Information collected through the Administrator’s Questionnaire for the Feasibility Study for the National 

Home and Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 

D.	 Information collected through the Client Questionnaire for the Feasibility Study for the National Home 

and Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 

E, Results of the Feasibility Study for the National Home and Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 

iii 
---

F. 

G.


H. 

J. 

K. 

L. 

M. 

N. 

o. 

P. 

Q. 

R. 

Changes made in the data collection instruments for the National Home and Hospice Care Survey as a result of the 

Feasibility Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...’ . . . . . . . . . . .’. , 6 

Changes made in the procedures for the National Home and Hospice Care Survey as a result


of the Feasibility Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4... 6


Sample selection for the Pretest for the National Home and Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8


Questiormaires used and information obtained for the Pretest for the National Home and Hospice Care Survey ..,..,.8


Information collected through the Facility Questionnaire for the Pretest for the National Home and Hospice


Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..’..... ,. ..,. 9


Information collected through the Patient Questionnaires for the Pretest for the National Home and Hospice


Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. .,..” 9


Changes made in the data collection instruments and procedures for the National Home and Hospice Care Survey


as a result of the Pretest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10


Sample selection for the National Home and Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ..’ 12


Distribution of hospices and home health agencies in the 1992 National Home and Hospice Care Survey universe


(sampling thrne), National Health Interview Survey primary sampling units, and 1992 survey sample by


primary strata and region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‘,. , 12


Questionnaires used and information obtained for the National Home and Hospice Care Survey . . . . . . . . . . . . . ...’.. 13


Information collected through the Facility Questionnaire for the National Home and Hospice Care Survey , . . . . . . . . . 14


Information collected through the Patient Questionnaires for the National Home and Hospice Care Survey. . . . . . . . . . 14


. . . 

— 

0.0 

z 

* 

Symbols 

Data not available 

Category not applicable 

Quantity zero 

Quantity more than zero but less than 

0.05 

Quantity more than zero but less than 

500 where numbers are rounded to 

thousands 

Figure does not meet standard of 

reliability or precision 
Development of the National 

Home and Hospice Care 

Survey 

I by Barbara J. Haupt, D.V.M., Divisionof Health Care 

I Statistics 

Introduction 

This report provides a description of the development of 

the National Home and Hospice Care Survey (NHHCS). The 

NHHCS is one of a number of surveys conducted by the 

Division of Health Care Statistics, National Center for Health 

Statistics (NCHS), The NHHCS was implemented in 1992 and 

will be conducted annually; data are collected by means of 

personal interviews with the administrators and staff of a 

nationally representative sample of hospices and home health 

agencies. 

The legislative mandate 42 USC (Section 306 of the 

Public Health Service Act) states that one of the duties of 

NCHS is to “collect statistics on...health resources...[and the] 

utilization of health care, including utilization of...services of 

hospitals, extended care facilities, home health agencies, and 

other institutions ....” (see appendix I). Data about the utilization of home health and hospice care services are collected 

through the NHHCS, which is a part of the National Health 

Care Survey (NHCS) (l). The NHCS is a program designed 

by NCHS to collect data on the use of health care providers in 

the United States. The NHCS is an integrated set of recordbased health care provider surveys that has been developed by 

the Division of Health Care Statistics in response to changes 

during the 1980’s in the delivery of health care. 

The National Health Care Survey 

The NHCS is composed of five basic components: L.ongTerm Care, Health Provider Inventory, Patient Follow-on, 

Hospital and Surgical Care, and Ambulatory Care. This family 

of surveys is designed to answer questions concerning the 

utilization of health care services. The surveys generate data 

that permit analysis of the relationship between the use of 

health services and health characteristics that can be used to 

monitor current and changing patterns in health care use. 

The Long-Term Care Component of the NHCS includes 

two surveys the National Nursing Home Survey and the 

National Home and Hospice Care Survey. Through this component, data are collected on the services and stti of the 

facilities and on the personal and health characteristics of 

current and discharged residents or patients. 

The National Health Provider Inventory (NHPI) Component, formerly called the National Master Facility Inventory 

and the Inventory of Long-Term Care Places, provides a 

comprehensive national listing of health care facilities such as 

nursing homes, facilities for the mentally ill and mentally 

retarded, home health agencies, hospices, and licensed residential care facilities. Data from the NHPI are used to describe the 

number, distribution, and types of facilities and to select 

samples of facilities for other component surveys. 

The Patient Follow-on Component provides data on outcomes of patient care and subsequent use of health care 

services through periodic contacts with patients, patients’ 

families, or facilities. Data are available from the 1985 

National Nursing Home Survey Followup. A feasibility study 

is underway to develop, test, and fine-tune the data collection 

methodology for other provider-based follow-on studies. 

The Hospital and Surgical Care Component collects data 

on the utilization of resources in short-stay hospitals and 

ambulatory surgical centers. This is done through the National 

Hospital Discharge Survey, which has been conducted annually since 1965, and the National Survey of Ambulatory 

Surgery, which will be operational in 1994. 

Data on visits to office-based physicians and hospital 

emergency departments, outpatient departments, and clinics 

are collected through the National Ambulatory Medical Care 

Survey and the National Hospital Ambulatory Medical Care 

Survey. These surveys, which are currently conducted on an 

annual basis, make up the Ambulatory Care Component of the 

NHcs. 

Purposes of the NHHCS 

The purposes of the NHHCS include collection of 

National baseline data on the characteristics of hospices


and home health agencies in relationship to patients they


serve and the type of stall they employ


Data on Medicare and Medicaid certiilcation


Data on charges to patients by hospice and home health


agencies


Information about the source(s) of payment for services


from hospices and home health agencies


Information about patients receiving home and hospice


care including functional status and diagnosis


Information about the categories of people employed by


hospices and home health agencies


1

Data from the NHHCS will be available to analyze 

relationships that exist between services offered and the populations served by hospices and home herdth agencies. Such 

analyses of data ‘oh utilization, diagnoses, and services can 

make important contributions to specific areas of epidemiologic surveillance, particularly chronic disease, injury, and 

aging. 

The data set and procedures for the NHHCS were developed and evaluated in 1990 in the study, Feasibility of 

Studying Hospices and Home Health Agencies (2). Results 

from this study were refined and pretested in 1991 in preparation for the National Survey. The developmental, testing, and 

evaluation processes, which resulted in the NHHCS, are 

presented in this report. Appendix II contains definitions of 

selected terms used by the NHHCS. Changes will be documented as needed in the Technical Appendix of the NHHCS 

summary reports (see “Data publication and availability” in 

the section “The National Home and Hospice Care Survey” in 

this report). 
Feasibility of studying 

hospices and home health 

I agencies 

I 

The first step in the development of the National Home 

and Hospice Care Survey (NHHCS) was the study, Feasibility 

of Studying Hospices and Home Health Agencies (Feasibility 

Study) (2). This study was done under contract in 1990; its 

purpose was to determine the availability of data and to 

develop and test data collection plans for the NHHCS and the 

hospice and home health agency part of the 1991 National 

Health Provider Inventory (NHPI). Because of this dual 

purpose, there were two elements of interest in the Feasibility 

Study: the agency providing the service (the NHPI part) and 

the client or patient served (the NHHCS part). Although this 

dual nature is evident throughout the Feasibility Study, this 

report will concentrate on the NHHCS part of the study. 

Sampling frame and sample selection 

The sampling frame and sample selection for the Feasibility Study are summarized in table A. The agency sampling 

frame was a list of hospices and home health agencies 

developed from lists of agencies provided by States, the 

Medicare Provider of Service file of the Health Care Financing 

Administration, and national directories created by trade groups 

and other organizations. Based on this sampling frame, it was 

estimated that there were approximately 1,600 hospices and 

10,000 home health agencies in the United States. The client 

sampling frames were lists of current and discharged clients 

(or patients) that were constructed by the interviewer at the 

time of the interviewer’s visit to the agency. See appendix III 

~ for copies of the forms used to construct these patient lists, 

The design used to select the sample for the Feasibility 

Study was a multi-stage design similar to that planned for the 

NHHCS. The first stage consisted of eight purposively selected 

TableA. Sample seleetion for the Feasibility Study for the 

Natlonsl Home and Hospice Care Survey 

Sampling frame source-s 

Agencies 

Lists from States 

Medicare Provider of SeM”ca File 

National diraetories 

Client= 

Lists constructed by intem”ewer 

Sample selection 

Primary sampling units (a) 

Agencies (192) 

Hospices (80) 

Home health agencies (112) 

Cllents+eleeted from 96 agencies 

Current patients (4 per agency) 

Dlscherges (4 per agency) 

areas called primary sampling units (PSU’S). These PSU’S 

were geographically dispersed throughout the contiguous United 

States and included urban and nonurban areas. Within each of 

the eight PSU’S, the frame was sorted by ZIP Code and type of 

agency (hospice or home health agency). A systematic random 

sample of 192 agencies was selected from these areas-24 (10 

hospices and 14 home health agencies) in each PSU. These 

agencies were used to test the questionnaires and procedures 

for the NHPI. Half (96) of these agencies were randomly 

selected for the NHHCS part of the Feasibility Study. Lists of 

current clients and of discharges were constructed for these 

agencies. Client informatiori was obtained from a systematic 

sample of four current patients and four discharges that were 

on these lists. 

Data collection instruments 

Three questiomaires and two listing forms were used in 

the Feasibility Study: an Agency Questionnaire, an AWstrator’s Questionnaire, a Client Questiomiike, a Current Client 

Listing Form, and a Discharged Client Listing Form. These 

data collection instruments are shown in appendix III. The 

questionnaires were used to collect data about the agencies, 

the clients (or patients) served, and the services provided 

(table B). The listing forms were used by the interviewers to 

aid in selecting the samples of current clients and of discharges. 

The Agency Questionnaire included the types of agency 

data that were to be collected primarily through the NHPI. 

This information included identification, operating status, type 

of ownership, Medicare and Medicaid certification, and maintenance of clinical records by the agency. Also included were 

questions on the types of services provided by the agency, the 

types of personnel providing the services, the types and 

numbers of clients served, and the number of visits made to 

clients during the previous year. 

Table B. Questionnaires used and information obtained for the 

Feasibility Study for the Nstional Home and Hospice Care Survey 

Agency Questionnaire Client Questionnaire 

(NHPI) (NHHCS) 

Agency data Demographic chsraoferistioa


Services provided Administrative data


Personnel Family and home environment


Ctient data Sources of referral


Health status 

Administrators Questionnaire Functional status 

(NHHCS) Services provided 

Agency data Payment information 

Client data 

3 
The Administrator’s Questionnaire was a shortened version of the Agency Questionnaire and included agency data 

that were to be collected through the NHHCS. This is summarized in table C. Included are identification information, type 

of ownership of the agency, primary service category of the 

agency, maintenance of clinical records, and Medicare and 

Medicaid certifmation. Questions were also asked about the 

types and numbers of clients served and discharges that 

occurred during the previous year. 

The Client Questionnaire, which was also to be used in 

the NHHCS, collected data on current and discharged clients. 

Aa shown in table D, this questionnaire obtained information 

about the client’s demographic characteristics; family and 

home environment, including where and with whom the client 

was living, services provided to the clients, including number 

of visits made to the client by agency stti, health and 

fictional status of the clients, including presenting diagnoses 

charges and sources of payment for the services provided; 

sources of referral to the agency date of enrollment and, for 

discharged clients, date, status, and reason for discharge. In 

order to determine data availability, sources of the information 

used to answer the items on the client questionnaire were 

collected by asking the respondent if the information was 

obtained from the client’s primary record, from a supplementary record, from the respondent’s personal knowledge, or 

from consultation with another stafEmember. 

The Current and Discharged Client Listing Forms were 

used to list each client to aid in selecting the client samples. 

The date of enrollment was listed for each current client and 

the date of discharge was listed for each discharged client. 

Data collection methods 

The data collection methods for the Feasibility Study are 

summarized in figure 1. The Feasibility Study was done in two 

Table C. Information collected through the Administrator’s 

Questionnaire for the Feasibility Study for the National Home 

and Hospice Care Survey 

Agency data 

Identification information Primary service category 

Aaencv name. address. and HoaDice 

t&lepfione number “ Home health ssre 

Mailing and location Hospice and hame health care equal 

Administrator’s name, title, end Other 

telephone number 

Clinical records 

Ownership Maintained by agency? 

Independent agency Where kept (at this location or at 

Part af chain another location) 

Owned/operated by For currenf/a@-veclients 

Hosp”~ For discharges 

Nursing home 

Federal, atate, ar local Certiiicstion 

heatth deparirnent or agency Medicare 

Other Madiceid 

Client data 

Actiie clients served during 19S9 Discharges during 19a9 

Number of hospice-only clients Number of hospice discharges 

Number af home health care- Number of home health care 

only clients discharges 

Number of clients that were both 

home health oare and hospice 

clients 

Table D. Information collected through the Client Queetionnalre 

for the Feasibility Study for the National Home and Hospice Care 

Suwey - -


Demographic characteristics 

Date of birih 

Sex 

Race 

Whiie 

Black 

Ameriean Indian, Eskimo, Aleut 

Asian, Pacific Islander 

Other 

Hispanic origin 

Marital statue 

Married 

Widowed 

Divorced 

Separated 

Naver married 

Family and home environment 

Living children present 

Family involved in providing care 

Primary caregiver present 

Relationship ta client 

Spouse 

Parent 

Child 

Other relative 

Neighbor 

Friend 

Volunteer graup 

Other 

Whare client Iiw”ng 

Private residence 

Rented roam, boarding house 

Retirement home 

Health fecilii 

Other 

Wtih whom Iiiing 

Alone 

Wti others (family, nonfamily) 

Safety saaeaament dane of home 

Sources of referral 

Self or family 

Nursing home 

Hoap”W 

Physician 

Health department 

Other 

Functional status 

Vision 

Hearing 

Activities of daily Iiiing 

Bathing


Dressing


Eating


Transferring


Walking


Using toilet rmm


Instrumental activities of 

daily Iiing 

Doing light housework 

Handling money 

Shopping far grocerfee/clothes


Using telephone


Preparing meals


Taking medication


Administrative data 

Date of enrollment 

For discharges only 

Date of discharge 

Discharge status 

Alive 

Deceased 

Reason for discharge (narratfve) 

Social Seourity Number 

Payment infarrnation 

Sources and amount billed 

Private insurance 

Own income, family support, etc. 

Medicare


Madicsid


Religious organizdions,


foundations, votunteer agencies


No charge


Other ‘“ 

Care paid by Medicare or prkfa{e 

insurance hospice benefit 

Services provided 

Services provided to family? 

Number of visits made to client 

Days of respite oare provided 

Services to client 

Personal care


Nursing servioes


Physician servioes


Other medical sew~ces


Mental health services


Social services


Physical therapy


Oooupational therapy


Speech and hearing therapy


Vocational rehabiliilon


Special education


Nutritionist services


Sheltered employment


Hamemaker-household services


Transportation


Meals on wheels


Recreational servicim


Housing servicas


Protective overnight services


Medication


Other services


Heatth status 

Diag~osis at errrol~menf 

!2%#ary .--... (up to SfX)

Bladder and bowel status 

Catheter/oetomy 

Continence 

Mental status 

Behavioral problems 

Diaorientstion/memory 

impairment 

Psychiatric symptoms affsetfng 

daily functioning 

phases. In Phase I (the NHPI part) the Agency Questionnaire 

was mailed to all of the 192 sampled agencies. Half of these 

agencies were randomly selected to receive a prenotification 

letter. This was sent out 1 week before the main mailing, that 

consisted of a letter from NCHS explaining the survey, an 

Agency Questionnaire, and letters of endorsement from the 

National Hospice Organization and the National Association 

of Home Care. (Copies of the letters used are shown in 

appendix III.) Agencies not responding to the first mailout 

4 
I


PHASE I A enc Questionnaire Mailouf to 

(&Plf 112 home health agencies SOhospices 

Nonreapondents 

I Second mailout 

Telephone contact 

PHASE II Admiqiefrator’s Interview at 

QuaatlonnaIre (NHHCS) 53 home health agencies 40 hosp[ces ——— —— ——— —. 

Client Questionnaires Interview at 

(NHHCS) 28 home health agencies 20 hospices 

Current clients (4\facilii) 

Discharges (4\facility) Self- administration at 

28 home health agencies 20 hosp!ces ,, 

Verification of half of 

questionnairea 

Figure 1. Data collection methods for the Feasibility Study for 

the National Home and Hospice Care Survey. 

received a second mailed questionnaire with a reminder letter. 

If no response was received to the second mailout, a telephone 

contact was made with the agency. An interview was then 

conducted by telephone in which the information on the 

Agency Questionnaire was obtained. Half (96) of the agencies 

selected for Phase I were randomly selected to participate in 

Phase II (the NHHCS part). Seven home health agencies and 

five hospices were selected in each of the eight PSU’S. These 

96 agencies were then randomly assigned to 1 of 2 groups. 

Interviewers contacted both groups by telephone to gain their 

participation and to set up an appointment with the agency 

administrator. 

At the appointed time, the interviewer met with the 

agency administrator to conduct the interview using the Administrator’s Questionnaire. With the cooperation of the agency 

staff, the interviewer constructed two client sampling lists: one 

of current clients and one of discharges. The Current Client 

Listing Form and the Discharged Client Listing Form were 

used for this process. Current clients were those clients who 

were on the rolls of the agency on the calendar day immediately preceding the day that the interviewer visited the agency. 

The discharges that were listed were those that occurred 

between January 1, 1989, and Deeember 31, 1989. If a person 

was discharged more than once during the year, each discharge 

was listed separately. However, persons who were admitted 

and discharged on the same day were notincluded in the list of 

discharges. In agencies selected as home health agencies only 

home health clients were listed; only hospice clients were 

listed in agencies that were selected for the sample as hospices. Using a programmable calculator, the interviewer drew 

a systematic random sample of four current clients and four 

discharges. In the agencies assigned to the first group, the 

interviewer obtained the information on the Client Questionnaire 

for each of the sampled clients by interviewing a member of 

the agency staff designated by the administrator. In the agencies assigned to the second group, the interviewer trained a 

designated staff member how to complete the Client 

Questionnaire. The questionnaires were then left for selfadministration. In both groups the staff member providing the 

information was to refer to each client’s medical record when 

answering the questionnaires. When the interviewer returned 

to the second group of agencies to collect the completed Client 

Questionnaires, the titerviewer veritied the information reported 

in half of the questionnaires by interviewing the staff member 

who completed them or by abstracting the data from the 

patient’s medical reeords. 

Results of the Feasibility Study 

Results of the Feasibility Study are summarized in table E. 

The most important finding was that data about hospices, 

home health agencies, and the patients they serve are available 

and can be collected through a national survey, Of the 96 

agencies that were selected for Phase II, all were able to 

complete the Administrator’s Questionnaire. Moreover, 82 

agencies (85 percent) completed the sampling lists and client 

questionnaires. Some changes were made for the NHHCS 

based on the experiences gained from the Feasibility Study— 

both to the questionnaires and to the procedures used for the 

survey. 

The changes that were made to the data colketion instruments are shown in detail in table F. A shortened version of 

the Administrator’s Questionnaire, referred to as the “Facility 

Questionnaire,” would be used to collect the information 

needed about the sampled agencies. Clients of the agencies 

would more correctly be refereed to as “patients.” Since 

results of the Feasibility Study indicated that using only one 

questionnaire for the two different types of patienta (current 

and discharged) was confusing, two questionnaires (one for 

current patients and one for discharges) would be used to 

collect patient information. The Current and Discharged Client 

Listing Forms were renamed the Current Patient Sampling 

List and the Discharged Patient Sampling List, Since the date 

of enrollment of current patients was not needed, and was not 

always readily available at the listing stage, this item was 

deleted from the Current Patient Sampling List. However, the 

date of discharge was retained on the Discharged Patient 

Table E. Results of the Feasibility Study for the National Home 

and Hospice Care Survey 

Data about hospices and home health agencies are available and can be 

collected through a National survey 

Changes in data collection instruments 

One Facilii Questionnaire, two Patient Questionnaires, two sampling 

lists to be used 

Facility Questionnaire 

Less patient information collected 

Addtional information to be collected on setvicas and staff 

Patient Questionnaires 

Rewording of questions to allow for infants, children, comatose 

and very debilitated patients 

Revision of many questions 

Addtional information collected 

Changes in procedures 

Entire eurvey will be interviewer-administered 

All hospice and home health patients eligible 

Reference period for discharges changed 

Patient sampling done using sampling lists and fable of random numbers 

5 
Table F. Changes made in the date collection instruments for the 

National Home and Hospice Care Survey as a result of the 

Feasibility Study 

Date collection FeaeibilhyStudy 

instrumentsused	 Agency Que*-onnsire 

Administrator’sQuestionnaire 

CurrentClientLWng Form 

DischargedClientListingForm 

ClientQuestionnaire 

Changedtcx 

Facilii Que~-onnsire 

CurrantPatientSamplinglist 

DischargedPatientSamplingList 

CurrentPatientQuedonnaire 

DischargedPatientQuestionnaire 

Informationeolleotad “Clients” (l%aaibilii Study)will be 

referredto as “patients” 

Facilii information Questionson cliniselreeordsdropped 

questionnaire Questionaboutnumberof discharges 

droppad 

Referencetime periodfor cunent 

(active) patientschanged 

Ownershipcategoriesrevised 

Questions on selected services added 

Questionson facilii staffadded 

PatientSemplingLiata Date of enrollmentfor currentclients 

(pat~anta)droppad 

Patient information Demographicchsracteri~”csx 

questionnaires Age of patientasked if date of birth 

not available 

Administrativedst= 

Dischargestatusincludedin reason 

for dischargequestion 

Reason for dischargequestion 

modified 

category aboutassessmentonly 

addad 

Familyand home environment 

Questionon family involvementin 

providingcare d;opped 

Question about safety assessment 

dropped 

Relationshipof primaryoaregiverto 

p~”ent categories revised 

Where patient Iii”ng sategoriee 

rm”sail 

Questionaboutprimatycaragiver 

Iiing with patientadded 

Questionson next of kin addad 

Sourcesof referralcategories 

revised 

Paymentinformation 

Amountbillednot collectedfor each 

souroeof payment 

Souroesof paymentcategories 

revised 

Questionon primarysourceof 

paymentadded 

Services pmvidad 

Questionon servioaapmvidsdto 

familydropped 

Servicesprovidedcategories 

ravhd 

Health status 

Qu@”ons on mentalstatus 

dmppad 

Questionson bladderend bowei 

statusrevised 

Questionon current(ordischarge) 

diagnosisadded 

Questionon specialaids added 

Questionon types of staffthat 

providedservicesadded 

Sampling List since h would be used in deterrninin g which 

discharges are eligible for the sample. 

Several changes were made in the content of the questionnaires. The Facility Questionnaire would collect only agency 

information needed for the survey; therefore, the questions on 

clinical records were dropped since they had served their 

purpose for the Feasibility Study. Less patient information 

would be collected on the Facility Questionnaire-only the 

information needed to determine if the agency was eligible to 

participate in the survey would be necessary. The questions 

about agency ownership and operation were revised and 

questions about selected services and the agency staff were 

added. 

Many of the items on the patient questionnaires were 

re-worded to allow for the fact that hospices and home health 

agencies serve a wider variety of patients (for example, a 

wider age group) than are usually served by more traditional 

long-term care facilities. Some items were revised in order to 

collect better or more complete data. Some questions were 

dropped; others were added. Additional information to be 

collected include the identification of “assessment only” 

patients, the collection of current or discharge diagnoses (in 

addition to diagnoses at admission), information on special 

aids used by each patient, the types of staff that provided 

services to each patient, and information on each patient’s 

next of kin. “Assessment only” patients were those who had 

been admitted by the hospice or home health agency for an 

assessment or determination of eligibility for services but were 

not actually provided services by the agency (for example, 

they may not have met the requirements of the agency for 

provision of services or they may have elected not to receive 

services from the agency). The next of kin information was 

added as a Pretest item to determine the availability of this sort 

of information for use in future follow-up studies. Procedural 

changes and changes made in data collection methods are 

detailed in tabIe G. In the Feasibility Study, patient information was collected through two different methods: personal 

interviewer and self-administered questionnaires. Although 

participation in the Feasibility Study did not differ significantly between the two groups, the completeness of the 

questionnaires was significantly higher for the intervieweradministered group (96 percent) than for the self-administered 

Tabie G. Changes made [n the procedures for the National Home 

and Hospice Care Survey as a result of the Feaslbliity Study 

All questionnaireswouldbe completedby personalinterview: 

Bettercompletionrate 

More uniformityof date 

Lees respondentburden 

All hospiceand home health@“ente adm”ttedto and served by an 

agenoywouldbe eligibleforthe surveyregardlessof howthe agency 

was categorized(hospiceor home healthagency) 

Changea in referenea periodfor discharg~ 

Dischargesduringa 12-monthperiodendingat midnightof the 

day immediatelypraoedingthe day of the interv~ewer’svisit 

to the agency 

Dischargesfor an episodeof care of leasthan one day would 

be included 

Changes in patientsampling 

Numberof currentpatientsand of dischargessampledincreased 

ftom four to five 

Total number of patients listed on sampling lists used h selecting 

sample (ratherthen numbersreportedonAgencyQuealionnaire) 

Sample SelectionTable usadratherthan a programmablecalculatorto 

select sample patientsand discharges 

6 
group (91 percent) (2). Other advantages of an intervieweradministered survey over a self-administered survey included 

the higher motivation of the interviewers to obtain quality 

data, a more thorough and uniform training of the interviewers 

than was possible with agency staff, less respondent burden 

since the interviewer would handle all of the paperwork 

necessary for the survey, and no need for the interviewers to 

return to the agencies to pickup the completed questionnaires 

(or to rely on the agency persomel to mail them in). It was, 

therefore, decided that the National Survey would be entirely 

interviewer-administered. 

Another change that was made as a result of the Feasibility Study concerned the type of patient that was eligible for the 

survey. In the Feasibility Study, only home health patients 

were selected from facilities that were selected as home health 

agencies and only hospice patients were selected from facilities that were selected as hospices. However, it was found that 

many agencies served both types of patients. In addition, the 

Feasibility Study showed that agencies often changed or 

expanded the focus of their sewice. For example, agencies that 

previously served only hospice patients may expand their 

focus to also serve home health patients (or even change their 

focus to ody serve home health patients). Therefore, it was 

decided that all hospice and home health patients admitted to 

and served by an agency would be eligible for the National 

Survey. 

The reference period for discharges was also changed. For 

the Feasibility Study, all discharges that occurred during the 

previous calendar year (January 1, 1989-December 31, 1989) 

were in scope for the survey. This was changed to all discharges that occurred during a 12-month period ending at 

midnight of the day immediately preceding the day of the 

interviewer’s visit to the agency. For example, if the interviewer 

would visit the agency on September 11, 1991, the reference 

period for the discharges fi-om that agency would be September 

11, 1990-September 10, 1991. Many agencies did not have 

discharge information readily available if the discharges had 

occurred more than a year before the interviewer’s visit. By 

changing the reference period in this way, it was felt that more 

complete and more current discharge data would be obtained. 

Another change that was made regarding discharges was 

accepting discharges for an episode of care that lasted less 

than one full day. This change would give more accurate 

information about services provided by these agencies, 

especially by hospices, since, for example, some patients 

admitted to a hospice could die (and thus be discharged) on 

the same day as they were admitted. 

Changes were also made to the sampling procedures at 

the patient level. For the Feasibility Study, a systematic 

sample of four current patients and four discharges was 

selected from each agency. This was increased to five current 

patients and five discharges. Since the sampling interval for 

the Feasibility Study was determined by means of a programmable calculator, the total numbers of current patients and of 

discharges were’ needed in order to program the calculators. 

For the Feasibility Study, these numbers were obtained from 

the Agency Questionnaire (that had been completed before the 

interviewer’s visit) for each agency. If the numbers used in the 

program differed by more than 50 percent from the actual 

number (obtained from the current patient and discharged 

patient listings), the interviewer had to stop the interviewing 

process and call the home office for instructions on how to get 

the correct sampling interval. This problem occurred in over 

25 percent of the cases during the Feasibility Study (2). 

Therefore, a Sample Selection Table, determined from random 

numbers, was created for use in sampling patients. T’he total 

number of current patients and/or discharges was determined 

from the respective listing and a space was added to record 

this number on each listing form. Using this number, the 

interviewer then referred to the Sample Selection Table to 

determine which current patients and discharges should be 

included in the sample. 
Pretest for the National 

Home and Hospice Care 

Survey 

The Pretest, the “dress rehearsal” for the NHHCS, was 

conducted in 1991 by the U.S. Bureau of the Census as the 

data collection agent. The purpose of the Pretest was to 

evaluate all aspects of the data collection plans that were to be 

used in conducting the National Survey, including the methods, procedures, interviewer training materials, data collection 

instruments, and other survey materials. 

Sampling frame and sample selection 

The sampling frame and sample selection for the Pretest 

are summarized in table H. The facility sampling frame was 

the mailing list for the 1991 National Health Provider Inventory (NHPI) and a list compiled from State directories representing those places that opened for business after the NHPI 

list was completed. A total of 100 agencies was selected for 

the Pretest. The patient sampling frames were lists of current 

and discharged patients that were constructed by the interviewer at the time of the interviewer’s visit to the agency. 

The ultimate sampling unit for the Pretest was the patient 

served by each agency. The design used to select the patients 

was a multi-stage design similar to that used in the Feasibility 

Study. The ikst stage consisted of five purposively selected 

areas or primary sampling units (PSU’S) that were geographically dispersed throughout the contiguous United States and 

that included agencies in urban and nonurban locations. The 

second stage consisted of a systematic selection of 20 agencies 

(8 hospices and 12 home health agencies) within each area. 

The third stage of sample selection consisted of a systematic 

probability sample of five current patients and five discharges. 

This was done using a sample selection table and lists of 

Table H. Sampla selection for the Pretest for the National Home 

and Hospice Care Survey 

Sampling frame saurcea 

Agencies 

Mailing list for 1991 National Health Provider Inventory 

state directories 

Patients 

Lists instructed by interviewer 

Sample selection 

Primary sampling units (5) 

Agencies (100) 

Hospices (40) 

Home health agencies (60) 

Patients 

Current patienta (5 per agency) 

Discharges (5 per agency) 

current patients and discharges that were prepared by the 

interviewer during the visit to the agency. 

Data collection instruments 

Three questionnaires and two sampling lists were used in 

the Pretest: a Facility Questionnaire, a Current Patient Questiomaire, a Discharged Patient Questionnaire, a Current Patient 

Sampling List, and a Discharged Patient Sampling List, These 

data collection instruments are shown in appendix IV TIM 

questionnaires were used to collect data about the agencies, 

the patients served, and the services provided (see table J). All 

of the questionnaires in the Pretest were completed by personal 

interview. The sampling lists were used as worksheets by the 

interviewers to aid in selecting the samples of current patients 

and of discharges. 

Agency data were collected through the Facility Questionnaire and included identification information, type of ownership, and Medicare and Medicaid certification. The Facility 

Questionnaire also included a few questions on the types of 

services provided and the types of personnel providing the 

services. This is summarized in table K. 

The Current and Discharged Patient Questionnaires were 

very similar. ‘J3v0separate questionnaires were used, however, 

because results of the Feasibility Study indicated that using 

only one questionnaire for the two different types of patients 

was confusing. The information collected through these questionnaires is shown in table L. Data were collected about each 

patient’s demographic characteristics, including where and 

Table J. Questionnaires used and information obtained for the 

Pretest for the National Home and Hospice Care Survey 

Facilii Questionnaire 

Agency data 

Patient data 

Staffing data 

Patient Questionnaires 

Current Patient Questionnaire and 

Oischargsd Patient Questionnaire 

Demographic character-ktice 

Administrative data 

Family and home environment 

Sources of referral 

Health status 

Functional status 

SeM”ces provided 

Service providera 

Payment information 

8 
Table K. Information collected through the Facility Questionnaire 

for the Pretest for the National Home and Hospice Care Sunfey 

Agency data 

Identification information Primary service oategory 

Agenoy name, address, and Hospice 

telephone number Home health agensy 

Administrator’s name, title, and Hospice/home health care equal 

telephone number Other 

Ownership/operation Services provided 

Ownership Bereavement care 

For profit Pastoral care Nonprofit 

State or local government Number of volunteers 

Federal Government 

Ofher Certiioation 

Operated by hospital Medioare 

Operatad by nursing home Mactbaid 

Part of a group of facilities 

Patient data 

Number of patients served during paat 30 days


Hospice patients Home health care patients


Staffing data 

information obtained about each type of staff (listed below) 

Number of full-time staff Hours worked in last 7 daya 

On payroll By all payroll staff 

Budgeted poeitiona that are vacant By nonpayroll staff 

Number of part-time etaff 

On payroll Vis”h made in last 7 daya by all 

Budgeted positions that are vacant staff 

Type of staff 

Physicians Dieticiane/nutritioniete 

Registered nurses Occupational therapists 

Licensed practical or Speech patholcgiate and 

vocational nurses audiologists 

Nursing aides and attendants Physical therapists 

Home health aides Social workers 

Homemakers/personal oaretakem Health educators 

Other health care providera 

with whom they lived; sewices provided to the patients and 

the types of personnel that provided the services; health and 

functional status of the patients, including admitting and 

current or discharge diagnoses; charges and sources of payment for the services provided; sources of referral to the 

agency; date of admission and, for discharged patients, date 

and reason for discharge. 

The Current and Discharged Patient Sampling Lists were 

used to list each patient to aid in selecting the patient samples. 

After each list was constructed, the total number of current or 

discharged patients was determined. Using these lists and the 

sample selection table (shown in appendix IV), the interviewer 

was able to determine which current patients and discharges to 

select for the sample. 

Data collection methods 

The Pretest began with the mailing of a letter to the 

administrators of the sampled agencies to inform them of the 

survey (see appendix IV). About a week after the letters were 

mailed an interviewer contacted each agency by telephone to 

check that the letter was received, discuss the survey, and to 

set up an appointment with the agency administrator. 

At the appointed time, the interviewer met with the 

agency administrator to conduct the interview using the Facility Questionnaire. Since the staffing information was quite 

Table L, Information collected through the Patient Questionnaires 

for the Pretest for the National Home and Hospice Care Suwey 

Demographic characteristics Administrative data 

Date of birth (or age) Date of admission 

Sex Assessment only done 

Race For discharges only: 

Whtie Date of discharge 

Black Reason for dis&herge 

Amerioen Indian, Eskimo, Aleut Recovered 

Asian, Pacific Islander 

Other 

Hispanic origin 

Marital status 

Married 

Widowed 

Divorced 

Separated 

Never married 

Family and home environment 

Living children present 

Primary csregiver present 

Relationship to patient 

Spouse 

Parent 

Child 

Daughter/son-in-law 

Other relative 

Neighbor 

Friend 

~~e;teer group 

Living with patient? 

Where patient living 

Private residence


Rented roqm, boarding house


Retirement home


Board and care or residential


care facilii


Hospice inpatient


Other health facilii


Other


Wtih whom living 

Alone 

Wflh othera (fsmily, nonfamiiy) 

Next of kin information 

Functional Satus 

VLsion 

Hearing 

Activities of daily living 

Bathing


Dressifig


Eating


Tranafeming


Walking


Using toilet room


Instrumental activities 

of daily living 

Doing light housework


Handling money


Shopping for groceries/clothes


Using telephone


Preparing meals


Taking medcation


Health status 

Admission diagnosis 

Primary 

Seconday (up to five) 

Current or discharge diagnosis 

Primary 

Secondary (up to five) 

Bladder and bowel status 

Catheter/oetomy 

Continence 

Spaeial aids used 

Eye glasses 

Dentures 

Hearing aid 

Wheelchair 

Cane 

Walker 

Crutches 

Brace 

Other 

Stabilized


Moved out of district


Deceased


Adm”M?dto hospital


inpatient service


Admitted to nursing home


Other


Social Security Number 

Payment information 

Amount billed (including none) 

Sources of payment (primary, all) 

Private insurance 

Own income, family support, etc.


~eljJrJantal Saourity Ineeme


Medicaid


Other government assistance or


welfare 

Religious organizations, foundations, 

agencies 

Veterans’Adminiatratkmcompensation 

Not yet determined 

Ofher 

Source-sof referral 

SeMfarnily 

Nursing home 

HosPitel 

Physician 

Health department 

SOeialsetvfca agenoy 

Other 

Services provided 

Number of visits made 

Setvices 

Diafary/nutritionalservkea


0cx2upsfionaWccationaltherapy


Speech fherapyhudiobgy


Homemaker/mmpanionseM”ces


Meals on wheels


Transportation


Enteroatomaltherapy


counseling


Medications


Respiteoare


High-techcare


Referral services


Personal care


Willed nursing services


Physiciansem”cee


Social eervicee


Physicaltherapy


Other servbs


Service providets 

Physicians 

Reg’ksteradnurses


Licensed practbal or vocational nurses


Nursing sides and attendanta


Home health aides


Homemakers/personalcaretakers


Occupationaltherep”m


Spaaeh pathologists wdiilogiata


Physicaltherapists


Sw”al workers


Health educators


Other movidera


9 
extensive, a separate worksheet was available that the administrator or other agency staff member could complete while the 

interviewer continued with the rest of the survey. This worksheet was to be collected by the interviewer before leaving the 

agency. 

After the Facility Questionnaire was completed, the interviewer, with the cooperation of agency staff designated by the 

administrator, constructed two lists: one of current patients 

and one of discharges. The Current Patient Sampling List 

(CPSL) and the Discharged Patient Sampling List (DPSL) 

were available for this purpose. These lists are shown in 

appendix IV Current patients were those patients who were on 

the rolls of the agency on the evening before the day of the 

survey. The discharges listed were those that occurred during 

the 12 months before the day of the survey. 

Some agencies already had lists available that the interviewer could use. Other agencies, especially those with computer capabilities, offered to generate computer lists for the 

interviewer. In these cases, the interviewer used the agency 

lists rather than creating the lists by hand. After the lists were 

completed (whether they were interviewer-generated or agencygenerated), the interviewer checked them for completeness 

and accuracy. If the lists were not complete, the interviewer 

added any patients (or discharges) that were missing. SirniIarly, the interviewer deleted any patients (discharges) that 

were on the lists but were out of scope for the Pretest. The 

interviewer completed Step 3 of each sampling list that asked 

for the total number of patients or discharges listed. Then, 

using a sample selection table, the interviewer drew a systematic sample of five current patients and five discharges. In 

agencies with fewer than five current patients (or discharges), 

all patients (discharges) were selected for the respective 

sample. 

The interviewer then obtained the information on the 

Current and Discharged Patient Questionnaires for each of the 

sampled patients by interviewing a member of the agency 

staff. The staff member was to refer to each patient’s medical 

record to obtain the information in the questionnaires. At no 

time were the patients themselves contacted. The interviewers 

were instructed to complete as much of the interviewing 

procedure as possible in one visi~ return visits were discouraged since one purpose of the Pretest was to determine how 

much information could be obtained in only one visit to the 

agency. 

When all the interviews were completed, the interviewer 

returned to the administrator to collect the Facility Staff 

Worksheet (if applicable) and to leave a thank-you letter, 

thanking the administrator for his or her time and cooperation. 

A copy of this letter is in appendix W. 

Results of the Pretest 

Very few changes were made as a result of the Pretest for 

the National Home and Hospice Care Survey. Changes made 

to the data collection instruments and to the procedures are 

summarized in table M. 

The item in the Facility Questiomaire asking for the 

primary service category of the agency was deleted. Instead, 

Table M. Changea made in the data collection Instruments and 

procedures for the National Home and Hospice Care Survey as a 

result of the Pretest 

Changes to data collection instruments 

Facilii Que~”onnaire	 Question on primaty service category dropped 

Questions on services provided added 

Questions on certiieation revised 

Questions on patienta served revised 

Staffrng datzx 

Reference time period changed 

Stsff categories revised 

Patient Sampling Lists Line number and patient identiier listed 

for sampled patients 

Discharged Patient Sampling List 

Dates of reference period added 

Dates of partial listing added 

(ii applicable) 

Patient Questionnaires	 Question on type of care received added 

Family and home environment 

Question on living children dropped 

Questions on next of kin dropped 

Where patient living categories revised 

Special aids categories revised 

Sewices provided categories reordered 

Types of staff that provided services 

revised and reordered 

Changes to proesdures 

Number of current patients and of discharges sampled increased from five to SIX


Return visits made to agency if necessary to obtain complete data


Facilly staffing worksheet could be mailed to intem”ewer


Changes in reference period for discharges


Discharges during a 12-month period ending the last day of the month 

before the interviewer’s visit to the agency 

Listing of discharges for patt of a 12-month period accepted 

the agency administrator would be asked a series of questions 

to determine if the agency currently provides home health 

and/or hospice care services, if the agency provided these 

types of services to patients during the 12 months before the 

interview, and if the agency currently had any active home 

health or hospice care patients. If the answers to all three of 

these questions were “No,” the agency would be out of scope 

for the survey and the interview would be terminated. 

The questions on certification status of the agency were 

expanded to get more specific information. For the Pretest, 

only certification status (Medicare and/or Medicaid) was ascertained. Additional questions would be asked in the National 

Survey to determine if an agency is certified as a hospice, a 

home health agency, both, or neither. 

More information would be obtained on the Facility 

Questionnaireabout the numbersand types of patientsserved. 

The Pretest asked for the numbers of hospice and of home 

health care patients served during the past 30 days. The 

National Survey, on the other hand, would ask about the 

numbers of current patients and of patients served during the 

past 12 months. Separate numbers would be asked for those 

served ordy as hospice patients, only as home health care 

patients, and as both hospice and home health care patients, 

The question about the agency’s stafE would also be 

modiiied slightly. The reference time period would be changed 

from the past 7 days to the most recent pay period since 

personnel information by pay period was found to be more 

readily available. In addition, the categories of type of staff 

would be expanded to include additional types of service staff 

and administrative staff. 

10

Very few changes would be made to the Patient Sampling 

Lists. The interviewer wouId list the line numbers and the 

identifier of the sample patients on the frout of the form in 

order to make it easier for the agency personnel to pull the 

medical records for the sample patients. Space would be added 

to the Discharged Patient Sampling List for the dates of the 

reference period and, if applicable, the dates of partial listings 

(see the following paragraph on procedural changes for more 

information). 

Some changes wouId also be made to the Patient Questiomaires as a restdt of the Pretest. In order to identi& the 

numbers of patients receiving hospice or home herdth care, an 

item would be added to the Patient Questionnaires asking for 

the type of care the patient received from the agency (hospice, 

home health, or other). The questions about living children 

and the next of kin item would be deleted from the Patient 

Questionnaires. The next-of-kin questions were included in the 

Pretest to determine whether this type of information could be 

obtained through the NHHCS. The Pretest results indicated 

that it is indeed possible to obtain this type of intormatiom, 

however, it will not be collected by the NHHCS until follow-up 

studies will be done. Some questions on the Patient 

Questionnaires were revised, mainly by adding additional 

categories that were found to be needed based on the results of 

the Pretest. Finally, some rewording and reordering of data 

items were done to the questionnaires as a result of the Pretest. 

The Pretest also indicated the need for some procedural 

changes in order to get more complete and valid data. A 

sample of six current patients and six discharges would be 

selected for the National Survey (compared to five each for the 

Pretest). The interviewers would be instructed to make return 

visits to the agencies (if necessary) in order to obtain the 

information requested. The agencies would be able to mail in 

the stafiing information collected on the Facility Questiomaire 

if additional time was needed to respond to that item. The 

reference period for discharges would be changed to the last 

12 months as of the last day of the month before the interview 

rather than as of the day before the interview. For example, if 

the interview were conducted on September 9, 1992, the 

reference period for discharges would be September 1, 1991-

August 31,1992 (rather than September 9, 1991-September 8, 

1992, as was done in the Pretest). A list of discharges for less 

than a 12-month period would be accepted for sampling as 

long as the available time period could be identfied and it falls 

within the 12-month reference period of the N.HHCS. 

11

The National Home and 

Hospice Care Survey 

The National Home and Hospice Csre Survey (NHHCS) 

began operation in September 1992. This survey is conducted 

annually and collects baseline data on the characteristics of 

hospices and home herdth agencies, the patients they serve, 

and the types of statl they employ. 

Sampling frame and sample selection 

The sampling frame and sample selection for the 1992 

NHHCS are summarized in tables N and O. The agency 

sampling frame is the hospice and home health agency part of 

the 1991 NHPI and all agencies that opened for business after 

the 1991 NHPI and before June 30,1992, as identified through 

the Agency Reporting System (ARS) (3). A representative 

sample of 1,500 agencies was selected. The patient sampling 

frames are lists of current patients and discharges that are 

constructed by the interviewer at the time of the interviewer’s 

visit to the agency. See appendix V for copies of the forms 

used to construct these patient lists. 

The elementary sampling unit of the NHHCS is the 

patient served by the agency. The sampling design used to 

select the sample patients is a three-stage design. The first 

stage consists of the selection of 198 primary sampling units, 

or PSU’S. These PSU’S are the same ones used in the 1985-94 

NCHS National Health Interview Survey (NHIS), a survey of 

the civilian noninstitutionalized population of the United 

States (4). The PSU’s are counties, groups of counties, county 

equivalents (such as parishes or independent cities), or towns 

and townships (for some PSU’S in New England). 

The second sampling stage involves the selection of 

agencies within six primary strata. These strata, which are 

shown in figure 2, were formed in the 1992 sampling frame on 

Table N. Sample salection for the National Home and Hospice 

Care Survey 

Samplingframe souroas 

Agencies 

1991 National Health ProviderInventory 

AgencyReporlingSystem 

Patients 

Listsecmstruotedby interviewer 

Sample selection 

Primarysamplingun”k (198) 

Agencies(1,500) 

Hospices(3s4) 

Home health and other agencies (1,116) 

Patients 

Current patients (6 per agency) 

Discharges (6 per agerroy) 

Table O. Distribution of hospices and home health agenclea in 

the 1S92 National Home and Hoaplce Care Survey universe 

(sampling frame), National Health Interview Survey primary 

sampling units, and 1992 survey sample by primary strata and 

region 

Home healthend 

Hespieas otheragencies 

NHIS Survey NHIS Survey 

Agency Universe PS1l’s sample Universe PSU’S sample 

Number of agencies 

Al[agencies. . . . . . . 1,014 472 364 7,645 4,055 1,116 

Primary strata 

Self-representing. . . . 36S 351 263 3,226 3,112 566 

Non-seH-representing 

MA. . . . . . . . . . 213 76 76 1,701 710 315 

Non-MSA . . . . . . . 433 45 45 2,916 233 233 

Region 

Northeast . . . . . . . . 169 108 69 1,767 f ,327 340 

Midwest . . . . . . . . . 310 111 85 2,195 877 249 

south . . . . . . . . . . . 335 155 132 2,667 1,294 372 

Weat . . . . . . . . . . . 200 96 78 1,016 567 156 

NOTE PSU is primarysamplingunfi. 

the basis of type of agency, type of PSU, and metropolitan 

statistical area (MSA) status of the PSU. ~pe of agency was 

determined from information collected through the NHPI and 

the ARS. Four types of agencies were considered for selection 

and were placed into one of two groups: (1) hospices and (2) 

home herdth agencies, mixed agencies (those that provide both 

types of care), and unknown type of agency (this second group 

will be referred to as home health and other agencies), Tjrpe of 

PSU refers to those PSU’S that are self-representing (SR) in 

contrast to those that are non-self-representing (NSR). SR 

PSU’S are the largest PSU’S in the United States and were 

selected in the NHIS sample with certainty (probability of 1). 

NSR PSU’S are those that were not selected with certainty (4). 

NSR PSU’S are finther subdivided into MSA and non-MSA 

status. MSA is a metropolitanstatistical area definedby the 

U.S. Office of Management and Budget on the basis of the 

1980 Census. 

Within these six sampling strata, agencies were arrayed 

by one or more of the following characteristics: region (Northeast, Midwest, South, and West), type of ownership (for profit, 

nonprofit, State or local government, Federal Governmentt and 

other), certification status (certified by Medicare and/or Medicaid and not certified), and agency size (number of patients 

12 
I


Setf - r:~es~~nting 

Hospices Metropolitan 

statistical areaz 

Non - self--u~pting 

Nonmetro olitan 

statistic Pareaz 

NHIS PSU’S 

Self- r;~ef$ting 

Home health and 

other Metropolitan 

statistical areal 

Non- sel;~upvting 

Nonmetro olitan 

statistic Pareaz 

1 Facilitiesselected with probabilityproportionalto size. 

2 Facilitiesselected withcetiainty. 

b 

Figure2. Second stage of sample selection for the Natlonel Home and Hospice Care Survey. 

currently being served by the agency). These categories are 

based on information from the NHPI and the ARS. The 

number of agencies selected from each sampling stratum, 

shown in table O, was based primarily on the distribution of 

agencies in the universe and other research results leading to 

the best sample design for the 1992 NHHC!S, As shown in 

figure 2, hospices in the NSR PSU’S (MSA and non-MSA) and 

home health and other agencies in the non-MSA NSR PSU’S 

were selected with certainty. Hospices in the SR PSU’S and 

Table P. Questionnaires used and Infonrration obtained for the 

National Home and Hospice Care Survey 

Facilii Questionnaire 

Agency data 

Patient data 

Staffing data 

Patient Questionnaires 

Current Patient Questionnaire and 

Discharged Patient Que~”onnsire 

Demographic charscterietks


Administrative data


Family and home environment


Payment information


Sources of referml


Functional atetus


Health status


Services provided


Setvicss providers


home health and other agencies in the MSA NSR PSU’S, and 

the SR PSU’S were selected with probability proportional to 

the agency size (5). 

The third stage of sample selection, sampling of six 

current patients and six discharges within each agency, is done 

using a sample selection table to obtain systematic probability 

samples of current patients and of discharges. The patients and 

discharges are selected from sampling lists that the interviewers construct for each agency. Current patients are those 

patients who are on the rolls of the agency on the evening 

before the day of the survey. The discharges that are listed 

were those that occurred during the last complete 12-month 

period before the month the survey was completed. 

The agencies selected for the 1992 NHHCS sample will 

be retained for the 1993 and 1994 surveys. The agency sample 

will be updated when the ARS reports a significant number of 

new agencies. The sample patients and discharges will be 

drawn from sampling lists created each year in each sample 

agency as part of the survey procedures. 

Data collection instruments 

Three questionnaires and two sampling lists are used in 

the NHHCS: a Facility Questionnaire, a Current Patient Questionnaire, a Discharged Patient Questionnaire, a Current Patient 

13 
Sampling List, and a Discharged Patient Sampling List. The 

data collection instruments used for the 1992 NHHCS are 

shown in appendix V. Copies of the instruments used for 

subsequent years of the survey will be included in the 

appropriate reports. AU of the questiomaires are completed by 

personal interview. The questionnaires are used to collect data 

about the agencies, the patients serve~ and the services 

provided (see table P). The sampling lists are used as worksheets by the interviewed to aid in selecting the samples of 

current patients and of discharges. 

Agency data are collected through the Facility Questionnaire and include identiikation information, type of ownership, and Medicare and Medicaid cextiilcation. The Facility 

Questionnaire also includes questions on the numbers and 

types of patients served, a few questions on the types of 

services provided, and the types of persomel providing the 

services. This is summarized in table Q. 

The Current and Discharged Patient Questiomaires are 

very similar to each other and to the questiomaires used in the 

Pretest, Based on results of the Pretest, the ordering of some 

questions was changed, additional response categories were 

added to some items, and art item identi@ing the type of care 

Table Q. Information colleeted through the FacilityQuestionnaire 

for the National Home and Hospice Care Survey 

Agency data 

Identification information Services pmvidad 

Agency name, address, end Home health or hospice care 

telephone number Currently 

Adminiatratots name, title, and .During last 12 months 

telephone number Bereavement care 

Pastoral care 

Ownership/operation 

Ownership Number of volunteers 

For profit 

Nonprofit Certification 

Btate or local government Medicare 

Federal Government Aa home health agency 

Other Aa hospioa 

Operated by hospital Medicaid


Operated,by nursing home As home health agency


Psrt of a group of facilities Aa hospice


Patient data 

Number of patienta served during Number of patienta currently 

past 12 months being served 

Home health only Home heatth only 

Hospice only Hospice only 

Both hospice and home heaith Both hospice end home heaith 

Staffing
 date 

Information obtained about each type of staff (listed below) 

Number of full-time staff H;n&vorkad during last pay 

On payroll 

Budgetad positions that are vacant By all pSyrOtlatsff 

Number of part-time staff By nonpayroll staff 

On payroll 

Budgetad positions that are vacant V#y&d~&d; during last pay period 

Type of staff 

Physicians Physical therapists 

Registered nursea Social workera 

Licensed practical or Heaith educators 

vocational nurses Psstorst/bereavement staff 

Nursing aides end attendants Administrator/diractor 

Home haaIth aides Case manager/coordinator 

Homemakers/peraonal osretakers Sacraterisl/clerical 

Dietitians/nutritionists Other health paraonnel 

Occupational therapists Other personnel 

Speech pathologists and audiologists 

Table R. information colleeted through the Patient 

Questionnaires for the National Home and Hospice Care Survey 

Demographic characterfatica 

Date of birth (or age)


Sex


Race


Whiie


Black


American Indian, Eskimo, Aleut


Asian, Pacific Islander


Ofher 

Hispanic origin 

Marital dStUS 

Married 

Widowed 

DMonXd 

Separated 

Never married 

Family and home environment 

Primary caregiver present 

Relationship to p~”ent 

Spouse 

Parent 

Child 

Daughter/eon-in-law 

Other relative 

Neighbor


Friend


V#e$wr group


Living with patient?


where p~”ent ~wing 

Private residence 

Rented room, boarding house 

Retirement home 

Board and care or residential care 

facilii 

Health facilii 

Other 

Wtih Whom ~M”no 

Alone “ 

Wti Ofhem (family and nonfamily) 

Functional etatus 

Vision 

Hem-ng 

Actiiaa of daily Iii”ng 

Bathing


Dressing


Eating


Transfernng


Walking


Using toilet mom


Instrumental activities of daily Iiiing 

Doing light housework 

Handling money 

Shopping for groceries/clothes 

Using telephone 

PmpM”ng meals 

Taking medication 

Health status 

Admission diagnosis 

Primary 

Ssrmndary (up to five) 

Current or discharge diagnosis 

Primary 

Secondary (up to five) 

Bladder and bowel status 

Oathater/asfomy 

Continence 

Special aids used 

Eye glasses 

Dentures 

Heating aid 

Wheelchair 

Cane 

Walker 

Crutches 

Brace 

Oxygen 

Hos@talbad 

Commode 

Other 

Administrative data 

Date of admission 

Assessment only done 

For discharges only 

Date of discharge 

Reason for discharge 

Recavered 

stabilized 

Moved out of district


Deceased


Admitted to hoapifal krpafkmt


service


&d~$d to nursing home


Bociai Security Number 

Typa of care received 

Home health ewe 

Hospice care 

Other 

Payment information 

Amount billed (including none) 

Souroas of payment (primary, all) 

Private insurance


Own inmme, family support, etc.


~i~~eental Security Income


Medicaid


~whe&r3vamment aaslstanca of


Religious organkdions, 

found~”ons, snd agencies

vatersns’AdminMratkm Corrpneath Notyatdaafrnined 

SourceSofrefatlal 

K&L 

-

Healthdapam-w Sodalaendceagerrcy 

Sarvkesprwidsd 

Numberof viails made 

~ 

.ssw&w services 

Socii aer’&%3


counseling


Medi@ona


170’-K%%!%%L@orl rrsdc%e


Respitecare


Refafml sewices


D*/nulrihd Servkes


Pt@oiarr SeNicss


HUktc@r mm


~-


Spaeehfhqapy/atxti&gy


Tmapwk&m


EntntVmlU&aPy


Otha$Sarvices


Sefvicepmwa$s 

Re@fa$adnurses 

ucansadprastidorvo@iond 

Nn%&kfes and attendants 

Homaheantraidaa 

Wmemakars@nwnd Carefakare 

Bccial wrlrm 

V­

= M* 

Heanflducatom 

Vdunfeers 

other prwidars 

14 
provided to the patient (home health, hospice, or other) was 

added. The information collected through these questiomaires 

is shown in table R. Data are collected about each patient’s 

demographic characteristics, including where and with whom 

they lived; services provided to the patients and the types of 

personnel that provided the services; health and functional 

status of the patients, includhg admitting and current or 

discharge diagnosey charges and sources of payment for the 

services provided; sources of referral to the agenc~ date of 

admission; and for discharged patients, date and reason for 

discharge, 

The Current and Discharged Patient Sampling Lists are 

used to list each patient to aid in selecting the patient samples. 

After each list is constructed, the total number of current or 

discharged patients is determined. Using these lists and the 

sample selection table (shown in appendix V), the interviewer 

is able to determine which current patients and discharges to 

select for the sample. 

Data collection methods 

Although the NHHCS is an annual survey, it is not 

operated continuously throughout the year. The NHHCS is 

conducted once a year during a 3- to 4-month period, with the 

U.S. Bureau of the Census acting as the data collection agent 

for NCHS. Before each survey the interviewers undergo 

extensive training in survey procedures, using self-study materials and classroom training. In addition, each interviewer is 

given a manual that contains detailed instructions and information that can be used to answer respondent questions, 

provide detailed definitions of items, and ensure accurate 

entries on the data collection forms. 

Training for the NHHCS is done by the U.S. Bureau of 

the Census and consists of a supervisors’ conference, a 

self-study session, and a classroom training session. The 

supervisors’ conference is held centrally and is attended by 

supervisors from the 12 Census regional ofEces. During the 

conference the questionnaires and listing procedures are 

reviewed, and field and office procedures are discussed. 

The self-study sessions are done by each of the interviewers (referred to as field representatives or FR’s). These sessions consist of written material that the FR’s review and an 

audio tape. The self-study includes information about the 

survey objectives, the forms that are used in the survey, 

confidentiality procedures, and information on contacting agency 

administrators and on resolving problems with the sample or 

participation. The audio tape includes examples of calls to 

agency administrators; listening to the tape enables the FR’s to 

get some practice in calling the administrators and setting up 

an appointment. 

The classroom sessions are conducted by the Census 

supervisors that attended the supervisors’ conference. These 

sessions are held in the regional offices. To assure uniformity 

of training, each supervisor follows a written script that was 

prepared by Census headquarters stail. During the classroom 

sessions the FR’s conduct several mock interviews, completing several facility and patient questionnaires. The FR’s also 

complete several patient listing and sampling exercises. Roleplaying exercises, during which the FR’s respond to respondent 

questions about the survey, are also part of the classroom sessions. 

Each year the survey begins with the mailing of a letter 

from the Director, NCHS, to the administrators of the sampled 

agencies. The purposes of the letter are to enlist the cooperation of each administrator and to inform the administrator of 

the authorizing legislation, purpose and content of the survey, 

and its voluntary nature and confidentiality provisions. Letters 

endorsing the NHHCS are also enclosed. For the 1992 Survey 

an endorsement letter was received from the National &sociation of Home Care (see appendix V). About a week after the 

letters are sent, the interviewers contact each agency by 

telephone to check that the letter was received and to gain the 

participation of the agency. Each interviewer also sets up an 

appointment with the agency administrator at this time. 

At the appointed time, the interviewer meets with the 

agency administrator to conduct the interview using the Facility Questionnaire. Since the stalling information is quite 

extensive, a separate worksheet is available that the administrator or other agency stti member could complete while the 

interviewer continued with the rest of the survey. This worksheet is either mailed back to the interviewer’s supervisor at 

the regional office (a self-addressed stamped envelope is given 

to the agency administrator for this purpose) or is collected by 

the interviewer before leaving the agency.’ 

Mter the Facility Questionnaire is completed, the interviewer, with the cooperation of agency staff appointed by the 

administrator, constmcts hvo sampling list= one of current 

patients and one of discharges. The Current Patient Sampling 

List (CPSL) and the Discharged Patient Sampling List (DPSL) 

are available for this purpose. These lists are shown in 

appendix V. Current patients are those patients who are on the 

rolls of the agency on the evening before the day of the survey. 

The discharges that are listed are those that occurred during 

the last complete 12-month period-that is, during the 12 

months ending the last day of the month before the survey. For 

example, if the interview is conducted on September 9, 1992, 

the reference period for discharges will be September 1, 

1991–August 31, 1992. 

Some agencies may already have lists available for the 

interviewer to use. Other agencies, especially those with 

computer capabilities, may offer to generate computer lists for 

the interviewer. In these cases, the interviewer may use the 

agency lists rather than having to create the lists by hand. 

After the lists are completed (whether they are interviewergenerated or agency-generated), the interviewer checks them 

for completeness and accuracy. If the lists are not complete, 

the interviewer adds any patients (or discharges) that are 

missing. Similarly, the interviewer deletes any patients (discharges) that are on the lists but are out of scope for the 

Survey. Step 3 of each sampling list, which asks for the total 

number of patients or discharges listed, is completed. Then, 

using the sample selection table, the interviewer draws a 

systematic sample of six current patients and six discharges. In 

agencies with fewer than six current patients (or discharges), 

all patients (discharges) are selected for the respective sample. 

15

Steps 6 (number of patients or discharges selected) and 7 (the 

sampled patients or discharges) are answered last. 

The interviewer then completes the Current and Discharged Patient Questionnaires for each of the sampled patients 

by interviewing a member of the agency staff. The staff person 

is instructed to refer to each patient’s medical record to obtain 

the information in the questionnaires. As in the Pretest, the 

patients themselves are not contacted. If necessary, the interviewers will return to the agency to obtain all of the necessary 

information. 

When all the interviews are completed, the interviewer 

returns to the administrator to collect the Facility Staff 

Worksheet (if applicable) and leaves a thank-you letter, 

thanking the administrator for his or her time and cooperation. 

A copy of this letter is in appendix V 

All completed survey materials are reviewed by the 

interviewers in the field before being submitted for processing. 

Attempts are made at that time to retrieve missing data or to 

correct inconsistent data. Qurdity control is also maintained 

through standardized procedures of supervisor observation of 

interviews, review of completed questionnaires, and feedback 

to interviewers. 

Data processing and estimation 

After the entire interview process is completed for an 

agency, the interviewer sends all forms for that agency to the 

supervisor at the regional office where the forms are checked 

in and reviewed for completeness. Any Facility Staff Worksheets that the regional office receives are attached to the 

appropriate Facility Questionnaires. The forms are then sent to 

the NCHS data-processing facility in Research Triangle Park 

North Carolina. 

Manual editing and coding of data are done centrally by 

trained NCHS staff. Diagnoses are coded according to the 

International Classi$cation of Diseases, 9th Revision, Clinical 

Modification (ICD-9-CM) (6). Up to 12 diagnostic codes are 

assigned for each sample patient (a maximum of six at 

admission and a maximum of six at the time of the survey or 

discharge). After keying, extensive editing is conducted by 

computer to assure that all responses are accurate, consistent, 

logicrd, and complete. When necessary, records are reviewed 

manually to resolve inconsistencies. In some cases, missing 

data are’ imputed. All imputed data are identified as such on 

the data tapes to enable the analyst to distinguish between 

imputed data and reported data. After the editing is completed, 

the computer is used to calculate and assign weights, ratio 

adjustments, recodes, and other related procedures necessary 

to produce national estimates from the sample data. 

Because the NHHCS is designed to produce national 

estimates on the use of home herdth and hospice care services, 

the data must have weights to inftate the sample numbers to 

the national estimates. Each record on the IiI@ data tapes has 

a weight for this purpose. By aggregating these weights, 

estimated counts for national data can be obtained. The 

weights used to inflate sample data have three principal 

components: inflation by the reciprocals of the probabilities of 

sample selection, adjustment for nonresponse, and ratio adjustment to fixed totals (7). 

Inflation by the reciprocals of the probabilities of sample 

selection—There is one probability for each stage of sampling (a) the probability of selecting the PSU, (b) the probability of selecting the agency, and (c) the probability of 

selecting the patient or discharge within the agency. For 

example, the probability of selecting a current patient within 

an agency is the number of current patients selected divided 

by the total number of current patients on the agency’s roster 

as of the night before the survey. The overall probability of 

selection is the product of the probabilities at each stage, The 

inverse of the overall selection probability is the basic inflation 

weight. 

Adjustment for nonresponse+WHHCS data are adjusted 

for three types of nonresponse. The first type of nonresponse 

occurs when an in-scope (NHHCS eligible) sample agency 

does not respond. This adjustment is a multiplicative factor 

that has as its numerator the number of in-scope sample 

agencies within each PSU and as its denominator the number 

of in-scope agencies that completed an agency questionnaire 

in that same PSU. The second type of nonresponse occurs 

when an agency does not complete the sampling lists used to 

select the patient or discharge samples. This adjustment is a 

multiplicative factor that has as its numerator the number of 

eligible current patients (discharges) from in-scope sample 

agencies regardless of whether they completed a current 

patient (discharge) questionnaire within each PSU and as its 

denominator the number of eligible patients for in-scope 

agencies that completed at least one in-scope sample current 

patient (discharge) questionnaire in that same PSU. The third 

type of nonresponse occurs when the agency does not complete the questionnaire for a sample patient or discharge, This 

adjustment is a multiplicative factor that has as its numerator 

the number of in-scope sample current patients (discharges) 

within each agency and as its denominator the number of 

in-scope” current patients (discharges) that had a completed 

questionnaire in that same agency. The nonresponse adjustment brings estimates based only on the responding cases up 

to the level that would be achieved if all eligible cases 

respond. 

Ratio adjustment to jixed totals—The purpose of ratio 

adjustment is to take into account all relevant information in 

the estimation process, thereby reducing the variability of the 

estimate. Adjustments are made within each of eight groups 

defined by region (Northeast, Midwest, South, and West) and 

type of agency (hospice or home health and other agencies) to 

adjust for over or undersampling of agencies reported in the 

sampling frame. This adjustment is a multiplicative factor that 

has as its numerator the number of agencies in the sampling 

frame within each region-type of agency group and as its 

denominator the estimated number of agencies for that same 

group. 

Because the statistics produced from the NHHCS are 

based on a sample, they will differ somewhat from figures that 

wouId have been obtained if a complete census had been taken 

using the same schedules, instructions, and procedures. As in 

any sample survey, the results are subject to sampling and 

16

nonsampling errors. Nonsampling errors include errors due to 

response bias, questionnaire and item nonresponse, recording, 

and processing errors. To the extent possible, the latter types 

of errors are kept to a minimum by methods built into survey 

procedures. Such methods include standardized interviewer 

training, observation of interviews, manual and computer 

editing, verification of keypunching, and other quality checks. 

Because survey results are subject to both sampling and 

nonsampling errors, the total error is larger than errors due to 

sampling variability alone. 

The standard error is primarily a measure of the variability that occurs by chance because only a sample, rather than 

the entire universe, is surveyed. The standard error also 

reflects part of the measurement error, but it does not measure 

any systematic biases in the data. It is inversely proportional to 

the square root of the number of observations in the sample. 

As the sample size increases, the standard error generally 

decreases. 

The chances are about 68 in 100 that an estimate from the 

sample differs by less than the standard error born the value 

that would be obtained from a complete census. The chances 

are about 95 in 100 that the difference is less than twice the 

standard error and about 99 in 100 that it is less than 21%times 

as large. 

The standard errors used by NCHS for published data 

from the NHHCS are computed using SUDAAN software. 

SUDAAN computes standard errors by using a first-order 

Taylor approximation of the derivation of estimates from their 

expected values. A description of the sotlware and the approach 

it uses has been published (8). 

Data publication and availability 

This report presents a description of the NHHCS through 

its first year of operation (1992). Preliminary data from the 

1992 NHHCS has been published (9,10,11) and a report 

presenting final data will be available soon (12). Both of these 

reports will be done for each year of the NHHCS. In addition, 

more analytical reports, concentrating on special topics, are 

planned. These will be published by the National Center for 

Health Statistics Vital and Health Statistics, series 1,2, and 13, 

and in Advance Data porn Etal and Health Statistics. Information will rdso be made available in journal articles and in 

papers presented at professional meetings. 

Data from the NHHCS will also be available in the form 

of public- use computer data tapes. Three tapes were produced 

for the 1992 NHHCS: one containing agency information, one 

containing current patient information, and one containing 

discharged patient information. Comparable data tapes will be 

produced for subsequent years of the Survey. 

For general information on the NCHS data tape program, 

computer products currently available, schedule of release of 

upcoming data files, or published information, contacti 

Data Dissemination Branch (DDB)


National Center for Health Statistics


Centers for Disease Control and Prevention


6525 Belcrest Road, Room 1064


Hyattsville, MD 20782


(301) 436-8500


Data tapes and other computer products are sold by the 

National Technical Information Service (NTIS) and are not 

available from NCHS. To purchase computer products from 

NTIS, contacfi 

National Technical Information Service


5285 Port Royal Road


Springfield, VA 22161


(703) 487-4650


17


., .: 
References


1.	 Institute of Medicine. Toward a national health care survey, a 

data system for the 21st century. Washin@oIXNational Academy 

Press. 1992. 

2. Eisenhower D, MaiYeo C, DiGaetano R. Feasibility study for 

surveying hospices and home health agencies. Contract no 

200-88-7016. Rockville, Maryland Westat, Inc. 1990. 

3. National Center for Health Statistics. Development and maintenance of a national inventory of hospitals and institutions. 

National Center for Health Statistics. Wal Health Stat 1(3). 

1965. 

4. Massey JT, Moore TF, Parsons VL, Tadras W. Design and 

estimation for the National Herdth Interview Survey, 198>94. 

Nationrd Center for Health Statistics. Vhal Health Stat 2(110). 

1989. 

5.	 Hoffman K. Specifications for selecting the NHHCS sample 

home health agencies and hospices. Unpublished memo. 1992. 

6.	 Public Health Service and Health Care Financing Administration. International Classification of Diseases, 9th Revision, 

clinical modtication, 4th ed. Washington Public Health Service. 

1990. 

7.	 Hoffman K. Specbications of estimators for NHHCS. Unpublished memo. 1992. 

8.	 Shah BV, Barnwell BG, Hunt PN, LaVange LM, SUDAAN 

user’s manual, release 5.50. Research Triangle Park, North 

Carolimx Research Triangle Institute. 1991. 

9.	 Strahan G. Gverview of home herdth and hospice care patients: 

Preliminary data from the 1992 National Home and Hospke 

Care Survey. Advance data from vital and health statistics; no 

235. Hyattsville, Maryland National Center for Health Statistics. 1993. 

10.	 Centers for Disease Control and Prevention. Home-health tmd 

hospice care-United States, 1992, MMWR 42(42} 820-4. 

1993. 

11.	 Hing E. Characteristics of elderly home health patients: Preliminary data from the 1992 National Home and Hospice Care 

Survey. Advance data from vital and health statistics; no 247. 

Hyattsville, Maryland National Center for Health Statistics. 

1994. 

12.	 Haupt BJ, Hing E, Strahan G. The National Home and Hospice 

Care Survey 1992 summary for the United States. National 

Center for Health Statistics. Vital Health Stat. In preparation. 

18 
Appendixes


Contents 

I. NCHS authorizing legislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20


II.	 Definitions of certain terms for the National Home and Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21


Terms relating to agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21


Terms relating to patients and discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21


III.	 Letters and data collection instruments for the Feasibility Study for the National Home and


Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...’.... . . . . . . . . . . . . . . . . . 23


IV	 Letters, data collection instruments, and sample selection tables for the Pretest for the National Home and


Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63


v	 Letters, data collection instruments, and sample selection table for the National Home and


Hospice Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108


19

Appendix I 

NCHS authorizing legislation 

NATIONAL CENTER FOR HEALTH STATISTICS 

Sec. 306. [Z+zk] (a) There is established in the Department of Health and Human Services the 

National Center for Health Statistics (hereinafter in this section referred to as the “Center”) which shall be 

under the direction of a Director who shall be appointed by the Secretary and supervised by the Assistant 

Secretary for Health (or such officer of the Department as may be designated by the Secretary as the 

principal adviser to him for health programs). 

(b) In carrying out section 304(a), the Secretary, acting through the Center -

(1) shall collect statistics on­


(A) the extent and nature of illness and disability of the population of the United States (or


any groupings of people included in the population), including life expectancy, the


incidence of various acute and chronic illnesses, and infant and maternal morbidity and


mortality,


(B) the impact of illness and disability of the population on the economy of the United States


and on other aspects of the well-tilng of its population (or of such groupings),


(C) environmental, social, and other health hazards,


(D) determinants of health,


(E) health resources, including physicians, dentists, nurses, and other health professionals by 

. specialty and type of practice and supply of services by hospitals, extended care facilities, 

home health agencies, and other health institutions, 

(F) utilization of health care, including utilization of (i) ambulatory health services by 

specialties and type of practice of health professionals providing such service, and (ii) 

services of hospitals, extended care facilities, home health agencies, and other institutions, 

(G) health care costs and financing, including the trends in health care prices and costs, the 

sources of payments for health care services, and Federal, State, and local governmental 

expendkures for health care services, and 

(H) family formation, growth, and dissolution; 

(2) shall undertake and support (by grant or contract) research, demonstrations, and 

evaluations respecting new or improved methods for obtaining current data on the matters 

referred to in a paragraph (1J 

(3) may undertake and support (by grant or contract) epidemiologic research, 

demonstrations, and evaluations on the matters referred to in paragraph (1} and ....” 

(4 may collect, furnish, tabulate, and analyze statistics, and prepare studies, on matters 

referred to in paragraph (1) upon request of public and nonprofit entities under arrangements 

under which the entities will pay the cost of the service provided. 

Amounts appropriated to the Secretary from payments made under arrangements made under paragraph (4 

shall be available to the Secretary for obligation until expended. 

20 
Appendix II 

Definitions of selected terms 

used by the National Home 

and Hospice Care Survey 

Terms relating to agencies 

Hospice and Home Health Agen~Hospices and home 

health agencies are usually defined in terms of the type of care 

that they provide. They may be free-standing health facilities 

or units of larger organizations, such as a hospital or nursing 

home. 

Home health care—Home health care is provided to 

individuals and families in their places of residence for the 

purpose of promoting, maintaining, or restoring health or for 

maximizing the level of independence while minimizing the 

effects of disability and illness, including terminal illness, 

Hospice care-Hospice care is a program of palliative 

and supportive care services providing physical, psychological, social, and spiritual care for dying persons, their families, 

and other loved ones. Hospice services are available in the 

home and inpatient settings. Home hospice care is provided on 

part-time, intermittent, regularly scheduled, and around-theclock basis. Bereavement services and other types of counseling are available to the family and significant others. 

Certification-Refers to agency certification by Medicare 

and/or Medicaid. Both programs can certify home health agencies 

and hospices as meeting agency criteria for participation. 

Medicare-The medical assistance provided in title XVIII


of the Social Security Act. Medicare is a health insurance


program administered by the Social Security Administra­


tion for persons 65 years of age and over and for disabled


persons who are eligible for benefits.


Medicaid—The medical assistance provided in title XIX


of the Social Security Act. Medicaid is a Federal or State


administered protyam for the medically indigent.


Geographic region—Agencies are classified by location 

in one of the four geographic regions of the United States that 

correspond to those used by the U.S. Bureau of the Census. 

Region States included 

Northeast	 Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York 

New Jersey, and Pemsylvania 

Midwest	 Michigan, Ohio, Illinois, Indiana, Wisconsin, 

Minnesota, Iowa, Missouri, North Dakota, South 

Dakota, Nebraska, and Kansas 

South	 Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South 

Carolina, Georgia, Florida, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, and Texas 

West	 Montana, Idaho, Wyoming, Colorado, New 

Mexico, Axizona, Utah, Nevada, Washington, 

Oregon, California, Hawaii, and Alaska 

Metropolitan statistical area—The definition and titles of 

MSA’S are established by the U.S. Office of Management and 

Budget with advice of the Federal Committee on Metropolitan 

Statistical Areas. Generally speaking, an MSA consists of a 

county or group of counties containing at least one city (or 

twin cities) having a population of 50,000 or more plus 

adjacent counties that are metropolitan in character and are 

economically and socially integrated with the central city. In 

New England, towns and cities rather than counties are the 

units used in defining MSA’S. There is no limit to the number 

of adjacent counties included in the MSA as long as they are 

integrated with the central city, nor is an MSA limited to a 

single Statq boundaries may cross State lines. The metropolitan population in this report is based on MSA’S as defined in 

the 1980 census and does not include any subsequent additions 

or changes. 

Owzershi&The type of organization that controls and 

operates the home health agency or hospice. 

Forprojit-Operated under private commercial ownership, including individual or private ownership, partnerships, or corporations. 

Voluntary nonprofit+perated under voluntary or 

nonprofit auspices, including church-related and nonprofit 

corporations. 

State or local government-Operated under State, 

county, city, city-county, and hospital district or authority. 

Federal Government—Includes USPHS, Armed 

Forces, and Veterans Administration. 

Terms relating to patients and discharges 

Current patient-A patient on the agency’s roster as of 

midnight of the night before the survey. 

Discharge—A patient formally discharged from care by 

the home health agency or hospice. Live and dead discharges 

are included. A patient can be counted more than once if the 

patient was discharged more than once during the reference 

period. 

21

Activities of daily living—Refers to six activities (bathing, 

dressing, transferring, walking, using the toilet room, and 

eating) that reflect the patient’s capacity for self-care. The 

patient’s need for assistance with these activities refers to 

personal help received from agency stafE at the time of the 

survey (for current patients) or at the time of discharge or 

immediately before discharge (for discharges). 

Instrumental activities of daily living—Refers to six daily 

tasks (light housework preparing meals, taking medications, 

shopping for groceries or clothes, using the telephone, and 

managing money) that enable the patient to live independently 

in the community. The patient’s need for assistance with these 

activities refers to personal help received from agency staff at 

the time of the survey. 

Primary source of payment-The one payment source 

that paid the greatest amount of the patient’s charge during the 

billing period indicated. 

Private insurance+ncludes private health insurance. Excludes unemployment insurance. 

Own income or family support—Includes retirement 

funds, family income, and social security. 

SupplementalSecurityIlzcome+ncludes money from 

Social Security’s Supplemental Security Income. 

MedicareMoney received under the Medicare program for home health or hospice care. 

Medicaid-Money received under the Medicaid program for community-based care. 

Other government assistance or we~are-sources 

of government aid (l?ederal, State, or local) other than 

Medicare or Medicaid. Includes funds available under the 

Older Americans Act (Title III) and Social Service Block 

Oranta (’IMe XX). 

All other sow-ces—Includes religious organizations, 

foundations, volunteer agencies, Veterans Administration 

pensions or compensation, miscellaneous sources, 

no-charge arrangements, and unknown arrangements. 

22 
Appendix Ill 

Letters and data collection’ 

instruments for the ! Feasibility Study for the 

.’


‘
 I National Home and Hospice ~ ~


Care Survey. ,, ,, ,, 

. . 

DEPARTMENT OF HEALTH& HUMAN SERVICES	 Public Health Service 

Centera for Disease Control 

. . .’ ., National Center for Heatth Stati*”cs 

.,,. 3700 Esst-West Highway 

. Hyattsville, MD 20782 

Dear Administrato~ 

The National Center for Health Statistics (NCHS) of the .Centers for Disease Control 

co~ects and provides information on the health of the Nation and the utilization of its health 

resources. As part of this continuing program, NCHS ia conducting “The Study of the Feasibility 

of Surveying Hospices and Home Health Agencies.” This survey is authorized under section 306 

(42 USC 242K) of the Public Health Service Act. 

The purpose of this study is to develop and test the methodology and data collection 

instruments to be used in conducting a National Survey of Hospices and Home Health Agencies. 

The ultimate goal of the larger survey is to provide a more complete information base on available 

long-term care services and the utilization of those services. 

The Feasibility Study includes a small sample of Hospices and Home Health Agencies. 

Agency information will be collected through a mail questionnaire. Although your participation is 

voluntaty and there are no penalties for refusing to answer any question, it is essential that we 

obtain data from all sampled Hospices and Home Health Agencies to meet the survey goals. 

Within the next week, you will receive a short questionnaire from Westat, Inc., the company 

selected by NCHS to help conduct the Feasibility Study. The questionnaire contains items about 

your agenq location and ownership, services provided, and agen~ size and certification. 

Please return your completed questionnaire to Westat. If you have any questions, please 

call Susan Englehart at 1-800-937-8285. 

Sincerely yours,


Manning Feinleib, M.D., Dr. P.H.


Director 23

DEPARTMENT OF HEALTH &HUMAN SERVICES Public Health Service 

National Center for Health Statistics 

Centersfor Disease Control 

37OOEast-West Highway 

HyattsviHe, MD 20782 

January22,1990 

Dear Administrator 

The National Center for Health Statistics (NCHS) of the Centers for Disease Control 

collects and provides information on the health of the Nation and the utilization of its health 

resources. As part of this continuing program, NCHS is conducting “The Study of the Feasibility 

of Surveying Hospices and Home Health Agencies.” This survey is authorized under section 306 

(42 USC 242K) of the Public Health Service Act. 

The purpose of this study is to develop and test the methodology and data collection 

instrumentsto be used in conducting a National Survey of Hospices and Home Health Agencies, 

The ultimate goal of the larger survey is to provide a more complete information base on available 

long-term care services and the utilizationof those services. 

T’he Feasibility Study includes a small sample of Hospices and Home Health Agencies. 

Information about your agency will be collected through the enclosed mail questionnaire which 

should take 20 minutes to complete. Additionally, for a small subset of agencies, time involving 

some of your staff will be required to complete interviewsconcerning a small sample of clients. No 

clients will be contacted at any time. Although your participation is voluntary and there are no 

penalties for refusing to answer any question, it is essential that we obtain data from all sampled 

agencies to evaluate the data collection procedures and questionnaires. Copies of letters of 

endorsement from organizations which represent Hospices and Home Health Agencies are 

enclosed. 

I want to emphasize that the information you and your staff supply will be used only by the 

National Center for Health Statistics. In accordance with Section 308(d) (42 USC 424m) of the 

Public Health Serviee Act. no information collected in this survey maybe used for any purpose 

other than the purpose for which it was collected. Such information may not be published or 

released in any form if the individual or establishment is identifiable unless the individual or 

establishmenthas consented to its release. 

Please complete the enclosed questionnaire and return it within two weeks to Westat, Inc., 

the firm selected to help NCHS conduct the FeasibilityStudy. A postage paid return envelope is 

included for your convenience. If you have any further questions, please call Susan Englehart at 1-

800-937-8285. 

Sincerelyyours, 

,. .,:, 

..’ y ~ . ,.’. 

... ,,, .., >.:’ . . , 

Manning Feirdeib, M.D., Dr. P.H. 

Director 

24 
I


Ncrtional Hospice Organization 

January 5, 1990


Dear Hospice Administrator:


Enclosed is survey material being sent to you from the


National Center for Health Statistics (NCHS). The prompt~


accurate and thorough completion of the survey questionnaire


is important to the conduct of a national survey of long


term care services and utilization of those services?


including hospices.


Your cooperation can only help NCHS in its efforts to


include hospices in its National Survey of Long Term Care


Facilities~ for developing policies which promote efficient


allocation of health care resources~ and for supporting


research directed at finding effective means for,treatment


of long-term health problems.


The National Hospice Organization requests your assistance


in this most important matter.


Sincerely~
 w“% ohn J ahoney


President


Suite 901 � 1901 North Moore Street~ Arlington, Virginia 22209~ (703)243-5900 

25 
HOMF!mN-1 

NATIONAL ASSOCIATION FOR HOME CARE ANNE M. KATTERHAGEN HONORABLE FRANK E. MOSS 

519 C STREET, N. E., STANTON PARK CHAIRMAN OF THE BOARn SENIORCOUNSEL 

WASHINGTON. D.C. 20002-5809 VAL J. HALAMANDARLS STANLEY M. BRAND 

Telephone (202) 547-7424, FAX (202) 547-3S40 PRESIDENT GENERAL COUNSEL 

January 5, 1990


Dear Colleague:


The enclosed survey material is being sent to you from the


National Center for Health Statistics. It represents an important


first step in the development of a minimum data set for home care


agencies and their patients and the expansion of the National


Survey of Long-Term Care Facilities to include our industry.


The National Association for Home Care supports these


objectives and requests your cooperation.


ncerely,


/


d


? 

Val J. Halamandaris


President


RwRESENTING THE NATION’S HOME HEALTH AGENCISS. HOMEMAKER-HOME HEALTH AIDE ORGANIZATIONS AND HOSPICES 

26 
.

I 

# Swfcz,.e 

# %

[ DEPARTMENT OF HEALTH &HUMAN SERVICES Public Health Service 

1 f ,4 ‘k,,.

c 

National Centerfor Health Statistics 

Centers for Disease Control 

3700 East-West Highway 

Hyattsville, MD 20782 

February 7,1990 

Dear Administrator 

You were recently asked to complete a questionnaire for “The Study of the Feasibility of 

Surveying Hospices and Home Health Agencies.” The survey is being conducted by the National 

Center for HeaIth Statistics (NCHS) of the Centers for Disease Control. 

I want to emphasize that the information you supply will be used solely for statistical 

research and reporting purposea. No information collected under the authority of Section 306(d) 

(42 USC 242K) of the Public Health Service Act maybe used for any purpose other than the 

purpose for which it was collected. Such information may not be published or released in any form 

if the individual or establishment is identifiable unless the individual or establishment has 

consented to such release. 

The data from this study will be used to test the methodology and data collection 

instruments to be used in conducting a National Survey of Hospices and Home Health Agencies. 

The ultimate goal of the longer study is to provide a more complete information base on available 

long-term care services and the utilization of these services. It is important that hospice and home 

health agencies be part of this information set. Although your participation is voluntary, it is 

essential that all those surveyed respond so that the estimates areas aaxrate as possible. 

Since we have not received your completed questionnaire, another copy of the questionnaire 

and a postage-paid business reply envelope are enclosed. We would greatly appreciate your 

cooperation in completing and. returning your questionnaire within five working days. The 

questionnaire takes only 20 minutes to complete, and your answers are totally confidential. If you 

have any questions, you may cdl Susan Englehart at 1-800-937-8285for answers. 

Sincerely yours, . ....+ 

. i

.. b.?” . ... ,.. /... ,,,,-.- t.><... .‘.:.- -, 

Manning Feinleib, M.D., Dr. P.H. 

Director 

27 
OMB ~ 0920-0236 

Expires 01/01/92 

(Placelabeihere) 

PublkfofJolung burdwlrorlhhcdhdbll d Infomdon b odlmdod 10 

~adnbwf~. sod cannwnh rqardfng thb 

burdm dlmdo or anydhor mpod d this colbdon ofInfmdon, 

Inciudlng 811ggodbn8 for rwwllg thb bufdon to PHs Fbpolia 

CIOUMCQOffkq Alltk W HuboIIH. HumphmySLMIIW, Room 

721-W 200 IndopmdoncaAwnuo, SW Waahlngton,D.C. 26201, and 

to thaDmcod Wlqmenl andSudm, PapelwOlkFbdlJcllonProJecf 

~ti Wuhinf@n, D.O.2aso3. 

DEPARTMENT OF HEALTH AND HUMAN SERVICES


Centers for Disease Controi


National Center for Heaith Statistics


FEASIBILITYOFSURVEYINGHOSPICESANDHOMEHEALTHAGENCiES 

AGENCY QUESTIONNAIRE 

informationcontained on this form which would permit identificationof any individualor establishm&t has been 

collectedwith a guarantee that it willbe held in”strictconfidence,wili be used only for purposesstated for this study, 

and will not be disclosedor releasedto otherswithoutthe oonsent of the individualor establishmentin accordance 

withSection30S(d)ofthe PublicHeaithServiceAct (42 USC 242m). 

Conductedby 

WESTAT, INC. 

28 
AGENCY LOCATION AND OWNERSHIP 

1. If your agency’s name, mailing address or telephone number is not printed correctly on the label above, 

please make any naoessary changes in the spaces provided below. If the label inform~”on is correct, skip 

this item and goon to Question 2. 

Agency name: 

Agency mailing address 

2,	 If your agerqts location addreas is different than it’s mailing address, please write the location address in the 

spaces provided below. If the a~enoy mailing address is the same as the location address, skip this item and 

goon to Question 3. 

Agency location address 

cm state zip 

Agency’s phone numbec I——— I I I I——— I I \ l_l_l —— I [ 

29 
3. What isthisagent@ operatingstatus? 

[CIRCLEONEl 

1 Agency currentlyprovideshospicecare and/or home care. 

2	 Agenoydoes notYetprovidehospiceand/or home oare, 

b~ plans to do so in the future. [SPECl~ EXPECTED 

OPERATIONAL DATE BELOW’J “ 

month day year 

3	 Agency is in operationbut no longer provides 

hospiceor home care. 

4 Agency is no longer in operation. 

5 Agenoynever providedhospiceor home care. 

6 Other [PLEASE EXPLAIN] 

IFYOU 

CIRCLED2,3, 

4,5, OR6 IN 

QUESTION 

3, PLEASE 

SKIPTO 

QUESTION 

27ON 3
 PAGE 9.

4.	 What isthe name, titleand telephone number ofthe personwho has day-to-dayresponsibilii for 

administeringor directingthis agent@ 

Administrator’sname 

Administrator’stitle 

30 
1

2

3

4

5

6

?,.. 5. What is the type of ownership of this agency? 

[CIRCLE ONEl 

1 For profit (includes individual or private, partnership, corporation) 

2 Nonprofit (includes church-related, nonprofit corporation, other nonprofrt ownership) 

3 State or local government (includes state, county, C“W,city-county, hospital district or authority) 

4 Federal government (includes USPHS, armed forces, Veterans Administration) 

5 Other [SPECi~ 

6. Is this agency .... 

[CIRCLE ONE] 

an independent organiza”on? 

a branch of a parent agency or part of a chain? 

owned or operated by a hospitat? 

owned or operated by a nursing home? 

owned or operated by a federal, state or local health department or agerr~ 

Other [SPECIFYj? 

7. Does this agency maintain clinical records and/or progress notes of client vis”mor services provided? 

1 YES 

2 NO [SKIP TO QUESTION 11 ON PAGE 5] 

8. Where are clinical/progress records on current/active clients kept? 

[CIRCLE ONEl 

1 At this location. 

2 At another location [PLEASE SPECIFY IN THE SPACE PROVIDED BELOW 

I Agency, place or building name I 

Street address 

I 

c~. State zip 

I 

I I 

3 

31 
9. Where are clinical/progress records on discharged/inactive clients kept? [CIRCLE ONE CODE] 

[CIRCLE ONEl 

1 At this location. 

2 At another location [PLEASE SPECIFY IN THE SPACE PROVIDED BELOWl 

Agency, place or building name 

Street address 

cm state Zip 

10.	 How long are the records on discharged/inactive clients kept? 

Length of time kept [Specify Number in one below] 

l_l_l weeks 

I I I months 

I I I years 

32 
1

2

3

4

5

6

SECTION Ik SERVICES PROVIDED 

I 11.	 What is the primary service category of this agency. Is it primarily a home heatth agency, primarily a hospice, 

a ‘mowed’agency with equal emphasis on both home care and hospice, or an agency with a primary focus 

that is neither home care nor hospice? [CIRCLE ONLY ONE CODE] 

1’ 

[CIRCLE ONLY ONEl 

1 Home care. 

2 Hospice. 

3	 Both hospice and home care 

are equal. 

4 Neither - PLEASE SPECIFY AGENCY’S PRIMARY FOCUS _ 

I 

12. Does this agency provide hospice care to any of its clients? 

1 YES 

2 NO [SKIP TO QUESTION 14 ON PAGE 6] 

13. What type of p~”ent care is provided by this hospice? 

[CIRCLE AU THAT APPLYl 

Hospice oare for persons terminally illwith cancer 

Hospice care for persons terminally illwith chronic obstructive pulmonary disease 

Hospice care for persons terminally illwith neuroiogic diseases 

Hospice care for persons terminally illwith AIDS 

Hospice care for children who are terminally ill 

Other [SPECIFYl 

5 

33 
14.	 How many persons are serving youragency as volunteers (i.e., without remuneration)? 

List numbec 

15. The table below lists categories of care providers who are otten involved in home care and hospice osre. In 

Column A of the table please indicate which types of providers are employed on the staff of this agency. In 

Column B, for each category of provider on staff, please indicate the number of full time equivalents (ITEs) 

!W@l!Y emPloYed by tie agency. Finally, in Column C please indicate whether the agency contracts for 

services of providers, either as an alternative to employing them directly or in addfiion to employing them 

a. Physicians


b. Registered nurses


c. LPNs or vocational nurses


d. Home health aides/personal care taker


e. Psychologists


f. Medioal sooial workers


9. Health educators


h. Ph~ical therapista


..


L	 Nurse’s aides, orderiies, student


nurses and attendants


i.	 Other medical providers (e.g., dentists, 

podiatrists) 

k Other [SPECl~


A. B. c. 

Is/Are List number Any part of 

providers of mEs services 

on staff? on agency provided by 

staff’? contract’? 

YES NO YES NO 

1 2 1 2 

1 2 1 2 

1 2 1 2 

1 2 1 2 

1 2 1 2 

1 2 1 2 

1 2 1 2 

1 2 1 2 

1 2 1 2 

1 2 1 2


1 2 1 2 

6


34

16.	 The table belowlistsservicesthat home healthand hospiceagenciesmay provideto clients. Pleaseindicate 

whetheror not each sarvioelistedbelow is providedby this agenoy. 

I


Is thisservice 

provided? 

YES NO 

a. Dietaryand nutritionalservices 1 2


b. Occupationaltherapy/vocationaltherapy 1 2


c. Speech therapy/audiology 1 2


d. Homemaker/companion servioes 1 2


e. Meals on wheels


f. Transpatation


9. Enterostomaltherapy


h. Bereavementcare


i. Pastoraloare


1 2 

1 2 

1 2 

1 2 

1 2 

j. Counseling(cJientand family) 1 2


k. Medications 1 2


L Respitecare 1 2


m. Hightech care (e.g., iVtherapy) 1 2


n. Referralservices 1 2


o. Other [SPECl~ 1 2


7 
SECTION Ilk AGENCY SIZE AND CERTIFICATION 

17.	 What isthe numbarof activehospicaand otherhome care clientscurrentlyon the agency rolls? Ifthisis 

unavailable,givethe “averagedailycensus”forthe lastperiodtallied. 

a. Enternumberof activehospiceclients........................................................................... 

b. Enternumberof otheractivehdme care clients............................................................. 

c. Entertotal numberof activeclients................................................................................. 

Check sour= current � averagedailycensus � 

18.	 During1889 whatwas the numberof hospicaand otherhome care clientsenrolledbythe agenq(? 

a, Enternumberof hospiceclientsin 1989’. ....................................................................... 

b. Enternumberof home care clientsin 1989.................................................................... 

c.	 Enternumberof clientswho were enrolledas both home care and hospiceclients 

in l= [DO NOT INCLUDE THESE CLIENTS IN 18 “a”OR 18 “b’ ABOV~ .............. 

d. Entertotal number of clientsenrolledin 1989. ............................................................... 

19.	 Whatwasthe total number of hospiceand/or home care visits providedby your agency in 1989? [INCLUDE 

VISITS PROVIDED BY AGENCY STAFF AND VISITS PROVIDEDTHROUGH CONTRACT SERVICES] 

Entertotal numberof home visitsin 188!3. ................................................................................. 

20.	 During1989 wh.tiwasthe numberof hospiceand otherhome careclientswho were dischargedby the 

agen~ [IF CLIENT WAS BOTH A HOSPICE CLIENT AND A “NONHOSPICE’ HOME CARE CLIENT, 

PIACE THE CUENT IN THE CATEGORY IN WHICH S/HE WAS ENROLLED AT’DISCHARGE.] 

a. Enternumberof hospiceclientsdischargedin 1988 .................................................... 

b. Enternumberof otherhome care clientsdischargedin 1989 ...................................... 

c. Entertotalnumberof dischargedclientsin 1988 .......................................................... 

21 Does thisagencyprovideacute (inpatient)careto itshospiceand/or home care clients? 

1 YES 

2 NO [SKIPTO QUESTION 24] 

8 

36 
22. 

I 

23. 

24. 

25. 

26. 

27. 

. . .,j, 

How many beds, including contract beds, does the agency have for acute care of hospice and home care 

clients? 

Enter total number of beds 

How many of the agenq?s active hospice and home care clients are currently in acute (inpatient) care? 

Enter total number of clients currently in acute (inpatient) cara 

Is this agency certified by Medicare? 

[CIRCLE ON~ 

1 Certified 

2 Certification pending 

3 Not certified 

Is this agency certified by Media”d? 

.[CIRCLE ON~ 

1 Certified 

2 Certification pending 

3 Not oertified 

Is this agency certified by Medicare to provide hospice care under the special hospice benefit provision? 

[CIRCLE ONEI 

1 Certified 

2 Certification pending 

3 Not certified 

Enter date Agency Questionnaire was oompkrted 

--+-../ 

year 

9 

37 
28. Responders Name 

Respondent’sTfila _ 

The NationalCenterfor HealthStatisticsalongwithWestatwould liketo 

thankyou foryourtime and participationinthissurvey. 

We reallyappreciateyourcooperation. 

10


38

Interviewer Name 

Interviewer ID: 

(Place label here) Date completed 

OMB # 0920-0236 

Expires 01/01 /92 

Public reprflng burden forthls wkrction of information is esfimakd to 

~W ~ mhruf= Per response. Send cornmenfs regsrding this 

burden esfimefe or any other sspecf of this collscilon of information, 

including suggasfions for reducing this burdsn to PHS Reports 

Ckwarsca Dffkac ATIN PRk Hubrxt H. Humphrey Building, Room 

721-N 2u0 Independence Avenue, SW Wsahingfon, D.C, 20Z+J1, and 

10 the Office of Management end Budget Papsrwork Reducfion Projecf 

(C92Ux?xs); Wsshinglon, D.C. 20503. 

DEPARTMENT OF HEALTH AND HUMAN SERVICES


Centers for Diseaae Control


National Center for Heatth Statistics


FEASIBILITY OF SURVEWNG HOSPICES AND HOME HE/iLTH AGENCIES


ADMINISTRATOR’S QUESTIONNAIRE


Information contained on this form which would permit identification of any individual or establishment has been 

collected with a guarantee that it will be held in strict confidence, will be used only for purposes stated for this study, 

and will not be disclosed or released to others without the consent of the individual or establishment in accordance 

with Section 308(d) of the Public Health Service Act (42 USC 242m). 

Conducted by 

WESTAT, INC. 

39 
SECTION k AGENCY LOCATION AND OWNERSHIP 

1.	 If your agen~s name, mailing address or telephone number is not printed oorrectly on the label above, 

please make any necessary changes in the spaces provided below. If the label information is correct, skip 

this item and goon to Question 2. 

Agency name 

Agency mailing address 

cm state zip 

2.	 If your agency’s location address is different than its mailing address, please write the location address in the 

spaoes provided below. If the agency mailing address is the same as the location address, skip this item and 

goon to Question 3. 

Agenoy location address 

cm. state zip 

Agency’sphone numbecl ——— I I I I 

——— I I I I ——— I I I — I

3.	 What is the name, title and telephone number of the pereon who has day-to-day responsibilii for 

administering or directing this agency? 

Administrator% name 

Administrator’s title 

Administrator’s phone numbec I 

——— I ] I I ——— I I I I ——— I I I I _ 

40 
~ 

4. Is this agency . . . [CIRCLE ON~ 

1 an independentorganiza”on? [SKIP TO QUESTION 6] I 

2 

3 

4 

5 

6 

a branchof a parentagenoyor part of a chain?


owned or operated by a hospital?


ownedor operated by a nursinghome?


Owned or operated by a federal, state or 100alhealth department or agen@


Other [SPECl~


5.	 In the space provided below, please enter the mmplate name and address of the agency or organization that 

owns, operates or is the ‘parent’ or head office of this agency. [PLEASE DO NOT ABBREVIATE THE 

ORGANIZATION NAMEl 

Organization name 

Organizationaddress 

c~ State zip 

6. Does this agency maintain clinical records and/or progress notes of client visits or services provided? 

1 YES


2 NO [SKIP TO QUESTION 9 ON PAGE 3]


41

7. Where are clinical/progress records on currentlactive clients kept? [CIRCLE ALL THAT APPLYl 

1 At this location.


2 At another location [PLEASE SPECIFY IN THE SPACE PROVIDED BELOWl


i 

Agency, plaoeor buildingname


Street address


CM state zip


8.	 Where are clinical/progress records on discharged/inactive clients kept? [CIRCLE ALL THAT APPLY_j 

1 At this location. 

2 At another location [PLEASE SPECIFY IN THE SPACE PROVIDED BELOWl 

I Agency, place or building name 

Streetaddress I 

I cm state zip 

9. Does this agency provide hospice care to any of its clients? 

1 YES 

2 NO 

42 
10, What is the primary service category of this agen~ Is it FI& arily a home health agenoy, primarily a hospice, 

a “m”wed’agency ~ e L@ emphasis on both horne$%% an 3 hospice, or an agency with a primary focus 

11. 

12. 

that is ne”tier homeA#&1 ~ hospice? [CIRCLE ONLY ONE CODE] 

~omeh&$\ti 1 A2 Hospice. 

\eQ\&\ 

3 Both hospice and home~care .- are equaf. 

4 Neither * 

PLEASESPECIFYAGENCY’SPRIMARYFOCUS _ 

hai~ 

During 19S9 what was the number of hospice and other homeAcareclients served by the agenc~ 

a. Enter number of hospice clients served in 19S9. .............................................................. 

he&\+h 

b. Enter number of hom~care clients served in 1989 . .......................................................... 

ba.m c.	 Enter number of clients who were served as both homeAare and hospice clients 

in 19&l [DO NOT INCLUDE THOSE CLIENTS IN 1la OR 11b ABOVE] ....................... 

d.	 Enter total number of clients served in 19S9. .................................................................... I 

ha\% 

During 19S9 what was the number of hospice and other hom~care clients who were discharged, both alive 

and de &~fdf ythe agen@ [IF A CLIENT WAS BOTH A HOSPICE CLIENT AND A “NONHOSPICE” 

HOh&AFtECk IENT, PLACETHE CLIENT IN THE CATEGORYIN WHICH S/HE WAS ENROLLEDAT 

DISCHARGE. 

a. Enter number of hospice clients discharged in 1989”. ....................................................... 

hea\*\ 

b. Enter number of other homeAcareclients discharged in 1989°. ......................................... 

I c. Entertotalnumberof discharged clientsin 19S9. ............................................................. I 

4 

4s 
13.	 - Isthisagencycertifiedby Medicare? ~HIS CERTIFICATION STATUS REFERSTO THE PARTOF THE 

AGENCY SAMPLED, LE., HOSPICE M HOME HEALTH CAREAGENCY REGARDLESSOF WHETHER 

THEY PROVIDE BOTH TYPES OF SERVICE. IF RESPONSE IS “NO: ASK IF CERTIFICATION IS PENDING 

CIRCLE ONE.] 

1 Ceftitied 

2 Certifi*”on pending 

3 Not cettified 

14.	 Isthisagenoyoeftifiedby Medicaid? ~HIS CERTIFICATION STATUS REFERSTO THE PARTOF THE 

AGENCY SAMPLED, LE., HOSPICE ~ HOME HEALTH CARE AGENCY REGARDLESSOF WHETHER 

THEY PROVIDE BOTH TYPES OF SERVICE. IF RESPONSE IS “NO,’ ASK IF CERTIFICATION IS PENDING 

CIRCLE ONE.] 

1 certified 

2 Certificationpending 

3 Not certified 

I I 

On behalfof the NationalCenterfor HealthStatisticsand Weetat, Inc., 

I would liketo thank you for yourtime and participationinthis survey. 

We reallyappreciateyour cooperation. 

5 

44 
,. 

(Place label here) 

I 

Date / /19!30


Client #:


Listing Line:


CLIENT CURRENT �


DISCHARGED � 

Interviewer Name 

Interviewer ID: 

OMB#: 0920-0236 

Expires: 01/01/92 

Public reporting burden for this sallaction of Information is estimated 10 

average 20 mlnutaa per reaponae. Bend sommenfs regarding this 

burden eatlrnate or any other aspect of this cdadon of Information, 

Insludlng auggeafions for reducing this burden to PHS Raporis 

ClearMCO OffisW AllN PFW Huberi H. Humphrey Building, Room 

721W 200 Independence Avenue, SW Washington, D.C. ZX?OI, and 

to the office of Management and Budget PaperworfrReduction Project 

(0920-xxsx); Washington, D.C. 20503. 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control 

National Center for Health Statistics 

FEASIBILITY OF SURVEWNG HOSPICES AND HOME HEALTH AGENCIES 

CLIENT QUESTIONNAIRE 

Information contained on this form which would permit identification of any individual or establishment has been 

collected with a guarantee that it will be held in strict confidence, will be used only for purposes stated for this study, 

and will not be disclosed or released to others without the consent of the individual or establishment in accordance 

with Section 308(d) of the Public Health Service Act (42 USC 242m). 

Conducted by 

WESTAT, INC. 

45 
SECTION 1: CLIENT DESCRIPTION 

1. What is/was this client’s date of birth? 

Ill I I I l_l_l_l_.1 

month day year 

2.	 What is/was the sex of this client? 

1 Male 

2 Female 

3.	 Whatis/was the'racial background that bestdescribesttis ctienfl [CIRCLE ONE CODE] 

1 White 

2 Black 

3 Asian, Pacific Islander 

4 American Indian, Eskimo, Aleut 

5 Other [SPECIFYl 

4. Is/was this client of Hispanic origin? [CIRCLE ONE CODE] 

1 Hispanic origin 

2 Not Hispanic 

5. What is/was this client’s current mariial status? [CIRCLE ONE CODE] 

1 Married 

2 Widowed 

3 Divorced 

4 Separated 

5 Never married 

1


46 
., 

As a part of this survey, we would like to have this client’s Social Secur”kyNumber. Provision of this number is voluntary and not 

providing the number will have no effect in any way on this client’s benefits. This number will be useful in conducting future 

follow-up studies. It will be used to match against the vital statistics records maintained by the National Center for Health 

Statistics. This information is collected under the authority of Section 306 of the Public Health Service Act. 

6.	 What is/was this client’s Social Security Numbefl 

Social Security Number: 

l_l_l_l l_l_l l_l_l_l_l 

X6.	 Wheredid you obtainthe information 

used to answer items 1 through 6? 

1 Primary client record 

2 Supplementary record 

3 Your personal knowledge 

4 Consulted another person 

7.	 What was the date of this client’s most recent enrollment with your agenc~ 

Date of enrollment 

L&l L.-L-l lLlal_Ll 

day year 

8.	 Who referred this client to your agenc~ [CIRCLE ALL THAT APPLYl 

1 Self/family referral 

2 Nursing home 

3 Hospital 

4 Physician 

5 Health department 

6 Other [SPECIF’Yj 

9. Does/did this client have any living children? 

1 Yes 

2 No 

2 

47 
1

2

3

4

5

6

7

8

10.	 Is/was the family of this client actively involved in providing care for the clienf? 

1 Yes 

2 No 

11.	 Is/was there an identified individual (such as a family member, neighbor, or friend) not associated with your agency who k 

the client’s primary caregivefl 

1 Yes 

2 No 

“= 

12. What is/was the relationship of the primary caregiverto this client? [CIRCLEONE CODE] 

Spouse


Parent


Child


Other relative


Neighbor


Friend


Volunteer group


Other [SPECIW


13.	 Does/Did the family of this client receive services (such as counseling) lrom your agency, as a part of the plan of care for 

this client? 

1 Yes 

2 No 

14. Has this client been formally discharged? 

1 Yes 

SKIPTO QUESTION18 

. 2 No ON PAGE4 

15. On what date was this client discharged? 

l_l_l l_l_l ll19Ll_l 

month day year 

48 
16. What is this client’s discharge status? 

1 Discharged alive 

2 Dkcharged dead ~ E 

.“ 17. What was the primary reason for discharge from agency services? 

18. Where is this client currently living? [CIRCLE ONE CODE] 

1 Private residence (house or apartment) 

2 Rented room, boarding house 

3 Retirement home 

4 A health facility (including mental health facility) ~ SKIPTO QUESTION21 I 

ON PAGE6

I 

5 Other [SPECIFYl 

19.	 Is this client living with family members, nonfamily members, or alone? [CIRCLE ONE CODE] 

1 With family members 

2 Wtih nonfamily members 

3 Wkh both family and nonfamily members 

4 Alone 

4 

49 
20.	 Has a safety assessment been done of this client’s home environment? [CIRCLE ONE CODE] 

1 Yes, assessment was done by this agency. 

2 Yes, assessment was done by another agency. 

3 No, assessment not done. 

X20. Wheredid youobtainthe informationto 

answerquestions7 through20? 

1 Primaryclientreoord 

2 .%pplementaryrecord 

3 Yourpersonalknowledge 

4 Consultedanotherperson 

5 

50 
SECTION 11:CLIENT FUNCTIONAL ABILITIES 

1 ,, 

The questions in this section of the questionnaire pertain to the client’s functional capabilities at ttie time “ofthe most recent 

assessment by agency staff. It is ~ intended or suggested that a new assessment be conducted for the purpose of answering 

these questions. 

I 

3 21. At the time of the most recent assessment, how well did this client see (with corrective lenses if the client usually wore them)? 

I [CIRCLE ONE CODE] 

1 Normal vision. (Sees adequately in most situations can see newsprint, public notices, televisions, medications, 

etc.) 

2 Partially impaired. (Cannot see newsprint or public notices or television or medications labels, but can see 

obstacles in path, and the surrounding Iayow can count figures at arms length.) 

3 Severely impaired. (Cannot find way around without feeling or usingcanq cannot locateobjectswithouthearingor 

touchingthem;~ tell lightfrom dark.) 

4 Blind, vision completely lost. (No vision at alt cannot tell light from dark.) 

22.	 At the time of the moat recent assessment, how well did this client hear (with hearing aids if the client usually wore them)? 

[CIRCLE ONE CODE] 

1	 Normal hearing. (Hears adequately in most situation can carry on an unrestricted conversation or otherwise 

responds appropriately without speaker raising voice or altering normal pace and style of diction, in groups as well as 

oneto-one.) 

2	 Partially impaired. (Hears adequately only in special situations, such as one-to-one conversation% with firm, clear 

dictiow or with raised volume on radio, television, etc.) 

3	 Severely impaired. (Hears with difficulty even in special situations, such that conversation is restricted; there are 

many misunderstanding% or there is frequent failure to respond.) 

4 Deaf, hearing completely lost. (No hearing at all that is useful for conversation.) 

6 

51 
23.	 At the time of the most recent assessment, did this client require help or supervision in carrying out the daily activities Iiste 

in the table beloW? If this client does not do an activity because of a physical or mental health problem, circle code 4 for thi 

item. [CIRCLE ONE CODE FOR EACH ACTIVl~ 

Yes Yes Does 

At the time of the most recent assessment did the Help Supefvlslon No not 

client require help or supervision: 

a. Bathing or showering 1 

b. Dressing 1 

c. Eating 1 

d. Transferring in or out of beds or chairs 1 

e. Walking 1 

f. Using the toilet room 1 

do 

2 3 4 

2 3 4 

2 3 4 

2 3 4 

2 3 4 

2 3 4 

24. 

25. 

26. 

27. 

At the time of the most recent assessment, did this client have an ostomy? [CIRCLE ONE CODE] 

1 Yes 

2 No 

“-

Did the client require any assistance from another person in caring for this device?


1 Yes


2 No


What was the date of the assessment used to answer the questions on this client’s functional capabilities?


Date.of assessment


l_L_l l_l_l lu5Ll_I_l 

month day year 

At the time of the most recent assessment, did this client have any difficulty in controlling his/her bowels? 

1 Yes 

2 No 

52 
28. At the time of the most recent assessment, did this client have an indwelling catheter or similar device? 

1 Yes 

I i 

2 No > SKIPTO QUESTION30 

29.	 Did the client require any assistance from another person in caring for this device? 

1 Yes 

2 No > SKIPTO QUESTION31 

30.	 At the time of the most recent assessment, did this client have any difficulty in controlling his/her bladdef? 

1 Yes 

2 No 

31.	 At the time of the most recent assessment, did this client require help or supervision in carrying out the daily activities listed 

in the table below? If this client does not do an activity because of a “physicalor mental health problem, circle code 4 for that 

item. [CIRCLE ONE CODE FOR EACH ACTIVITYl 

At the time of the most recent assessment did the 

client require help or supervision: 

a. Doing light housework 

b. Handling money 

c. Shopping for groceries or clothes 

d,	 Using the telephone (dialing or 

receiving calls) 

e. Preparing meals 

f. Taking medication 

Yes Yes Does 

Actual Supervision No not 

Help Only do 

1 2 3 4 

1 2 3 4 

1 2 3 4 

1 2 3 4 

1 2 3 4 

1 2 3 4 

8 

53 
32.	 At the time of the most recent assessment, did the client display any of the following types of behavior problem- disrobing/ 

exposing onesel~ screaming; being physically abusive to self or other= stealing getting lost or wandering into unacceptable 

placeq being unable to avoid simple dangerq or other behavioral problems? (Assess the client’s behavior with medications 

if they are customarily taken.) 

1 Yes 

2 No 

33.	 Is the client disoriented or memory impaired to such a degree that he/she was impaired nearly everyday in performing the 

basic activities of ‘daily living, mobilii and adaptive tasks? For example, is he/she unable to remember dates or timeq 

unable to identify faniliar locations or peoplq unable to recall important aspects of recent events unable to make 

straightforward judgments; or other cognitive problems? 

1 Yes 

‘ 2 No 

34.	 At the time of the most recent assessment, did the client display any psychiatric symptoms to such a degree that he/she was 

distressed or restricted in functioning nearly every day? For example, did he/she have delusions (beliefs not keeping with 

realii);	 have hallucinations (seeing or hearing things that are not there); threaten or talk about suicidq act depressed, 

unresponsive, or withdraw have e@reme anxiety lack trust in other peoplq or have other psychiatric problems? 

1 Yes -

2 No 

9 

54 
35.	 What were this client’s primary presenting and other diagnoses at the time of enrollment with your agenc~ (If this client has 

been enrolled with this agency more than one time, please spedy the diagnoses at the time of the most recent enrollment.) 

Office Use Only 

ICD9 E/V code 

Primary presenting diagnosis 

a. 

Other diagnoses 

c. 

d. ‘ 

e. 

f. 

x35.	 Where did you obtainthe information 

usedto answerquestions21 through35? 

1 Primaryclientrecord 

2 Supplementaryrecord 

3 Your personalknowledge 

4 Consultedanotherperson 

10

36.	 Dqing the last billing month, which of the following services were provided to this client by your agen@ 

[CIRCLE ONE CODE FOR EACH TYPE OF SERViCEl -

I Not 

a. Personal care 

b. Nursing services


c. Physician services


d. Other medical services


e. Mental health services


f. Social services


9. Physical therapy


h. Occupational therapy


i. Speech and hearing tierapy


i. Vocational rehabiliiw-on


k. Special education


L Nutritionist services


m. Sheltered employment


n. Homemaker-household services


o. Transportation


P. Meals on wheels


q. Recreational services


r. Housing services


s. Protective oversight services


t. Medication


u. Other services [SPECl~


Provided provided


1 2


1 2


1 2


1 2


1 2


1 2


1 2 

1 2 

1 2 

1 2 

1 2 

1 2 

1 2 

1 2 

1 2 

1 2 

1 2 

1 2 

1 2 

1 2 

1 2 

11 
37.	 During the last billing month, how many visits did your agency make to this client? [INCLUDE BOTH VISITS MADE BY 

AGENCYSTAFF AND VISITS PROVIDED THROUGH CONTRACT SERVICES.] 

Number of Visits 

I 

3a.	 In the table below, please indicate all sources who have paid or are expected to pay for this client’s most recent month o 

care by your agency. Then enter the amount billed for that month of care by each of the payment sources. 1 

Sources 

a. Private insurance 

b.	 Own income, family support,retirement funds, Social 

Securii, etc. 

c. Medicare 

d. Medicaid 

e.	 Religious organizations, foundations or volunteer 

agencies 

f. No charge made for care 

9. Other 

SPECIFY 

Source of 

payment for 

this client? Amount billed 

for most recent 

Yes No month of care 

1 2 $ 

1 2 $ 

1 2 $ 

1 2 $ 

1 2 

1 2 

1 2 

$ 

12 

57 
39.	 Is this client’s care paid by the Medicare special hospice benefit, or by a private insurance company’s hospice benefti or 

neithefl [CIRCLE ONE CODEl 

1 Paid by Medicare special hospice beneft 

2 Paid by private insurance hospice benefit 

3	 Not paid by Medicare special hospice beneft 

or by private insurance hospice benefti 

40.	 During this client’s most recent enrollment with your agency, how many daya of respite care did s/he receive in an inpatient 

unit of a hospice, nursing home, or hospital? 

a. Number of respite days in hospicsx 

b. Number of respite days in nursing home 

c. Number of respite days in a hospital: 

X40.	 Where did you obtainthe information 

usedto answerquestions38 through40? 

1 Primaryclientrecord 

2 Supplementaryreoord 

3.	 Your personalknowledge 

4 Consultedanotherperson 

41. Date Client Questionnaire completed 

-RF-%& ‘gyear

42. Respondent’s Name 

Respondent’s Title 

The National Center for Health Statistics along with Westat would like to 

thank you for your time and participation in this survey. 

We really appreciate your cooperation. 

13 

58 
DEPARTMENT OF HEAL~ AND HUMAN SERVICES


Cmtw8 for Diseaso Control


Ndionsl Cantor for Hdth Statistics


OMW: 0920423S 

Expir~”on Dato nn/nn/nn’ 

@tCX I I [-L I 1-1 I I 

Month Day Year 

Start Time am/pm 

End Timsx ‘ am/pm 

FEASIBIIJIY OF SURVEYING HOSPICES AND HOME CARE AGENCIES 

CURRENT CUENT LISTING FORM 

NOTICE Informationoontained on this form which would permit identificationof any individual or establishmenthas been 

collaotedwitha guaranteethat it will be held in atriotoonfidsnce,will be usedonlyfor purposesstated in this study, andwill not 

b. disolosedorrcloaaedto otherswithoutthooonsentof thoindividualor establishmentin aocordanccwithSaotion308(d) of the 

PublicI-Wth ServioaAd (42 USC 242m). 

a 

1. 2. 3. 

ENROLLMENT DATE 

UNE # CUENT IDENTIFIER (MM/OD/YY) 
60 

Sheet of Sheets 

CURRENT CLIENT LISTING FORM - CONllNUEO — — 

1, 2. 3. 

UNE # CUENT IDENTIFIER 

ENROLLMENTDATE 

(MM/DD/YY) 
DEPARTMEW OF HEALTH AND HUMAN SERVICES OMB#: 0920-0236 

Contors for Disease Control Expiration Data 01/01/92 

National Center for Health Statiatic8 

Date IL..I_J-~-~ 

Month Day Year 

Start Tima am/pm 

EndTim% am/pm 

FEASIBILITY OF SURVEYING HOSPICES AND HOME CARE AGENCIES 

DISCHARGED CLfENl LISI’ING FORM 

NOTICE InformationcontsIned on this form whiohwould permit identificationof any individualor establishmenthas been 

oollectadwith a guaranteethat it will be held In ~“ot oonfiderwe,will be used only for purposesstated in this study, and will 

not be discfosador released to otherswithoutthe oonsentof tho individualor establishmentin aooordarm with 3eotion 

306(d) ofthe PublioHeafth3arvicaAct(42 WC 242m). 

‘ YI :.::::NA:. —— 

1. 2. 3. 

DISCHARGE DATE 

LINE # CUENT IDENTIFIER (MM/DD/YY) 

I 

I 

61 
Sheet of Sheets 

DISCHARGED CUENT LISTINGFORM - CONTINUED — — 

1. 

UNE # 

2. 

CUENT IDENTIFIER 

L 

r 

I 

I 

I 

3. 

DISCHARGE DATE 

(MM/DD~ 

62 
Appendix IV 

Letters, data collection 

instruments, and sample 

I	 selection tables for the 

Pretest for the National 

Home and Hospice Care 

Survey 

/-””%

4

* DEPARTMENT OF HEALTH& HUMAN SERVICES Public Health SeNice 

$ Canters for Disease Control 

‘8 L 

% National Canter for Health Statistics %/,. 6525 Belcrest Road 

Hyattaville,MD 207S2 

Dear Adminiatraton 

The Netional Center for Health Statistics (NCHS), ona of the Centars for Dieease Control, 

collects and provides information on the health of the Nation and the utilization of its health 

resources. As part of this continuing program, the NCHS is conducting e pretest for the 

National Home and Hospice Care Survey. This survey is authorized under section 306 

(42 USC 242K) of the Public Health Service Act. 

The purpose of tha pretest is to test a data collection plan and data collation instruments to


be usad in conducting a National Home and Hospice Care Survey. The ultimate goal of the


Iargar survey is to provide a more complete information base on available long-term care


services and utilization of those. aarvicas.


The pretest includes a small sample of hospices and home health agencies. Information about


your facility will be collected through a personal intarview that should take no longer than 15


minutes of your time. In addition, time involving some of your staff will be required to


complete interviews for a small sample of p6tiants, No patiants will ba contacted at any time.


Although your participation ia voluntary and there are no penalties for rafusing to answer any


quastione, it is essantial that we obtain data from all sample facilities to evaluate the data


collation procedures and quastionnaires.


I want to amphasize that the information you and your staff supply will ba used only by the


National Canter for Health Statistics. In accordance with Saction 308(d) (42 USC 242m) of


the Public Health Service Act, no information collected in this survey maybe used for any


purpose other than tha purpose for which it was collected. Such information may not be


published or ralaased in any form if the individual or establishment is identifiable unlass the


individual or establishment hae consented to its release.


Within tha next few days, a fiald representative will contact you for an appointment. This


parson will be with the Bureau of the Census, the agency under contract to conduct this


survey. I greatly appreciate your cooperation in thie survey.


Sincerely yours,


MANNING FEINLEIB, M. D., Dr. P.H.


Director, National Center for Health Statistics


HHCS.1O[L)X 13.1-911 

63 
HOW WM THIS FACILITY CHOSEN? 

A sample of hospices and home health facilities was chosen from a list to represent similar 

facilities in the United States. Since each represents several others, it’s full participation is very 

important to the outcome of this pretest. 

WHAT ARE YOU GOING TO DO WITH THE RESULTS OF THE PRETEST? 

Because this is a pretest, the data will be used to evaluate questionnaire content for the 

National survey that will include a much larger number of hospices and home health facilities. 

These data will not be used for publication. 

Information on hospices and home health facility providers and the populations they serve is 

needed by policymakers for assessingthe availabilityof and need for hospice and home health 

services. Data from the National survey could assistpolicymakers in determining where and by 

whom these types of care are needed as well as identfiing who is already receiving hospice or 

home care. Eventually these data could be used to identi& any increased demand for hospice 

and home care services which could tax the ability of social service facilities to meet the needs 

of the terminally and chronically ill. 

WE’VE ALREADY PROVIDED SIMILAR INFORMATION. 

The information we are collecting in this survey maybe similar to what you have provided in 

other surveys,but it is not identical. For this pretest to be worthwhile, we have to collect the 

same information fkom all participatingfacilities in exactly the same way. So using information 

collected for other purposes would not meet our needs for comparability of method and 

completeness of data. 

WE’RE TOO BUSY AND DOIVT HAVE ENOUGH STAFF. 

We can work around the schedule and availabilityof your staff. We know they are busy. We 

can interview any staff member who is knowledgeable about the patient records. Eventually 

your help will increase the viability of hospice and home health facilities and their essential 

contribution to the care and comfort of patients and their families. 

64 
,,uwcss.ti ~* $ + 

DEPARTMENT OF HEALTH& HUMAN SERVICES PublicHealthService : Centera for Disease Control i

‘% Jg %. National Center for Health Statistic %v,,a > 6525 BelcrestRoad 

Hyattaville,MD 20762 

I want to personally thank you for participating in the pretest for the National Home and


Hospice Care Survey and for assisting the field representative from the Bureau of the Census,


who conducted the pretest in your facility. It is only through the cooperation of administrators


like yourself that we are able to conduct a survey such as this one. The experience we gain


from this pretest will be invaluable in helping us to collect data to support effective treatment


of long-term health problems.


Again, I appreciate the time and effort you have given in support of this survey.


Sincerely yours,


MANNING FEINLEIB, M. D., Dr. P.H.


Director, National Center for Health Statistics


HHCS.1 l(L)X (3-91) 

65 
OMB No. 0920-0283 ADD1OVC4Eti03islfd2 

g~RMliHCS-l (X)	 NOY3CE - Publfc reporticq burden far this collection of Information k ~tsd ~ 

aversge 15 minutae per mspenee. Sand comments ragerding this bwdnm qte 

of any ether aspact of this collection of information, including ~ * 

OFCOMMERCE U.S. DEPARTMEN7 raducing thii burden to PHS Repona Cfeerance Offiir; AITN F$w ~ H.

SlmEAuOFTHECwsus Humphrey Bldg., Rm 721-B: 200 Indwwtdsmce Ave., SW; Washfn@.xI, DC AC71NG ASCOLLECTINGAGEN7FOR7HE 20201, and to tha Office of Mansgammt and Budget; Psparwork Raductbm’r DEPARTMENTOFHSALTHANo HUMAN3SRVICES Ho@ 10920-0283k Washkaatqn. OC 20503. Information contain.d on thii tents U.S.PUBLICHEALTHSERVICE wh!ch would parmit identification of any individual or establishment has hart cwms FOR0t5*Ec0~0L 

HE4LTHSTA7ETCS collactad withs gusramee thet it will be held in strict confidence, will h uesd & NA710NAI.CEMERFOR pwpcses steted for this study, end will not be disclosed or relmasd to otfwe 

without the conaant of the individual or establishment In accordance #dt -n 

30Sd of the Public Heslth Smvice Act (42 USC 242m). 

FACILITY QUESTIONNAIRE 

NATIONAL HOME AND 

HOSPICE CARE SURVEY 

PRETEST 

Srmtion A – ARRANGING’ IE ADMINISTRATOR APPOINTMENT 

1.Facility telephone number 

!. Administrator name 

1. Record of calls 

Oay Oste Time Notes 

(s} (b) (c) (d) 

sm. 

p.m. 

a.m. 

p.m. 

sm. 

p.m. 

). INTRODUCTION 

Good mornbrg(afternoon).My name is . . .. i’m fsomtho 

Burameof the Cmmus.We � recurrentlyeondteetingthe Natlorml Horn s-d Hospice Care Survey pretest for the 

National Cantor for HaafthStatistltxof theCantorsfor 

Disessn Control. We me studyinghome health agenclas 

�nd hosplcas �nd their patiattta. You should hava receivasf 

a iattar from Dr. Manning Folttloib, tha Diractstr of the 

NationalCenterfot HaaftftStatistics,whichdascribasthis 

proJact.Havayou racahmdthinlatter? 

� Yea– SKIP to Item6, NAME VER/F/CAT/ON. 

� No - Contln.ewithItem5, SURVEYEXPL4NATION. 

;. SURVEY EXPLANATION 

If administrator wants a copy of the letter, explain that you will 

bring a copy when you viift the facility. 

I’m SOtW thst you didnot recaivothelatter.Letmmbsfafiy 

outline its contartts. 

Thm National Homa �nd Hospice Cwa Suwey is 

�uthoriaad sendar Sactfon 306 of tha PublicHaalth 

6SNhX Act to coilect basdine Information�bout homa 

�nd hoapico cam facilities, tfmir s~wic,s, wtd patiwsta. 

The statistics compiled from the data will bo tread to 

support research for �ffoctive tsemtmant of Iong-twm 

haaith probloma wtdto studyutilizationof hospicaand 

homa cero facilities �nd the �fficisnt usa of the Netftsn”a 

health earn saeourcas. 

Th- puspoaa of this pretestistotestthodatactsflaction 

plmt�nd dataachctfon btstrummttsthatwillbe rmad 

itscoetduothrgtho NationalHomeand HoepicaCare 

Susvay. Ail Infestnration which would permit 

identificationof thaindwldualpatfantor facilftywiiibe 

heldIn strictconfidsnca,willbs usadONLYbyparsons 

involvedinthe �usvay�ndonIyfor thopurpososof the 

SESWOY, �nd willnot bedisclos-dor saloasedto othwa 

for any ptrrpoae. 

Tho pretest fncirsdos� smaiisampleof hospices and 

horn. haaith sgwrclea. Aftfwrugh your paniclpation in 

voiuntasy �nd thorn�m no pwtaltiesfor rafusingto 

� rawtrr�nyquestions,it laessmstialthatwcobtaindata 

from ali samplefacilitiesto �mluata the det~ collection 

pmaedursta and qtmationnaims. 

Continue w;th Item 6, NAME VERIFICATION. 

6.NAME Verification 

I would Iikoto vwify somainformationfrom my racords.fs 

(Nameof facility on /abef)tho cotmct name of yossrfacility? 

� Yes-Go toItem 7,ADDRESS VERIFICATION. 

� No – l%tercorrect facifityrtame below.~ 

?. ADDRESS Verification 

Is (Addrese of facility OIElabel) Vm cots-at �ddrass? 

� Yea– GotoItem 8 – SETAPPOINTMENT. 

� No - Ertrercorrecr feclliry eddress below. ~ 

Number Street P.O. sex, FfOuta. ate. 

city ortown county 

i 

Stste ZIP coda 

I 1 1 

B. SET APPOINTMENT 

I would fiks to mrcngo �morning �ppointmwttetyam 

convaniancato conductthasurvsy.What wouldboa 

convmtiwttdate and time to vieit your facility? 

Oay Oata Time	 �.m. 

o.m. I 

6. FIELD REPRESENTATIVECONTACT 

I would iikatogivayou my talophonenumber �nd tkatd 

my supwviaorintheavant thatyou steedtocontactme 

prior to my visit.if you can’tmath ma,you ows:osve� 

mossagawith my �uporvisor. My rmmo is (name). MY 

numbar is (Number). My stspesvisor”s nama is (namek MT 

8uPaWiUr”8 numbar is (Number). 

Thankvou varymuchforyourtimo. I will �ss you at fllnd 

on (Date). Good-bye. 

Seatfon S - RECORD OF INTERVIEW 

1. STATUS OF INTERVIEW – Mark (X) appropiete box. 

01 � Ccmplate interview


02 � Partiai interview


030 Refusal


04D Net a Hospice/Hcme Heeith Agency


050 No longer operating


oen Temporarily closed


07 � Not yet in operation


OSD Uneble to locate


09U Other noninterview – Specify


2.RO number 

3 .Field Representative 

Name [ Code 

t 

4.Date of interview 

Month I Day	 I Yaar i 1 1 

NOTES 

66 
ScotIon C - QUESTIONS ABOUT THE FACILITY 

Bafora I baghttfw ~ ,l”d3&atotckaamomcntto q)falnthepurymaa of the Susvay.1baffwmyou (rOcolvcd/didnotcecafsaltbc~ fzomtheNatfonalCwrtcrfor HcafthS~cs. 

If admkkrratordid notracawcthefatter. hsndhim/hers copy. Allow him/hwto read it through brfafiy. 

Ask saymInthefatter,tfropmpoaaof Sfrfssursayfstoteat� da~ ortff.ctionplan �nddatasxrflacfion 

frwtzummrta to beumrfIncsrsrdrrcting � NetlormlHomaand HosplcoCam Surv-y. Thouftlmatogoalof tfra

largermrrvoy10to ptwkloa moracomplafofrrfornmffonbcaoon svsllsblolong-farmrxm satvfoas�nd 

utlllzaffonof tfzosa SWVICOB. Thofnfornmtlonyou prswlda 1sconffdontkl �nd wIIIbeussdonlyby pmaorm 

Involvad[33thasurvayandostfyfor thepurpomsof tfwsuNsy. 

la. Is tfmPfflMARYeersfcocatagmyof thlefaciuty� 

horn. hmfth �gencyora fwapfca? [ 01� Home Health Agency - SKIP to item 2

I 02 � Hosplca - SKIP to item 2 Mark IX) only ONEbox.	 ~ 03 � Both Hospice end Home Health are equal - SKIP to Item lb 

! M � Neither– GotoCheck Itam A 

I 

I 

EHECK 

ITEM A 

I b. Duriru 

of hoa 

THIS FACILITY IS OUT-OF-SCOPE I FOR THE SURVEY I 

Probe as newsaery to determine the facilky’s 

prime~ function, the aervice(s} they now provide / 

{if any) andtm y otharinforrnatkor describing the ~ 

stetus of this fecilisy. Explain in deta;l. I 

I 

Thank the respondent and END THE INTERVIEW. ~ 

.Fill Section B on the front of the form. I 

Ih=fast days,~hm wa~tharrumfsor 1 30 

l= patfonfsewvadby thisfaclllty? : Number 

, 0. Durfngthelast30 days,whatwastfwnumber I 

of horn, Itdth patlenfasotvodbythisfacility? I 

Number 

I 

t 00 � None 

!. What Isthormmq tlth,�nd talepfrononumberof the i Adminietretor neme 

patamrwho haathe day-today meporwlblllty for I 

cdmlnlatarfrrg or dkactfrsff this fmlltty? t Title
 I


I 

I Area code Number I 

I 

Is. HAND FLASHCARD 1	 I 

~ 01 � FOR PROFIT — Includas individual or privete, 

What Isthotypoof ownershipof thl$faclllfyas partnership, corporation.


shown on thisocrd? : 02 � NONPROFIT - Includes church-related, nonprofit


I corporation, other nonprofit ownership 

Merk [X) only ONE box. I 03 � STATE OR LOCAL GOVERNMENT — ‘Includes State, 

county, city, city-county, hospital dietrkt or authority 

~ 04 � FEDERAL GOVERNMENT.– Includes USPHS, 

I Armed Forces, Veterens Administration 

[ 05 � Other - Spec;fy ~ 

I 

I 

I 

I 

I 

b. la this facility~aratad by � boapffal? I

I 01 •l Yas 

1 02DN0 I 

c. Is thisfacdlltyoperatedby � nurslrrghorns? 

\ 01 •l Yes 

I 02DN0 

CHECK { ot � If one of boxes 01,02, or 05 is msrked - Go to item 3d Refer to item 3a. ITEM B I I 02 � [f none of b~~es 01,02, or 05 are marked – SK/PtO itam 4 

I 

3d. 10(Name of faci/ity)a mmnberof � group of facllkfes \ otUYee - Continue with item 3e opcmtlngunder 0n9garraml�thorfty or ganoml 

otvrtarshlp?	 I 02 � No – SKlPtoitern4 

I 

. . What IsUS-nameof theparantorganization?	 I Parent organization I 

I 

I 

6.	 Isthis facllltycartffiadunder Madicam? I 

I ot •l Yee 

~ 02DN0 

I 03 � Certification pending 

6. Is this facilitycartifiadunder MadIcald? j 01•l Yes 

I 02DN13 

~ 03 � Certificetlon pending 

Ea. Does Uristacilityprovfdabarosvamentcamto tha ~ 01� Yee famllloaof thepatfantsYOUserv.? 

[ 02DN0 

b. Doaathfs faofffty prwfda pastoral oam? I 01 •l Yes 

[ 020No 

SwMCS.l(X1 (3.!.911 Page 

67 
I 

7.	 How many persons served your facitity � s volunteers I


during the last 7 days? I Number


~ 00 � None 

i


:HECK ~ 01 � Respondent is the person listed - SK/Pto item 9a
 ~EM ~ Refer to item 2, on page 2.


I 02 � Respondent is NOT the person listed - Go to item 8
 I


B. What 1syour name, tftla, �nd telephona number?	 I Respondent name


I


; Title 

I


r Area code Number


i


Ba.	 1 need to lint �ll currimt patients from which 1will ~ Name


draw a �ampla of no morn than 5 parsons. From I
 whom shall I obtain the list
 of current patients?


I Title


1


I will rwad thesa patlants’ madical racords and the I


cooperation of � staff mamber best �cquainted with ;
 thasa patients In ordar to obtain the information on I


thin qrmstiomraka. \ 01 D Yes - Go to item 10a 

Hand the administrator a copy of the current patient I 02 � No — Determine which steff member would have this 

queationna;re. Allow h;m/her to examine it briefly. knowledge and enter the name and title below. ~ 

Retdeve the questionnaire and continue reading. I


I will not ba contacting orintewiawing the patients in I


any way. I will dopand on your staff to consult tha


madical records. I Name


I


b.	 Would (person named in item 9a) know whloh staff I


member I should Interview for thoso patients aekscted Title


for tha �ampla?
 ; 

Oa.	 1�lso need to list all patients discharged alive or I Name


doceasad during the last yaar. From the list I will I


8aMpl.S no mom than 5 discharges. From whom


should 1obtain tha tist of discharges? I Title


I


1


1willneed thehdp of a staffpersonfamiliarwith tha ~ 01 � Yea – Go to item 11 below
 discharge records to aid me in completing the 

information mquestad in this quastionneire. I02DN0 - Determine which staff member would have th;a I know/edge and enter the name and t;tk? below. ~ 

Hand the administrator a copy of the discharged patient ~ 

questionnaire. Allow him/her to examine if briefly. Retrieve , 

the questionnaire and continue reading. I


Name b.	 Would (person /iated in item 70a) know which staff 

member I should intarviaw for those d[schargas that fait ! 

into the eempla? 

HAND FORM 1A(X) 

1a.	 I also need this information about your staff. From 

whom shall t obtain this information? 

b.	 At this tima, could you introduca ma to (this/thosel


paraon[s)?


IOTES 

-. 

rage 3 

/ TMe


I


I Name


1


; Title 

I


1


I


I


FORM HHCS-lIX) 12491) 

68 
12.	 HAND FORM HHCS-IAIX). Number of Number of Number of Number of Total hours Total hours of service Total number 

full-time staff full-time part-time staff part-time worked by ell provided by staff not on your of visits in the 

[35 + hours budgeted (less than 35 budgeted full-time and payrollinthe Iaat7 daya. For last 7 days by 

Please provide the information requested about the numbar of perweek] on positions that hours per positionsthat pan-time staff example, temporary payroll and 

emplo yaes and services provided for ea~h type of employee your payroll are vacant week) on your are vacant on your payroll employment services, visiting nonpayroll 

listed, even If the answer IS zero, payroll in the last 7 nursesaervicea, or any other staff 

daya aarvice contracts 

(al {b) (c) (d) (s1 (f) (9} 

Physicians


Registered nurses


Licensed practical or vocationalnursea


Nursing sides and attendants


Home health sides


Homemakers/personal caretakers


Dteticians/nutritionists


Occupational Therapists


Speech pathologists and audiologists


Physical therapists


Social workers


Health educators


Other haalth care providers - Specify ~

OMB No. 0920-0283: Amroval . ExDbes 03/31/92

KI:09~HCS-lA(XJ U.S. DEPARTMENT~~#~&~$~fi: 1. F~~ility n~rne 2. Control number 

FACILITY STAFF WORKSHEET 

Number of Number of Number of Number of Total hours Total hours of service NATIONAL HOME AND HOSPICE CARE SURVEY full-time staff full-timo 

Total numbar 

part-time staff part-time worked by ell provided by steff not on your of visits in the

PRETEST (35 + hours budgeted {lessthan 35	 budgeted fuli-time end 

positions that part-time staff 

peyroll in the lest 7 daya. For Iaat 7 deya by 

per week) on Po::fijs:hat i$::;)lrtlre your example, temporary payroli and 

your payroll are vacant on your payroli employment services, visiting nonpayroli 

payroll in the Iaat 7 nurses sewicea, or any other staff 

days service contracta 

p For e8ch catagory //steal be/o w, enter tha Information raqurmted about the staff of 

this f8c//ky. Enter zero if appropriate, (e) (b) (c) {d) (e) II) 10) 

Physician 

Registered nurses


Licensedpracticalor vocationalnurses


Nursingaides and attendants


Home heaith aides


Homemakers/parsonel caretakers


Dieticiana/nutritionists


Occupationaltherapists


Speech pathologistsand audiologists


Phyeice(therapists


Sccial workers


Haaith educators


Other health care providers - Specify ~

(lMR 

-------------

Nn 09?0.09R2. ----- .Annrtnmt .Fr,------ F.ml.m~,.-.--,­ 0313$1!S2 .,--


mmJJiHCS-2(X) NOTICE - Public rapom”ng burden for this collection of information b astirnsted to 

weraga 15 minutes per response. Send comments regarding this burden astimate 

or any other aspect of this collection of [“formation, imhcding suggesDons for 

U.S. DEPARTMENTOF COMMERCE reducing this burden to PHS Raporta Clearance Officer; ATrN PRA Mbsrl H. 

WRWJOFTHECU4SUS Humphrey Bldg., Rm 721-B 200 Indapmdence Ave., SW Washington, DC ACFING AS C0UEC11Nt3 AGENT FGR1’NE 20201, and to tha Office of Management and Budgeti Paparwork Raduction OEPAFITMENTOF HEALTHANO HUMAN SERVICES Project (0920-02831; Washington, DC 20503. Information contalnad on this form U.S. WS41C HEALTHSERVICE which would wnnit idmtification of any i“dwidual or essabfishmem has baen CENFERSFORDISEASECOUTROL 

CENIEFr STATISTICS r.ollected with a guarantee that it will be held in strict confidence, will be used for NATIONAL FORHEALTH purposes stated for this study, and will not be disclosed or released to others 

without tha consent of the individual or establishment in accordance w“ti Sactian 

308d of the Public Heslth .%rvlca Act (42 USC 242ml. 

CURRENT PATIENT 

SAMPLING LIST 

NATIONAL HOME AND 

HOSPICE CARE SURVEY 

PRETEST 

.RO number 2 .Field representativenama ~Code 3.Date of listing 

I 

1 

l. Raspondant nama S. flespondant title 

READ INTRODUCTION – 

In order to obtain national date about tha patients of hoaplcaa and home haalth agerto[assuch as this 

ona, wa �re collecting information about a sempla of currant patients. lhia information and tha Ilatof 

names you provlda will be held in striot confidence and will ba usad ONLY by parsons involved in the 

survey �nd only for tha purpoees of the survey. Plaaaa give ma tha names of all currant patients; that is 

all patients on the rolls of this facility aa of midnight last night, so that I may select the sample. 

FOLLOW THE STEPS BELOW TO LIST CURRENT PATIENTS -

STEP 1.	 Start listing the patiants on Iina number 1 on page 3 of this 

form. List the patients consecutively in the order in which Type of identifier used they are given to you. Be sure to complete the “Page of 

Page” item. If patient namea are not used, explain the type 

ofidentifier uaad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

NOTE –	 If the facil;t y supplies an appropriate list that you can use, do not transcribe the 

inf~rmation onto the sampl;ng list(s). If you can keep this list, a~ach it to this form; 

write the control number and facility nama on aach page of the list. /n either case, 

number the petients on the provided list; and go to step 2. 

STEP 2.	 Review the list. Verify that all eligible patiente have been listed. Delete any duplicate entries 

and any patients that do not meet the definition of a currant patient. Renumber the Iinea if you 

delete any namas. 

Number 

STEP 3. Enter the total number of patianta listed. . . . . . . . . . . . . . . Cl 

STEP 4.	 Look at Form HHCS-30(X), Sample Selection Tables. Find the number in the column labeled 

“Total number listed” that matchas the total numbar of patients Iiated. 

STEP 5.	 Circle the line numbers on the listing sheets that correspond to those in the 

columns labeled “Sample line numbers.” 

Number 

STEP 6. ::~t:he amount of circled line numbers on the listing 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

STEP 7.	 The current patients to be sampled are those listed on lines with a circled line number. 

Enter the neme or other identifier and line number of each sampled patient in section B of a 

Form HHCS-3(X), Current Pstient Questionnaire. 

STEP 8.	 Make sure you complete all information on the front of this form. Use the notes section on 

page 2 to describe the types of files you used and any problems you encountered in using 

these files to prepare the list. This information will help us properly train FRa for the survey. 

GO TO FORM HHCS-3(X) 

71 
05

10

15

20

25

30

35

40

45

50

PAGE~OF _ PAGES 

CURRENT PATlENT SAMPLING LIST 

Line 

number Patient name (or other identifier) 

la) (b) 

02 

03 

04 

06 

07 

08 

11 

12 

14 I 

19 

21 

22 

23 

24 

26 

27 

28 I 

29 I 

I 

31 1 

32 I I 

33 I 

34 I I 

I 

36 { 

38 

39 

I 41 I 42 I 

43 I 

44 I I 

I I 

46 

47 

48 I I 

49 I i 

I 1 ORM HHCS21X1 {3.1.ell Page 3 

72 
nnlm Ah na.Y4 ,1.*9. . . . . . . . . . e..-:.. - -?.,.2. ,07 -,.,- ,.”. “.,-” -”=”-. ~p~,”.s, -p,.. “.7,.Z ,,” -

:y91#HCS-4(X) NOTICE - Public repotting burden for this collection of information is estimated to . . average 15 minutes par response. Send comments regarding ths burden estimate 

or any other aspast of this collection of information, including suggastiens for 

U.S. DEPARTMENTOF COMMERCE reducing this burden to PHS Reports Cfaarance Officer; AITN PM Hubert H.


8UREAUOFTHE CENSNS Humphrey Bldg., Rm 721-B: 200 Independence Ave., SW: Washin en. DC
 ACTING AS COLLECTINGAGENTFORNiE 20201, and to she Office of Management and Budget; Papa-work $ eduotion
 DEPARTMENTOF HEALTH AND HUMAN SERVICES project (0920-02S3); Washington, OC 20503. Information containad on thw form
 U.S. FULILICHEALTHSERVICE which would permit Idmtiflcetion .of my indwidual or establishment has been CE~RS FORDISWSE cOwROL 

NATIONALCENTERFoi-(HEALTHSTATISTICS collected with a gusrantea that it will be held in striot confidence, will ba used for 

purpoees stated for this study, and will not be disclosed or released to others 

without the consent of the Individual or establishment i“ mxxjrdmce WM Section 

308d of the Publlc Health Swvice Aot (42 USC 242rn). 

DISCHARGED PATIENT 

SAMPLING LIST 

NATIONAL HOME AND 

HOSPICE CARE SURVEY 

PRETEST 

.RO number 2.Field representative name ; Code 3.Date of Iiating 

I 

t 

..Respondent neme S. Respondent title 

READ INTRODUCTION -

In order to obtain national data about discharged patients of hospicas and homa health agancias such as 

this ona, we ara ooliacting information about a sampla of discharges. This information end tha list of names 

you provide wIII ba bald in strict confidante and will be used ONLY by persons involvad in the suwey and 

only for the ptsrposasof the suwey. Piaase give me the names of all patients dlschargad aliva or deceased 

betwean (Seepage 2 for reference period). [f eny patient was cfischargad mora then once during the rafaranca 

pariod, give me their name and tha discharge date for EACH time they were discharged. Be sure to include 

tha nama and discharge data for patients currantly being served by your faciiity who wara also discharged 

batween (First and Iast day of refarerrce period], �o that I may selact the Sampia. 

FOLLOW THE STEPS BELOW TO LLSTDISCHARGED PATIENTS – 

STEP 1.	 Start listing the patients on line number 1 on page 3 of this 

form. List the patients consecutively in the order in which Type of identifier used they are given to you. Be sure to complete tha “Page of 

Page” item. If petient nemes are not used, explain the type 

of identifier used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

NOTE - If the facility supplies an appropriate Iiat that you can use, do not transcribe the 

information onto the sampling list(s). If you can keep this list, attach it to this 

form; write the control number and facility name on each paga of the list. In either 

caae, numbar the discharges on the provided list; and go to step 2. 

STEP 2.	 Raview the list. Verify that all eligible discharges have been listed, Delete any duplicete 

discharges end eny discharge that does not fall into the raference period. If both the 

patient name and date of discharge are the same, probe to determine if it is a duplicate 

entry. Renumber the Iinas if you delete any names. 

Number 

STEP 3. Enter the total number of discharges listed. . . . . . . . . . . . . n 

STEP 4.	 Look at Form HHcs-30(x), Sample Selection Tablee. Find the number in the column iabeled 

“Totel number listed” that matches the total number of discharges listed. 

STEP 5.	 Circle the Iina numbers on tha listing sheeta that correspond to thoee in the 

columns iabeled “Semple line numbers.” 

Number 

STEP 6.	 Enter the amount of circlad line numbers on the fiating 

ahaets, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . m 

STEP7. Thetischarged patients to besampled arethosehsted onhneawith acircled linenumber. 

Enter thename orother identifier, linenumber, andtischarge dateofeach sampled patient ‘ 

in section B of e form HHCS-5(X], Discharged Patient Questionnaire. 

STEP8.	 Makesureyou complete ailinformation onthefront ofttisform. Usethenotes sectionon 

page 2 to describe the types of files you used and any problems you ancounterad in using 

these files to prepare the list. This information wili help us properly train FRs for the survey. 

GO TO FORM HHCS-5(X) 

73 
LIST OF REFERENCE PERIODS FOR DISCHARGED PATIENTS 

Datoof interview Disshwged 

August 26 . . . . . . . . . from August 26,1990 

August27 . . . . . . . .. from August 27.1990 

August 28 . . . . . . . . . from August 28, 1990 

August29 . . . . . . . .. from August 2!3. 1990 

August 30 . . . . . . . . . from August 30,1990 

August31 . . . . . . . .. from August 31.1990 

September . . . . . . . from September l,1990 

September2 . . . . . . . from September 2,1990 

September3 . . . . . . . from September 3,1990 

September4 . . . . . . . from September 4.1990 

September5 . . . . . . . from September 5,1990 

September6 . . . . . . . from September 6,1990 

September7 . . . . . . . from September 7,1990 

September8 . . . . . . . from September 6,1990 

September 9 . . . . . . . from September 9,1990 

September 10 . . . . . . from September 10, 1990 

September 11 from September 11, 1990 

September 12:::::: from September 12, 1990 

September $3 . . . . . . from September 13, 1990 

September 14 . . . . . . from September 14,1990 

September 15 . . . . . . from September 15,1990 

September16 . . . . . . from September 16, 1990 

September 17 . . . . . . from September 17, 1990 

September 18 . . . . . . from September 18, 1990 

September 19 . . . . . . from September 19, 1990 

September 20 . . . . . . from September 20, 1990 

NOTES 

‘sge2 

74 

through midnight Auguet 25, 1991 

through midnight August 26, 1991 

through midnight August 27, 1991 

through midnight August 28, 1991 

through midnight August 29, 1991 

through midnightAugust30, 1991 

through midnight Auguet31,1991 

through midnightSeptember 

through midnightSeptember 

through midnight September 

through midnight September 

through midnightSeptember 

through midnight September 

thmughmidnightSeptember 

through midnight September 

through midnight September 

through midnight September 

through midnight September 

through midnight September 

through midnight September 

through midnight September 

through midnight September 

through midnight September 

through midnight September 

through midnight September 

through midnight September 

l,1991 

2,1991 

3,1991 

4,1991 

5,1991 

6,1991 

7,1991 

8,1991 

9, 1991 

10, 1991 

11, 1991 

12, 1991 

13,1991 

14,1991 

15, 1991 

16,1991 

17, 1991 

18, 1991 

19, 1991 

F- HHCS41XI (3 
01

02

03

04

05

06

07

08

09

10

11

12

13

14

PAGE ~ OF _PAGES 

DISCHARGED PATIENT SAMPLING LIST 

I Line Oischarge data 

number patient name (or other identifier) iMonth/Day/Year) 

b) I lb) I (c) I I 

16 

16 

I 1 1 

17 1 

18 

19 

20 

21 

22 

I I 1 

24 

25 

26 

27 

28 

29 

30 

31 

1321 I I 

33 

34 

35 

36 

37 

36 

39 

40 

41 

42 

43 

44 

45 

46 

47 

48 

49 

1 I I

60 FORM HHca.41x)(s.1.s,, Page 3 

75 
)NfB No. 0920-0283 ApprovalExpires03/31/92 PAGE_ OF —PAGE 

‘FOnMHHCS-SIX) U.S.DEPART~:&T~:~::H~~~:~ A. COnt,Olnumber C. Sampling list typa 13.*.911 Mark IX) one 

SAMPLING LIST (Continued) •l Current patient 

B, Facility name (Do not complete 

PRETEST column (c) 

� Oiacharged patien 

IMPORTANT – Add appropriate first digit to preprintad line numbers. 

Line 

number patient name [or other identifier) 

la) lb) 

02 

03 

04 

I 09 I I


10


I 16 I I


17


19
 .. 20


21


22


23


24


25
 *


I 26 I I


27


32


33


34


39


40


41


42


43


44


46


46


47


48


49


50


76 

I 
----- Nn. ---- ------

----

---- --- --- ---- ----

CEMR ..-. 097 fS.02R3: Annroval .rr. —-— .,. Exoires . 03/31 /92

y#HCS-3{X) 

. . NOTICE - Public reporting burden for this collection of information ia estimated to

U.S. DEPARTMENT OF COMMERCE 

aUREAU OF THE CENSUS
 ACTING AS COLLECTING AGENT FOR THE


DEPARTMENTOF HEALTHAND HUMAN SERVICES 

U.S. WSLIC HEALTHSERVICE 

CENTERS FOR OISEASE CONTROL 

NATIONAL CENTER FOR HEALTH STATISTICS 

CURRENT PATlENT 

QUESTIONNAIRE 

NATIONAL HOME AND 

HOSPICE CARE SURVEY 

PRETEST 

Section B -

. Facility name 

. Patient name 

First ; Ml. 

I 

I 

average 15 minutes per response. Send comments ragarding this burden eatimete 

or any other aspect of this collection of information, incluting eu99estions for 

raducing this burden, to PHS Reports Clearance Officefi AlTN: PRA Hubert H. 

Humphrey Bldg., Rm 721-B; 200 Independence Ave.r S.W.; Washington, DC 

20201, and to the Offica of Menagament and Budge~ Paperwork Reduction Project 1 

(0920-0283); Washington, DC 20503. I 

Information contained on this form wiJch wouid permit identification of any I 

individual or eeteblishment has been collected with a guarantee thet it will be held in ~ 

strict confidence, will be used for purposesstated for this study. and will not be I disclosed or released to others without the consent of the individual or the 

establishment in accordance with Section 308(d} of the Public Health Service Act 

(42 USC 242m). 

Section A - ADMINISTRATIVE INFORMATION 

1.RO 2. Fieldrepresentative name 3. FR code 

PATIENT INFORMATION 

2. Control number 3. Patient line number 

5. Date of interview ., 

‘ Last MonthlDaylYear I 

I II 

Section C – RESPONDENT INFORMATION 

a. Respondent name 

-.—- ———— —.-— ———— ———— -—— ———- -——— ———— ———- -——- ——— -.—- ——— -

b. Title 

c.providedanswersforitems Oto m 

a. Respondent name 

—-— —--- --—- ---— —-— -—- -—— — ---— —--- ---— -—-

b. Title 

c.,rovidedanswersforitem$Oto m 

Section D — STATUS OF INTERVIEW 

01� Complete 05 � Assessment only/Not admitted


02 •l Partial 06 � Other noninterview - Specify ~


03 � Refused


04 � Unable to locate record


NOTES 

77 
Read to each new respondent. 

In order to obtain national Iaval data abouttha patienta of ho8picas �nd horn. hoaIth �gancles such �s this on., we �re 

Eollaotfng information about � sample of ourrent pstionts. I will bs �sking questions �bout the background, hoatth 

Btatus,trsatment, �oclal contacts, and billing information for �ach sampIed patitmt. 

rhtr information you provido wIII be haId In strict confldenca �nd w1lIbe used ONLY by parsons invoIwd in the survey 

mtdonly for the purposes of the suwey. 

in �nawaring thosa quostlons, it la aspacislly important to locate the Infotmatlon In the patiant’a madical rscord. Do you 

have the madiosl fils(s) and record(s) for (Read name(s) of selected current patient(s))? 

If not, ask the respondent to get it/them prior tobaginning tha interview. Fillsactions A and B on the front of the fiva current 

Datiant forms whila tha respondent gets the racords. If no record is available for a patient, try to obtain as much information as 

possible from whatever adminietrativa records are available andlor from the respondent’s memory. 

t . What 1s.. .*asax? i 01� Male I 020 Female I 

!. What Is.. .’a data of birth? j Month Day Year Age (at admission] 

\ mmmnoRm3 

Hand Flashcard 3. 1 01El White 

la. Which of thaae best describes.. :s race? ! 020 Black 

I 03U American Indian,. Eskimo, Aleut 

Mark (X) only one box. I

I 04 � Asian. Pacific Islander 

I 050 Other – Specify 

I 990 Don’t know I 

b. Is... of HlspanIc origin? I 01 Cl Yes 

\ 020 No 

I gea Don’t know 

I 

L. . What is.. .’s cuttant marital status? ~ o, a Married 

Mark (X) only ona box.	 I 020 Widowad 

\ 03D Div~~Ced 

I 040 Separated 

~ 05n Never married 

I 990 Don’t know 

Read the introductory paragraph for tha Social Sacurity Number only once for each respondant.. 

As patt of this autvey, we would like to have.. .’s Social Security Numbar. Provision of this number Is voluntary and not 

providing the number will hava no �ffect in anyway on . . .‘8 benafita. This numbar will be usafrd in conducting futura 

followup studiaa. It will ba uaad to match against tha vital ststiatics racords maintained by the National Center for Haalth 

Statistics. This Information is collected undartha authority of Saotion 306 of tha Public Haalth StrrvicaAct. 

6. What is.. .’s Social Sacutity Numbsr? ~ Social Sacurity Number 

If the patient does not have a Social Security Number, obtain \ ~].~1.~]
 whataver Socia/ Sacurity Nr.rmbar is in the record. Mark tha


box that bast describes tha Social Sacurity Number antarad. I


I ol D patiantta number 

I


1 020 Spousa’a numbar


\ o~u parent8a number


I 040 No Social Security Number available


~ 97 D Refused


I e9D Don’t know


Hand Flashcard 4. 

I

I 01 � Salf/Family 

6. Who refarred . . . to this facility? I 020 Nursing homa 

I 03D Hospital I Mark (X) all that apply. I 040 Physician 

~ 050 Health department 

I 060 Sociel service agency 

~ 070 Other - Specify 

I 990 Don’t know 

aae 2 FORMHHC3-31XI(3-1411 

78 
7.	 What was the date of.. .’s most recant ~ Month Day Year 

admission to this facility, that is, the data on I 

which . . . was admitted for tha currant 

�pisoda of care? ~ {

mmm

00a Only an assessment was dona for this patient (patient 

I was not provided services by this facility) 

8a. According to.. .*smedical record, what ICD-9-CM codes 

were the primary and other diagnoses at tha / , Written form if available 

tima of that (admiaaiordassessment)? 

Please provida the ICD-9-CM coda if one ia ‘ 

availab!a. 1 Primary: 1 ————.—— 

/

Probe: I Others: z ————.—— Any other conditions I 

I 3 ——— —.— — 

; 

I .4 ————.—— 

/ 

I 5 ————.—— 

I


I 6 ————.——
 I


I


CHECK / 01n Box00 is NOT marked— Go to item 8b 

ITEM A Refer to item 7. i 

I 02 � Box 00 is marked — END THE INTERVIEW. Complete 

I sections C and D on the cover. 

8b. According to.. .’s medical records, what ~ ICD-9-CM codes � re . . .’s CURRENT primary and other Written form if availabie 

diagnosas? Plaasa provida the ICD-9-CM { 

coda if ona ia availabia. [ 

I Primary: 1 ———_ ___ 

Probe: I 

Any other conditions? 1

I Others: 2 ———— .—— 

I 

3 ———— .—— 

I 

I 

I 4 ———— -—— 

/ 5 ———— .— _ 

6 ———— .—L 

9.	 Doss . . . havp any living children? I 

i 01•l Yes 

1 02DN0 I


I 99 � Do~t know


Oa. Does . . . hava a primary caragiver?	 I 

~ 01 •l Yes 

020 No....... SKIP to item 118 

\ 990 Don’t know } 

Hand flashcard 5.	 I 

I 

I 01 •l Spouse 

b.	 What is the relationship of the primary 02 � Parent 

caragiver to ...? I 03 � Child 

Mark (X) only one box. 

I 04 � Daughter/aon-in-law 

I 05 n Other relative — Specify ~ 

/ 

i 

I. 06 � Neighbor 

I 07 � Friend 

I 08 Cl Volunteer group 

I oe � Other _ specify 

7 

I


I


/ 99 � Don’t know 

FORM HHCS.31XI (3.1-WI Page 

79 
Hand flashcard 6.	 1 

I ot � Private residence 

la. Wharais... currently Ihrlttg? I

I 02 � Rented room, boardinghouse 

03 � Retirement home Mark (X) only one box. i

I 04 � Board and care or residential care facility 

OEI� Hospice inpatient 

I

I 06 � Other type health facilii (including mental health 

I facility) – SKIP tO ;tem 12 

1 07 � Other – Spec;fy ~ 

! 

I 

b. Is. . . living wlthfamily members, nonfamlly ; 01� With family members members, both family and nonfamily 

I

I 

members, or �lone? 02� With nonfamily members

I 03 � With both family members and nonfamily members
 I


I 04� Alone – SKIP to item 12


I


CHECK I 01 � Either box 02 or 99 is marked — SKIP to itam 12 

ITEM B Refer to item 10a 

I 

I 

02� Box01 is marked — Go to item 17C 

c.	 Dotrs . . . usually live with (his/her) I 

01•l Yes primary carsgivar? / 02 � No 

I 99� Don’t know 

Read the question below and fill in as marry ~ � Best contact namas and addrassas as available. Ask the 

respondent to indicate which contact is the I First nsme Middle initisl Last neme 

“Bast contact” and Mark (X) the box above ~ 

that name. I 

I Number Street name P.0, box, RR No., etc. 

2.	 In ordar to followup on.. .’s compiete 1. 

history of health care utilization, we would ~ frf~n~, 

like any information you have that will allow other City State ZIP Code 

us to locata. . .’s nast of kin. Plaasa giva ma ] 

tha namas, addrassas, and telephona I Area Code Telephone number numbars of. . .’s naxt of kin, as wall as any , 

othar mlativas, friands, or anyona alsa who 

might know about . . .. /

I Relationship to patiant 

(Tha sponsor may contact thasa people in I


the future to obtain additional information


about ...0 s complate history of haath care. ~ � Best contact


varifiad with relativas or friands.) First nama Middle initial Last nam6 

1’ If more than 3 names and addresses 

ara provided; mark (X) this box+ � I 

I Numbsr Street name P.O. box, RR No,, etc. 

I Kin! 

use form HHCS-7(X) to list additional names, 1 ~ friendl other city State ZIP Code 

addresses, and telephone numbers. 

! Area Code Telephone numbar 

I 

I 

I Ralationahip to patient 

I 

I 

I D Best contact 

/ 

I First name Middla initial Last name 

1 

/ Number Streetneme P.O. box, RR No.. WC. 

I 

~ Kin/frjend/ 

other City Stete ZIP Code 

1 

I 

I Area Code Telephone number 

I 

/ Rsrletionship to pstient 

I 

No information providad by you wIII ba I


I 

FORMHMCS-31X} 

80 
Hand flashcard 7.	 I 

~ 01 � Eye glasses (including contact lenses) 

13. Which of these aidsdoas . ..currsntlyuse? , ozo Dentures !full orpartial) 

I oz.o Hearing aid 

Mark (X) all that apply. 

I 040 Wheelchair 

~ 050 Cane 

, OGD Walker 

j 070 Crutches 

, os � Brace (any type) 

~ 090 Other aids or devices – Specify ~ 

I 

I 

I 

I IOH No aids used 

I 990 Don’t know 

I 

14a. Does . . . have any difficulty in seeing (when I 01Cl Yes wearing glasses)? ~ 020 No . . . . . . . . . . . . . . . . . . . . . . . . 

I 030 Not applicable (e.g., comatose) SKIP to item 15a 

I 

, sr9n Don’tknow . . . . . . . . . . . . . . . . . 

I } 

Hand flashcard 8. I 01 � Partially impaired 

b. Is.. .’s sight (when wearing glasses) partially, eevere[y, , 

I 02n Severely impaired 

or completely impaired as defined on this card? I 03D Completely lost, blind 

i ego Don’t know I 

I 

I SE. Does . . . have any difficulty in hearing (when 1 010 Yes wearing a hearing aid)? 

i 020 No . . . . . . . . . . . . . . . . . . . . . . . . 

1 03D Not applicable (e.g., comatose) SKIP to item 16 

9en Don’tknow . . . . . . . . . . . . . . . . . } 

Hand flashcard 9. ~ 01 � Partially impaired 

b.	 la... “shearing (whrm waaring a hearing aid) I 020 Severely impeired 

partially, sevaraly, or completely impaired, es ‘~ 030 Completely lost, deaf defined on this card? 

I 990 Don’t know 

I 

Hand flashcard 10. No ‘i Yes does not Unable to 

16.	 Does . . . currently need ANY assistance in any of I needs need do Doesn’t do Don’t know 

the following activities as defined on this card – - 1 assistance assistance 

I 

Mark (X) one box for each activity. I 

a. Bathing or showering? I

I 01 •1 02� 03� 04� 99n 

b. Dressing? I

! 01 •1 02 •1 03 � 04 •1 99 •1 

I 

c. Eating? / 01 •1 02 •1 03CI 04 •1 99 � I 

I 

I 

cf. Transferring in or out of beds or chairs? 01 •1 02 •1 030 04 •1 99 •1 

/ 

I 

a. Walking? I

I 01 � 02 •1 030 04 •1 99 •1 

I 

I 

f. Using the toilet room? I 01 � 02 •1 03 •1 04 •1 99 •1 

I 

17a. Doss . . . have an ostomy, an indwelling catheter I 01•l Yes or similar devica? I 

I 020 No....... SKIP to item 18, page 6 

; 990 Don’t know } .—


IRM HHCS.31X) [3-1-91 ) Page


81 
I
 7b. Does . . . require ANY assistance from �nether person I
 in caring for this device? 

! 

1


I


8. ~OOS . . . currentIy have any difficulty In controlling 1
 (hlshtr) bowels?	 J


I


i


I

I


If patient has an indwelling catheter or an ostomy, mark ~ box 03 without asking. , 

9. Does . . . currantly have any difficulty in controlling i


(his/bar) bIadder?	 I


I


Hand flashcard 11. I


1


10. Does . . . raceive personal hslp or supervision in any ~ 

of the following activities - — I


Mark (X] one box for each activity. I


, 

a. Doing light housawork? i


b. Managing money? I


c. Shopping for groceries or clothes? I


I
 d. Using tha talephona (dialing or receiving calls)? 

1
 a. Preparing meals? 

I


f. Taking medications? I


Hand flashcard 12. i


I


1a. During the last 30 days, which of these services ~ 

were provided to . . . by your facility? , 

Mark (X) all that apply. 

Hand flashcard 13. 

b.	 Which of thase servica 

the last 30 days~ 

Mark (X) all that apply. 

lge 6


i


I


,


i


~ 

I


I


~ 

I


\ 

,

1


I


I


I


I


I


I


i


I


1


1


I


providan visited . . . during I


I


!


I


I


I


i


I


I


I


I


I


I


I


I


I


01El Yes


020 No


SIgO Don’t know


01� Yes


020 No


030 Not applicable (e.g., infant, has an ostomy)


99� Don’t know


010 Yes 

020 No 

030	 Not applicable (e.g., infant, has an indwelling 

catheter or ostomy) 

99� Don’t know 

I I I


help receive help 

Doesn’t do I Don’t 

I I I 

01 •1 02 •1 03 � 04 •1 99� 

01 � 02 •1 03 � 04 � 99El 

01 •1 02a 03 •1 04 •1 99 •1 

01 El 02 •1 03 •1 04 � 99 c1 

01 � 02 •1 03 � 04 •1 99 •1 

01 •1 02 •1 03 •1 04 •1 99 •1 

Yes No 

receives does not ‘na$~’0 know 

01 � Dietary and nutritional services 

020 Occupational therapylvocational therapy 

030 Speech therapy/audiology 

04U Homemaker/companion services 

050 Meals on wheels 

06 � Transportation 

07D Enterostomal therapy 

080 Counseling 

OSID Medications 

10D Respite care 

I I � High tech care (e.g., IV therapy)


120 Referral services


13CI Personal care 

I 40 Skilled nursing services


15 � Physician services 

16 � Social services 

17� Physical therapy 

1all Other services – Specify


01 � Physicians


020 Registered nurses


03� Liscensed practical or vocational nurses


04U Nursing aides end attendants


05D Home health aidea


06n Home makers/personal caretakers


07 � Dietitians/nutritionists


08D Occupational therapista


090 Speech pathologists end audiologists


10D Physical therapists


II � Social workers


12D Health educatora


130 Other providers — Specify 

FOFM tiHCS-31XI [3.1.: 

82

were mada to. . . during the I k2. How many visits t 

last 30 days? Number of visits / 

i oon None


I


I 990 Don’t know


Z3a.	 For your most racant biliing pariod, what was the total I 

charga billed for. . .’s care, including ali chargas for ~$ 

.00 

sarvicas, drugs and spatial madical supplias? � ~ 96D Was not a patient during most recent billing period — 

I SKIP to item 24 

I 00 � No charge was mede for care — END INTERVIEW. 

Complete sections C and D on the front of this form. 

/ 

1 990 Don’t know – SKIP to item 24 

b. What time pariod does this cost rafer to? ~ OID1 Day 

i o~n 1 Week ,. 

I	 .,, 

I 0301 Month 

I

I 040 Other period – Specify ~ 

I ,. I 

I 990 Don’t know (not billed yet, etc.) , 

I 

Hand flashcard 14. I OI •l Private insurance 

!4.	 What ara ALL tha (axpactad) sourcas of PaYmant (for ~ 020 Own income, family support, Social .Security benefits. 

this bili/whan billed)? I retirement funds ., 

Mark (X) all that apply. 

I 0311 Supplemental Security Income (SS1) “ “ 

,,, ; 040 Medicare 

], 05n Medicaid 

I 06 � Other government assistance or welfare 

I 07 � Religious organizations, foundations, agancias I 

I Oa� VA contract, pensions, or other VA compensation 

I os � payment source not yet determined 

I 

IOU Other — Specify ~ 

,! 

I


~ esa Don$t know


1 Hand flashcard 14. I 

I 01 •l Privata insurance 

26.	 What was tha PRIMARY (expected) source of 

/ 02 � Own income, family support, Social Security benefits, paymant (for this bilVwhen billad]? retirement funds 

Mark (X) only one box.	 I 03 � Supplemental Security Income (SS1) 

1 

, 04 � Medicare 

I 05 � Madicaid


I


, oa � Othar government assistance or welfare


I 07 � Religious organizations, foundations, agencies


; Oa � VA contract, pensions, or other VA compensation


I 09 � payment source not yet determined


~ IO � Other — Specify ~


,, 

; 

I 

I 99 � Don’t know 

I 

FILL SECTIONS C AND D ON THE COVER OF THIS FORM. 

NOTES 

IHM HHCS-31XI {3-1-91) Paga 

83 
----

-- --

yJIHCS-5(X) 

U.S. DEPARTMENT OF COMMERCE 

BUREAU OF THE CENSUS
 ACTING AS COUECTING AGENT FOR THE


DEPARTMENT OF HEALTH ANO HUMAN SERVICES 

U.S. PUBLIC HEALTH SERVICE 

CENTERS FOR DISSASE CONTROL NATIONAL CENTER FOR HEALTH STATISTICS 

DISCHARGED PATIENT 

QUESTIONNAIRE 

NATIONAL HOME AND 

HOSPICE CARE SURVEY 

PRETEST 

Section B — 

. Facility name 

. Patient name 

First ‘ !

‘ Ml. 1 Last 

OMB No. 0920-0283: Arwroval . . ExDires03/31/92

NOTICE- Public reporting burden for this collection of information is estimated to 

average 15 minutes per response. Send comments regardingthis burdersastimate or any other aspect of this collation of information, including suggeatf offi for, ~ 

reducing this burden, to PHS Reports Clearance Officer; AlTN: PFtk Hubert H. 

Humphrey Bldg., Rm 721-% 200 lndependance Ave., S.W.; Waahhgton,, DC 

20201, end to tha Office of Management and Budget; Paperwork Reducdon Pro@t 

(0920-0283); Washington, DC 20503. 

Information contained on this form which would permit ~ or any 

individual or establishment haa baen collected with a guarantee that it will be held in 

strict confidence, will be used for purposas stated for this study, and wjll nor be 

disclosed or releasad to others without the consent of. the ‘krdiivfduel or the 

establishment in accordance with Section 308(d) of the PubIii Health Service Act 

(42 USC 242ml. 

Section A – ADMINISTRATIVE 

. RO 2. Field representative name 

1 

PATIENT INFORMATION 

2. Control number 

I 

5.	 Date of interview 

MonthlQayNear 

INFORMATIOIW 

3. FR code 

, 

3. Patient Iii number 

6.	 Date of discharge 

Month/DayNear 

—-—. ——-—. 

Section C — RESPONDENT INFORMATION 

a. Respondent name 

--—- ———- -.-— ——_— —.—— —__’— --—— -——— -——— ———- -—-—— 

b. Title 

c.providedanswersforite’ms Oto m 

a. Respondent name 

———- -——,— ——-— —————-—— ————————-———— —--- -— —--- --4- ---— -— 

b. Title 

c.providedanswersforitems 0:0 m 

Section D - STATUS OF INTERVIEW 

01 El Complete 05 � Asaesament only/Not admitted


02 •l Partial oa � Other noninterview - Specify ~


03D Refused


04 � Unable to locate record

Read to each new respondent. 

[n order to obtain national Iavel data about patients who ara discharged from hospicas and homa haalth agancies such as 

thla one, we am collating Information about a sample of discharges. I will ba asking quaations about tha background, health 

atatua, traatmant, aoclal contacta and billing information for aach aamplad discharge. 

The information you provida wiii be bald in strict confidante and will be uaad ONLY by parsons involvad in tha �urvay and 

only for tha purposas of tha survey. 

In �nswaring thaaa quastions, it is �speclaiiy important to Iocata the information in the patient’a madical record. Do you have 

the madIcai file(s) and racord(a) with the details for (Read name(s) of selected dischargedpatients)? 

If not, ask the respondent to get it/them prior to beginning the interview. Fill sections A and Bon the front of the five dischar~edpatient 

forms while the respondent gets the records. If no racord js evailable for a patient, try to obtain as much information as possible from 

whatev& administrative records sre available andlor from the respondent’s memory. 

I 1. What was. . .“. sax? I 01n Male 

I


I 020 Female


2.	 What waa.. .*adata of binh? I Month Day Yaar Age (at admission) (mmmnoflnm

Hand Flashcard 3, I 

3a. Which of thasa best dascribad.. .*arace? ~ 

I 

Mark (X) oniy one box. I 

~ 

I 

1 

b. Was . . . of Hispanic origin? I 

I 

1 

! 

I 

I $. What waa. ..* � marital status at tha time of dischatga? I 

1 Mark (X) only one box. I 

I 

01 •l White 

020 Black


030 American Indian, Eskimo, Aleut


04 � Asian, Pacific islander


05 � Other – Specify€

gea Don’t know 

ol � yes 

020 No 

.99U Donrt know 

ol n Married 

02 � Widowed 

03 � Divorced 

1. 

1 040 Separated 

I 05u Never married


\


I 990 Don’t know


Read the introductory paragraph for the Social Security Number only once for each respondent. 

Aa part of this survey, we wouId Iika to hava.. .“a Social Security Numbar. Provision of this number is 

voluntary and not providing tha number will hava no effect in any way on.. .’s benefits. This number will 

ba usaful in conducting futura followup studias. Itwiil ba ussd to match against tha vital statistics racords 

maintained by the National Cantar for HaaIth Statistics. This information is collacted undar tha authority 

of Saction 306 of tha Public Haaith Sarvica Act. 

6. What was.. .’s Social Security Numbar? 

If the patient did not have a Social Security Number, obtain 

whatever Social Security Number is in tha record. Mark the 

box that best describes the Social Security Number entered. 

Hand Flashcard 4. 

6.	 Who rafarrad . . . to this faciiity? 

Mark (X) till that apply. 

. agez 

~ 

~I 

! 

I 

I 

I 

I 

I 

\ 

I 

I

I 

I 

I 

~ 

I

I 

1 

~ 

Social Security Number 

cm-m-cm


o, � patient-~ number 

020 Spouse’s number 

o~a parentcs number 

040 No Social Security Number available 

97 � flefu~ed 

990 Don’t know 

01 D Self/Family 

02 � Nursing home 

030 Hospital 

040 Physician 

OE.O Health department 

060 Social service agency 

070 Other _ specify 

I 99 � Don’t know 

FORM HHCS-51XI 13-1-911 

85 
7.	 What was the date of.. .’s admission for the ~ Month Day Year 

pariod of cara which endad on (Date of 

discharge)? ~mmm
 1OO � Only an assessment was done for this patient (patient


I was not providad services by this facility)


8a.	 According to.. .’a medicai record, what 1 ICD-9-CM codes 

wera tha primary and other diagnoses at the I Written form if available 

time of. . .’s admission that andad with this I 

(dischargelassassmant)? Plaasa provida the : primarY: 1 ———_ ._— 

ICD-9-CM coda if ona is available. I Others: 2 ———— ._— 

Probe: 

Any othar conditions? 

I 

1 

3 ———_ ._— 

I 4 ——_— .—— I 

I 5 ———— .—— 

/ 6 ———4 .—— 

I 

i 

CHECK I 01 � Box 00 is NOT marked - Go to item 8b 

Refer to item 7. I 02 � Box 00 is marked — END THE INTERVIEW. Complete ITEM A I sections C and D on the cover. 

8b. 

were. . .’s primary and othar diagnosas at , 

: Written form if available 

the tima of discharga — that is, on (Date of 

discharge)? Please provida the ICD-9-CM 1 Primary: 1 1 ———-4— — 

code if ona la avaiiable. 1 Others: I 2 ——-— .—— 

Probe: I 

According to...’ s medical racords, what ICD-9-CM codes 

Any other conditions? I 3 —-—- .-— 

I 4 ———- .—— 

;

1 5 ———- .——


I


I 6 ———— .——


1 c.	 Why was... discharged? I 

I 01 � Recovered 

I 02 � Stabilized 

I 03 � Moved out of district 

~ 04 u Deceased 

I

1 05 � Admitted to hospital inpatient sarvice 

I 06n Admitted to nursing home 

~ 07a Other — Specify ~ 

I 

I 

I 

1 99 � Don’t know 

I 

9. Did . . . have any living chiidran7 I

I ol U’fes 

I


I 02i3No


~ 99 D Don’t know 

t Oa. Did . . . hava a primary caregiver7 

~ 0; � Yes 

I 020 No.......


I SKIP to item 1 la


I 9s a Don’t know 1


Hand flashcard 5. 

; Oi n spouse 

b.	 What was tha relationship of the primary I 02 Q parent 

caraglvar to. ..? ~ 03 D Child 

Mark (X) only one box. I 

I 04 n Daughter/son-in-law 

I 050 Other relative – Specify 

] os O Neighbor 

I 07a Friend


I 08 Cl Volunteer group
 I


I 090 Other – Specify


~ 99 D Don~t know


‘W HHCS-51XI 13.1.91) Pagt 

86 
01

02

03

04

05

06

Hand flashcard 6. / D Private residence 

1� . During the episode of care ‘“lot ended on ~ � Rented room, boarding house 

(Date of discharge), where was... living? i � Retirement home 

Mark (Xl only one box. I I � Board and care or residential care faciiity 

D Hospice inpatient 

/	

[ � Other type health facility (inciuding mental heaith 

I faciiity) - SKIP to item 12 

b. Was . . . iiving with family members, 

nonfamiiy members, both famiiy and 

nonfamiiy mambers, or alone? 

CHECK Refer to item 10a ITEM B I 

c. Did . . . usualiy ihrewith (his/her) 

i 07 � Other — Specify 7 

; 

,


I 01 � Whh family members
 i


I 02 � With nonfamily members


/ 03 � With both family members and nonfa~;ly members 

i 04 � Alone - SK/P to item 12 

I


i 01 � Either box 02 or 99 is marked — SKIP to item 12
 I


I 02 � Box 01 is marked - Go to item 1 Ic 

I


I 01•l Yes


I 02 � No
 I


I 99 � Don’t know


primary caregivar? 

Read the question below end fill in as many 

names and addrasses as available. Ask the 

respondent to indicate which contact is the 

‘West contact” and Mark (X) the box abova 

that name. 

In ordar to foliowup on.. .’s compiete 

history of heafth care utilization, we wouid 

Iiko �ny information you have that wili ailow 

us to iocate . ..’8 next of kin. Please give me 

the names, addresses, and teiephona 

numbars of. . .’s nasttof kin, as weli as any 

othar relatives, frfends, or anyone elsa who 

might know �bout.... 

(The sponsor assaycontact these people in 

the future to obtain additional information 

about . ..’ � complate history of haath care. 

No information provided by you wiii be 

verified with retatives or friends.) 

If more than 3 names and addresses 

are provided; mark (X) this box+ � 

Use form HHCS-7(X) to list additional names, 

addresses, and telephone numbers. 

; 

I 

I 

/ 

I 

I Kin/ 

~ friend/ 

I other 

I 

I 

I 

i 

I 

i 

i 

i 

I 

I


i


i


I 

I Kin/ 

I

1 friend/ 

I other 

I 

I 

/ 

i 

i 

i 

I 

I 

I 

I 

I 

I 

I 

I Kin/ 

~ frienrj/ 

other I 

I 

I 

I 

I 

I 

I 

� Best contact 

First name Middla initial Last name


Number Street nsme P.O. box, RR No., etc.


City State ZiP Code


Area Code Telephone number


Relationship to patient


� Best ctrntad 

First name Middla initial Last neme 

Number Straet name P.O. box, RR No., etc. 

City Stata ZIP Code I 

Area Code Telephone number 

Relationship to patient 

� Best contact 

First name Middle initiai Last name 

Number Street name p.O. box, RR No., etc. 

City State ZIP Code 

1 

Area Code Telephone number 

Relationship to patient 

1 

FORM HHCS-51XI (3-1-911 

2. 

mga4 

87 
---

For items 13 through 20, use the phrase “AT THE TIME OF D/SCHARGE’O if the patient was discharged alive. Use the phrase 

“IMMEDIATELY PRIOR TO DISCHARGE” if the patient was discharged dead. 

Hand flashcard 7 ~ 01 D Eye glasses (including contact lenses) 

3. The following questions refer to the patient’s status ~ 02D Dentures (full or partial) 

(at the time of dischargelimmediately prior to I 030 Hearing aid 

discharge) on (Date of discharge). 040 Wheelchair : 

(At the time of dischargefimmediately prior to I 050 Cane 

discharge), which of these aids did... regularly use? ] 060 Walker 

I 07 � Crutches Mark (X) all that apply. 

~ 08D Brace (any type) 

I 09n Other aids or devices — Specify ~ I 

/ 

I IOU No aids used
 I


I 990 Don’t know


$a. (At the time of dischargefimmadiately prior to i 

discharge), did . . . have any difficulty in seeing I 01•l Yes 

(when wearing glasses)? ~ 020 No . . . . . . . . . . . . . . . . . . . . . . . . 

I 03n Not applicable (e:g., comatose) SKIP to item 15a


1


1 s@DDon’tknow . . . . . . . . . . . . . . . . . }


Hand flashcard 8.	 I 

I 01 ~ Partially impaired 

b.	 Was. ..’ s sight (when wearing glasses) partially, I 020 Severely impaired 

saverely, or completely impairad as defined on this card? ~ 03D completely lost,blind 

1 990 Don’t know [ 

8 

5a. (At tha time of dkchatgefimrnediataly prior to I 

discharge), did. . . have any difficulty in haaring I OIU Yes 

(when wearing a hearing aid)? I OZU NO . . . . . . . . . . . . . . . . . . . . . . . . 

~ 030 Not applicable (e.g., comatose) SKIP to ftem 16 

I ggo Don’tknow . . . . . . . . . . . . . . . . . 

1 } 

Hand flashcard 9. I

, 01 � Partially impaired 

b.	 Was...’ s hearing (when waaring a hearing aid) I 02D Severely impaired 

partially, severely, or completely impaired, as ~ 03~ Completely lost, deaf 

definad on this card? I 990 Don’t know 

I 

. Hand flashcard 10. I No 

6.	 (At the time of dischargefimmediately prior to discharge),! n~e%ed did not Unable to Didn’t do Don’t know 

do did . . . naed ANY assistance in any of tha following , assistance asg;;ce 

activities as da fined on this card - — I 

Mark [X) one box for each act;vity.	 I 

1 

a.	 Bathing or showaring? 1 01 n 02 � 03 El 04 •1 990 

I 

I 

b. Dressing? ! 01 n 02 c1 03 •1 040 99a 

I 

c. Eating? I

I 01 •1 02 •1 03 � 04 u 990 

t 

d. Transferring in or out of beds or chairs? I

I 01 D 02 � 03 � 04 � 990 

I 

e. Walking? I 01 � 02 n 03 c1 04 El 99 n 

1 

f. Using the toilat room? I .01 El 02 n 03 •1 04 n 99CI 

17a. (At the time of dischargefimmediately prior to I

I 010 Yes discharge), did . . . have an ostomy, an indwelling 

cathater or similar devica? [ 020 No...... 

SKIP to {tern 18, page 6

I 03~ Don’t know } I 

rl .. . .. L.”,-c =,”, ,.Y , 0, , rayu 

88 
I Tb. Did. . . require ANY assistance from another parson in I OICi Yes

caring for this davica? ~ 02!3N0 

I 990 Don’t know 

3. (At the time of dischargafimmediately prior to 

discharge), did . . . hava any difficulty in controlling j 01Cl Yes 

(his/her) bowals?	 I 020 No 

I 030 Not applicable (e.g., infant, had an OstOrrrY) 

I 

gen Don’t know 

I If patient had an indwelling catheter or an ostomy mark I 010 Yes 

box 03 without asking. 020 No : 

3.€ (At tha tlma of dischargafimmadiately prior to I 030 Not applicable (e.g., infant, had an indwelling 

discharge), did... have any difficulty controlling I catheter or ostomy) 

(his/bar) bleddar? I

! 990 Don’t know 

Hand flashcard 11. I 

I 

I Yas No 

!0. (At the time of discharga/immediately prior to I received did not Unaj~ to Didn’t do Don’t know 

discharge), did... receive personal help or 1 help receive help

supervision in any of tha following activities -- I 

I Mark (X) one box for each activity. I 

a. Doing light housework? I 01 •1 02 � 03 � 04 •1 99 •1 

b. Managing money? I 01 •1 020 . 03 El 04 � 99 c1 

c. Shopping for grocaries or clothas? I 01 •1 02 n 03 � 04 � 99 •1 

d. Using tha telephone (dialing or receiving calls)? 1 

I 01 c1 02 c1 03 � 04 � 9s c1 

I e.€ Praparing maafs? 01 •1 02 c1 03 •1 04 D e9 •l 

1 

f. Taking medications? I 01 •1 02 •1 03 � 04 � 99 � 

I 

Hand flashcard 12. I 

1 01 � Dietary and nutritional services 

1a. During tha 30 days prior to discharge, which of these ~ 02 � Occupational therapy/vocational therapy 

services wera provided to. . . by your facility? , 03 � Speech therapy/audiology 

Mark (X) all that apply. I 

I 040 Homemaker/companion services 

, 050 Meals on wheels

I 06D Transportation

I

, 07 � Enterostomal therapy

~ oaCl Counseling

I 09 � Medications

I 1o11 Respite care

~ 11 � High tech care (e.g., IV therapy)

I 12D Referral services

/ 130 Personal care

; 140 Skilled nursing services

I I 50 Physician services

I 16CI Social services 

1 170 Physical therapy 

I 1 an Other services – Specify 

I 

I Hand flashcard 13. 1 01 � Physicians I 

b.	 Which of these servica providers visited . . . during I OZU Registered nurses 

the 30 days prior to discharge? [ 03� Liscensed practical or vocational nursea 

Mark (X) all that apply.€ I 04 n Nursing aides and attendants 

I 05D Home health aides I

I 060 Home makers/personal caretakers

i 07 � Dietitians/nutritionists 

I

I os � Occupational therapists

[ 09 � Speech pathologists and audiologists I

I oa Physical therapists 

/ 11� Social workers I 

I 120 Health educators 

1 I 3D Othar providers - Specify I 

,“. ,.. ige 0 FORM HHCS-51X1 w. I.= I I 

89 
2.	 How many vlska were made to . . . during this tima -

that Ia,during tha 30 days prior to discharge? 

3a.	 For the billing pariod that Included (Date of discharge) 

what was tha total charga billad for.. .’s care 

Inciudlng all chargas mada for drugs, services, and 

spaclal medical supplias? 

b. What time period doasthis cost rafar to? 

Hand flashcard 14; 

!4.	 What were AL~ tha (expected) sourcas of payment fcr 

the amount billed? 

Mark (X) all that apply. 

t

Hand flashcard 14. 1 

I 

!5. What was the PRIMARY (axpected) source of I 

payment for.. .’s antira apiscde of care?	 I 

1 

Mark (X) only one box.	 I 

I 

I 

I 

/ 

I 

I 

1 

! 

I 

I 

I 

; 

I 

Number of visits 

000 None 

990 Don’t know 

.00 $ •1

000	 No charge was made for care — END INTERVIEW. 

Complete sections C and D on tha front of this form. 

99 � Don’t know — SKIP to item 24 

01 D 1 Day


0201 Week


03D 1 Month


040 Othar period — Specify ~


99U Don’t know (not billed yet, etc.) 

01 � Private insurance 

02D	 Own income, family support, Social Security benefns, 

retirement funds 

03U Supplemental Security Income (SS1) 

040 Medicare 

OEID Medicaid 

060 Other government assistance or welfare 

070 Religious organizations, foundations, agencies 

Oan VA contract, pensions, or other VA compensation 

09U Payment sourca not yet determined 

Ion Other – Specify ~ 

9an Don’t know 

01 •l Private insurance 

02 Cl	 Own income, family support, Social Secur”hy benefiis, 

retirement funds 

03 •l Supplemental Security Income (SS1) 

04 � Medicare 

os � Medicaid 

06 � Other government assistance or walfare 

07 � Religious organizations, foundations. agencies 

08 � VA contract, pansiona, or other VA compensation 

09 � Payment source not yet determined 

10 � Othar — Specify ~ 

9!3� Don’t know 

FILL SECTIONS CAND D ON THE COVER OF THIS FORM. 

NOTES 

FORM HHCS-SIXI (3.1.91) Page 7 
1 

1 

I 

, 

I 

J 

1’ 

OMB No. 0920-0283: Approval Expires 03131192 

I ;ORM 14H!2S-7(XI 

1 3-bau 

I 

U.S. DEPARTMENTOF COMMERCE 

BURSAUOF THE CENSUS ACTING AS COLLECTING AGENT FOR THE 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

U.S. PUBLICHEALTHSERVICE 

CENTERS FOROISEASE CONTROL

NATIONAL CENTER FOR HSALTH STATISTICS

CONTINUATION SHEET 

For Question 12 

NATIONAL HOME AND 

HOSPICE CARE SURVEY 

PRETEST 

Kin/


:kgl � Best contact


First neme Middle initisl Lest name 

1. SHEET_ OF_ SHEETS 

2. Type of patient - Mark (X] ona 

•l Currant patient 

a Discharged patiant 

3. Facility name 

4.	 Control numbar 

1 

5.Patient neme 

6. Patient line number 

Kin/ 

“friend/ � Best contact 

other 

First name Middle initial Last name 

Number Street name P.O. box, RR No., etc. Number Street name P.O. box, RR No., etc. 

city Stste ZIP Code City Stste ZIP Code 

Araa Code Telephone number I Area Code Telaphone number 1 

Relationship to patient Relationship to patient 

I 

Kin/ � Best contact I other 

friendl � Best contact 

Firat name Middla initial Last name Middla initial Last name 

Number Street name P.O. box, RR No., etc. Number Street name P.O. box, RR No., etc. 

I I 

city State ZIP Code State ZIP Code 

Area Coda Telephone number Area Code Telephone number 

Relationship to patient Relationship to patient 

Kin/ Kin/ 

::g:l � Best contact friendl � Best contact 

other 

Firat name Middle initial Last name First name Middle initial Last name 

Numbar Streat name P.O. box, RR No., etc. Number Street nsme P.O. box. RR No., etc. 

City State ZIP Code City State ZIP Code 

Area Code Telephone number I Area Coda Telephone number I 

Relationship to patiant Relationship to patient 

If additional sheets are used, mark (x) this box. - � 

91 
HHCS-20(X) 

(3-1-91 ) 

U.S. DEPARTMENT OF COMMERCE 

SUR3AUOFTHEIXNSUS 

ACTINGAS COLLECTINGAGENTFORTNE 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

LJJS.WBUC HEALTH SERVICE 

CENTERSFORDISSASECONTROL 

NATIONALCENTERFORHEAI.TNSTATISTICS 

FLASHCARD BOOKLET 

NATIONAL HOME AND


HOSPICE CARE SURVEY


PRETEST 

,,, 

., ,-

92 
CARD 1


1.	 FOR PROFIT – includes individual or private, partnership, 

corporation 

2.	 NONPROFIT – includes church-related, nonprofit corporation, 

other nonprofit ownership 

3.	 STATE OR LOCAL GOVERNMENT – includes State, county, 

city, city-county, hospital 

district or authority 

4.	 FEDERAL GOVERNMENT – includes USPHS, Armed Forces, 

Veterans Administration 

5. OTHER 

93 HHCS.20[X) (3-1-91) 
CARD 2 

EMPLOYEES ON PAYROLL 

Full-time (35 or more hours per week) 

Employed


Budgeted vacant positions


Part-time (less than 35 hours per week) 

Employed


Budgeted vacant positions


SERVICES PROVIDED DURING THE LAST 7 DAYS 

Total hours worked by full-time and part-time staff


Total hours of service provided by those not on your payroll


Total visits made


TYPE OF EMPLOYEE 

Physicians 

Registered nurses 

Licensed practical or vocational nurses 

Nursing aides and attendants 

Home health aides 

Homemakers/personal caretakers 

Dietitians/nutritionists 

Occupational therapists


Speech pathologists and audiologists


Physical therapists


Social workers


Health educators


Other providers


HHC3-20[X) {3-1-91) 

94 
I 

1. White 

2. Black 

3. American Indian, Eskimo, Aleut 

4. Asian, Pacific Mander 

HHCS-20(X) (3-1-91 I 

95 
CARD 4 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

SeltYFamily 

Nursing home 

Hospital 

Physician 

Health department 

Social service agency 

Other 

HHCS-20(XI (3-1-91 I 

96 
CARD 5 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

spouse 

Parent 

Child 

Daughter- or son-in-law 

Other reIative 

Neighbor 

Friend 

Volunteer group 

Other 

HHCS-201X)13-1-91) 

97 
CARD 6


1. PRIVATE RESIDENCE - rented or owned 

2. RENTED ROOM, BOARDING HOUSE — room or boarding house 

open to anyone as defined by the landlord for rental payment 

3. RETIREMENT HOME – a retirement facilitythat provides room 

and board to elderly or impaired persons; often includes a separate 

hospice wing or unit that provides nursing, medical, personal care, 

etc., to those needing it 

4. BOARD AND CARE OR RESIDENTIAL CARE FAC~LITY - a 

facility having three beds or more and that provides personal care or 

supervision to its residents, not just room and board (for example, 

help with bathing, dressing, eating, walking, shopping, or 

corresponding) 

5. HOSPICE INPATIENT 

6. OTHER TYPE OF HEALTH FACiLITY (including mental heaith 

facility) — other facility or institution that provides lodging, board, 

and social and physical care including the recording of health 

information, dietary supervision and supervised hygienic services for 

three or more patients not relatedto the operator 

7. Other 

HHCS-20[X) (3-1-91) 

98 
CARD 7


1.


2.


3.


4.


5.


6.


7.


8.


9.


HHCS201Xi (3.1-911 

Eye glasses (including contact lenses)


Dentures (full or partial)


Hearing aid
 .,.. 

Wheelchair ““” 

Cane”’ ‘ . ,’ “ 

WaIker “ 

Crutches 

Brace (any type) ~ 

Other aids or devices ,, 

., 

99 
CARD 8


1.	 PARTIALLY IMPAIRED – cannot read newspaper print but 

can watch television 8 to 12 feet awa} 

2.	 SEVERELY IMPAIRED – cannot watch TV 8 to 12 feet away, 

but can recognize the features of 

familiar persons if they are within 

2 to 3 feet 

3. COMPLETELY LOST, BLIND 

HHC3-20(X) (3-1-91) 

100

CARD 9


1.	 PARTIALLY IMPAIRED – can hear MOST of the things a 

person says 

2.	 SEVERELY IMPAIRED – can hear only a few words a person 

says or loud noises 

3. COMPLETELY LOST, DEAF 

101

CARD 10


a.	 BATHING or SHOWERING - washing the whole body; includes the 

process of getting in or out of tub/shower 

b.	 DRESSING – getting clothes from closets/drawers and putting them 

on. Includes managing buttons, zippers, and other fasteners; excludes 

tying shoes 

c.	 EATING – getting food from plate to mouth; excludes assistance 

with cutting meat or buttering bread 

d.	 TRANSFERRING IN OR OUT OF BEDS OR CHAIRS – getting into 

and out of bed or getting into and out of a chair/wheelchair 

e.	 WALKING — moving from one place to another by advancing the feet 

and legs in turn at a moderate pace 

f.	 USING THE TOILET ROOM – going to the toilet, transferring on and 

off the toilet, cleaning self after elimination and arranging clothes; 

excludes bowel and bladder functioning 

HHCS-20{X) (3-1-91) 

102 
CARD 11 ~


a. Doing Iight housework


b. Managing money


c. Shopping for groceries or clothes


d. Using the telephone (diaIing or receiving calls)


e. Preparing meaIs


f. Taking medication


HHC3-201XI {3-1-91) 

103 
CARD 12 

1. IDIETARY AND NUTRITIONAL SERVICES – direct counseling by a trained 

[wtritionist; does NOT include supervision of special diets 

2.	 (OCCUPATIONAL THERAPY/VOCATIONAL THERAPY - from a registered or 

Iicensed occupational therapist; special restorative treatment 

3.	 SPEECH THERAPY/AUDIOLOGY - evaluation, treatment, and monitoring of 

specific communication disorder(s) 

4. IHOMEMAKER/COMPANION SERVICES – servicesthat are necessary for 

Imaintaining a safe and healthy home environment for the patient (e.g., cleaning 

the patient’s kitchen, doing personal laundry, preparing meals) and other services 

to enable the patient to remain at home 

5.	 IMEALS ON WHEELS – program that provides regular delivery of food to elderly 

and handicapped persons with limited mobility. Often provided through a 

volunteer network 

6. TRANSPORTATION — provision of transportation 

7.	 ENTEROSTOMAL THERAPY - therapy designed to teach the proper method of 

caring for an ostomy site 

8.	 COUNSELING – counseling and/or therapy that assists the patient in minimizing 

stresses and problems that arise from social, economical, or psychological 

situations and that assists the patient in maximizing positive aspects and 

opportunities for growth 

9. MEDICATIONS — providing prescription medication 

10.	 RESPITE CARE - care provided to the patient in the home or inpatient setting to 

relieve the family or primary caregiver, due to family psychological problems, 

caregiver fatigue, or required short-term absence of the caregiver 

11. HIGH TECH CARE – specialized care, especially the setup of IV’S in the home 

12.	 REFERRAL SERVICES — referral to other sources for services that are not 

provided by the facility 

13.	 PERSONAL CARE - aid in bathing, dressing, using the toilet, getting in and out 

of bed, eating, or walking 

14.	 SKILLED NURSING SERVICES - coordination by an R.N. or an L.P.N. of a care 

plan; e.g., catheterization, injection 

15.	 PHYSICIAN SERVICES - evaluation and/or treatment from a licensed M.D. 

(not including psychiatrist), D. O., or physician associate 

16.	 SOCIAL SERVICES - counseling, advocacy coordination, information, referrals; 

e.g., legal aid, job, housing assistance 

17.	 PHYSICAL THERAPY - from a certified or licensed physical therapist; 

treatment to restore function, relieve pain 

18. OTHER SERVICES 

HHCS-201XI(2-1-91) 

104 
CARD 13


1.


2.


3.


4.


5.


6.


7.


8.


9.


10.


11. 

12. 

13.


HHCS-201XI(3-1-91) 

Physicians


Registered nurses


Licensed practical or vocational nurses


Nursing aides and attendants


Home health aides


Homemakers/personal caretakers


Dietitians/nutritionists


Occupational therapists


Speech pathologists and audiologists


Physical therapists 

Social workers 

Health educators 

Other providers 

105 
CARD 14


1.


2. 

3. 

4. Medicare 

5. Medicaid 

6. Other government assistance or welfare 

Private insurance 

Own income, family support, Social Security 

benefits, retirement funds 

Supplemental Security income (SS1) 

7.


8.


9.


10.


ReIigious organizations, foundations, agencies 

VA contract, pension, or other VA 

compensation 

Payment source not yet determined 

Other 

HHC3-20(XI (3-1.91) 

106 
-1 

Form HHCS-30(X) - Sample Selection Tables Page 1 

Total # Liste~ Samrde Line FJumkrs Total # Listed Silnlnl~ Line Numbers 

1 1 31 3 9 1$ 21 28 

2 1 2 32 2 9 15 22 28 

3 1 2 3 33 4 11 17 24 31 

4 1 2 3 4 34 1 8 15 21 28 

5 1 2 3 4 5 35 6 13 20 27 43 

2 5 36 1 8 16 23 30 

3 ‘: 6 ; 37 6 14 21 28 36 

4 5 7 38 5 12 20 28 35 

5 7 ; 39 2 10 18 25 33 

: 5 7 9 40 7 15 23 31 39 

11 2 4 6 8 10 41 4 12 21 29 37 

12 2 5 7 10 12 42 3 12 20 28 37 

13 3 5 8 11 43 10 18 27 35 

14 3 6 8 11 : 44 : 14 31 40 

15 2 5 8 11 14 45 4 13 : 31 40 

16 2 5 8 11 14 46 7 16 26 35 44 

17 3 6 9 13 16 47 3 13 22 31 41 

18 4 8 11 15 18 48 5 15 25 34 44 

19 1 5 8 12 16 49 10 20 30 40 49 

20 1 5 9 13 17 50 4 14 24 34 44 

21 8 13 17 21 51 7 18 20 38 48 

22 7 11 16 20 52 1 11 21 32 42 

23 9 14 18 23 53 11 21 32 43 53 

24 8 13 22 54 3 14 25 36 47 

25 7 12 :: 22 55 5 16 27 38 49 

26 3 8 13 24 56 9 20 31 54 

27 3 9 14 #l 25 57 11 23 34 2 57 

28 2 7 13 18 24 58 1 13 24 36 48 

29 2 8 13 19 25 59 7 19 31 43 54 

30 1 7 13 19 25 60 ‘5 17 29 41 53 

0 NOTE This Is the first page of form HHCS-30(X)-Sample Selection Tables. 
Appendix V 

Letters, data collection 

instruments, and sample 

selection table for the 

National Home and Hospice 

Care 

#’@”%

~L-%. 4 DEPARTMENTOF I-IEALTH & I-IUMAN SERVICES	 Public Health Service 

Centers for Disease Control 

NationalCenter for Health Statlstlos


6525 Belcrest Road


Hyattaville,MD 20782


Dear Adminiatrato~


The National Centar for Health Statistics (NCHS), of the Centers for Disease Control,


collects and provides information on the health of the Nation and the utilization of its


health resourcas. As part of this continuing program, the NCHS is conducting the


National Home and Hospice Care Survey. This suwey is authorized under section 306


(42 USC 242k) of the Public Health Service Act. In addition, the survey is endorsed by the


National Association for Home Care.


The purpose of the survey is to provide a more complete information base on available


long-term care services and utilization of those services. The survey includes a small,


randomly selected, nationwide sample of hospices and home health agencies, each of


which represents a number of similar facilities. Information about your facility will be


collected through a personal .interview which will require about 20 minutes of your time.


In addition, time involving some of your staff will be required to complete interviews for


a small samp~f patients. No patients will be contacted at any time. Your participation


is voluntary and there are no penalties for refusing to participate or refusing to answer


any question. We may need to contact you in about a year to update the information you


provide during this survey.


I want to emphasize that the information you and your staff supply will be used only for


statistical research and reporting purposes. In accordance with Section 308(d) (42 USC


242m) of tha Public Health Service Act, no information collected in this survey maybe


used for any purpose other than the purpose for which it was collected. Such information


may not be published or released in any form if the individual or establishment is


identifiable unless the individual or establishment has consented to its ralease.


Within the next few weeks, a Census Bureau field representative will contact you for an


appointment. The Census Bureau is under contract to conduct this surv6y. I greatly


appreciate your cooperation in this survey.


Sincerely yours,


MANNING FEINLEIB, M.D., Dr. P.H.


Director, National Canter for Health Statistics


HHCS-1OLI (5-22-92) 

108 
} SOME FREQUENTLY ASKED 

, HOW WAS THIS FACILITY CHOSEN? 

A sample of hospices. and home health facilities was chosen from a National list to 

represent similar facilities in the United States. Since each represents several others, 

your full participation is very important to the outcome of this survey. 

WHAT ARE YOU GOING TO DO WITH THE RESULTS OF THE SURVEY? 

Information on hospices and home health facility providers and the populations they 

serve is needed by policymakers for assessing the availability of and need for hospice 

and home health services. Data from this National survey will assist policy makers in 

determining where and by whom these types of care are needed as well as identifying 

who is already receiving hospice or home care. Eventually these data could be used to 

identify any increased demand for hospice and home care services which could tax the 

ability of social service facilities to meet the needs of the terminally and chronically ill. 

WE’VE ALREADY PROVIDED THIS INFORMATION. 

The information we are collecting in this National survey may be similar to what you 

have provided in other surveys, but it is not the same. The laws governing confidentialil 

prohibit our obtaining similar information from other sources. In addition, for estimates 

from this survey to be accurate, we need to collect the same information from all 

participating facilities in exactly the same way. 

WE’RE TOO BUSY AND DON’T HAVE ENOUGH -STAFF. 

W“ecan work around the schedule and availability of your staff. We know they are busy. 

We can interview any staff member who is knowledgeable about the patient records. 

Eventually your help will increase the visibility of hospice and home health facilities anc 

their essential contribution to the care and comfort of patients and their families. 

HHCS-10(L)(6-22-92) 

109 
,*WIQ5.0

8’ *$ 4 DEPARTMENT OF HEALTH& HUMAN SERVICES Public Health Service 

Centers for Disease Control ~ (L

‘%%,3.	 National Center for Health Statistics 

6525 Belcrest Road 

Hyattsville, MD 20782 

&zi!4f’f’ii% 

I want to personally thank you for participating in the National Home and Hospice Care 

Survey and for assisting the field representative from the Bureau of the Census, who 

conducted the survey in your facility. It is only through the cooperation of administrators 

like yourself that we are able to conduct a survey such as this one. The information we 

collect from this survey will be invaluable in helping us to support effective treatment of 

long-term health problems. 

Again, I appreciate the time and effort you have given in support of this survey. 

Sincerely yours, 

MANNING FEINLEIB, M. D., Dr. P.H.


Director, National Center for Health Statistics


HHCS-1 l(L) (5-22-92) 

110

: HO!b41-lQ!iRj . 

*V 

~ NATIONAL ASSOCIATION FOR HOME CARE ANNE M. KATTERHAGEN HONORABLEFRANKE. MOSS 

S19C STREET, N.E., ShiN’ION PARK CHAIRMANOFTHE BOARD SENIORCOUNSEL 

WASHING’ION, D.C. 20X)2-5809 VALJ. HALAMANDAIUS .WANLEYM. BRAND Telephone(202)S47-7424.FAX (202)547-3540 PRESIDENT GENERAL COUNSEL 

September 1992
,,


Dear Administrator:


I am writing to encourage your participation in the 1992


‘%& 

National Home and Hospice Care Survey (NHHCS) to be conducted this


month by the National Center for Health Statistics. This survey is


the first in what will become an annual survey by NCHS to collect


baseline and trend information about home health agencies and


hospices in relationship to the patients they serve and the type


of staff they employ.


Your support as a home care or hospice administrator is


critical to the successful development of invaluable data for


planning and organizing home care and hospice services, drafting’


health legislation and setting national polzcies and priorities to


obtain high quality care for all home care and hospice recipients.


A minimal amount of your time and staff time will be involved


and strict confidentiality will be maintained. Only summary data


will be published and made available to health planners,


researchers, health professionals and the public.


I am confident that the information derived from this survey


will be worth the investment of your time and effort. Your


participation assures that the development of information to be


used in-shaping


based on the


cooperation in


KS-15 REPRESENTINGTHE NATIONSHOKSHEALTH AGENCIES,HOMEI!LAKER-HOME HEALTHAIDEORGAN IZATIONSANDHGSPICS-S 

111

-. .-.,. .-.. .-. . . UMU No, UYW-UZYX: ApprOVal tXplrOS UWUP! 

y2qHCS-1 NOTICE - Public reporting burden far this collection of information is estimated 

to average 20 minutes per response. Send comments regarding this burden 

estimate or any other aspect of thk collection of information, including 

suggestions for reducing this burden to PHS Reports Clearance Officer; ATTN: 

PR& Hubert H. Humphrey Bldg., Rm. 721-8; 200 Independence Ave., SW; 

Washington, DC 20201, and to the Office of Management and Budget; Papenvork U.S. DEPARTMENT OF COMMERCE Reduction Projeer [OS20-0298);-Washington, DC 20503. Information contained on BUREAU OF THE CENaUa ACTING .4S COLLECTrdGAGENT FOR THE this form which would permit identification of any individual o< eatabliahment 

DEPARTMENT OF HEALTHANO HUMAN SERVICES has been collected with a guarantee that it will be held in strict confidence, will 

U.S. PUWtC HEALTH SERVICE be used for purposes stated for this study, and will not be disclosad or released 

CENTERS FOR DISEASECONTROL co others without the consent of the individual or establishment in accordance NATIONAL CENTER FOR HEALTH STATISTICS with Section 3081d) of the Public Health Service Act (42 USC 242m). 

FACILITY QUESTIONNAIRE 

NATIONAL HOME AND 

HOSPICE CARE SURVEY 

Section A-ARRANGING THE ADMINISTRATOR APPOINTMENT 

a. Facility telephone number 6. NAME VERIFICATION 

I would like to verify some information from my records. , b.	 Alternate telephone number IS (Name of faci/ity on /abe/) the correct name of your 

facility? 

� Yes -Go to /tern 7, ADDRESS VERIFICATION, 

c. Alternate telephone number � No - Etrtercorrect facility name below. z 

Administrator name 

7. ADDRESS VERIFICATION 

Record of calls 

Day Date Time Notes Is (Address of facility on label) the correct address? 

(a) (b] [c) {d] -. . � Yes-Go to Item 8- SETAPPLWW14ENT 

a.m. � No - Enter corract facility addraaa below. z 

p.m. 

a.m. 

p.m. 

a.m. 

p.m. 

a.m. c p.m. 

a.m. 8. SET APPOINTMENT 

p.m. 

INTRODUCTION I would like to arrange a morning appointment at your 

convenience to condust the survey. What would be a 

Good momin (afternoon). My name is. . .. I’m from convenient date and”time to visit your facility? 

the Bureau o ? the Census. We are currently 

conducting the Nationel Home and Hospice Care Day Data Time a.m. 

Survey for the National Cantar for Health Statistics p.m. 

which is part of the Centers for Disease Control. We 

are studying home health agencies, hos ices and 9. Could you give me directions to your fecility from
 their aatlents. You should have receive J a letter soma aasy to idantify statiing point? (Record
 from L/sr. Mannin Feinleib, the Director of the directions in number 10 below.)
 National Center or Health Statistics, which


dascribes this projact. Hava you receivad this letter? Thank you very much for your time. I will see you at


� Yes - Skip to Item 6, NAME VERIFICATION. (Time) on (Date). Good-bye. 

� No - Continue with Item 5, SURVEY EXPLANATION. 10. DIRECTIONS TO FACILITY 

I. SURVEY EXPLANATION 

/f administrator wants a copy of the /etter, explain that you 

will bring a copy when you visit the facility. 

I’m sorry that you did not receive the [etter. Let me . briefly outlina its contants. Section B- RECORD OF INTERVIEW 

The National Home and Hospica Cara Susva is 1. STATUS OF INTERVIEW - Mark [X) appropriate box, authorized undar Saction 306 of the Public L ealth 

Sanfice Act to qollact base!ip~ information about 01 •l Complete interview 

home and hosplca cara faclht[es, thair services, and 

patients. The statistics compiled from the data are 02 •l Partial intewiew 

usad to su port research for effeotive treetment of oa � Refusal


long-term R ealth problems and to stud utilization 04 � Not a Hospice/Home Health Agency
 of hospice end hcrma cere facilities an J the efficiant


usa of the Nation’s health cera resources. 05 D No longer operating


oa � Temporarily closed 

All information which would permit identification of 07 � Not yet in operation the individual patient or facility will be held in etrict 

confidence, wdl be used ONLY by persons involved oe� Duplicate (Control No, of duplicate) 

in the erarvey and only for the purposes of the oe � Unable to locate survey, and will not be disclosad or raleased to 

othara for any purpose. 10� Other nonintewiew - Specify 

The saarve includes a small sample of hospices and 2. Date of interview 

home hea 1’th agencies. Although your partlci ation 

is voluntary and there are no penelties for re l’-using 

Month I Oay 

I 

I Year 

to answer any questions, it is essential that we , 

obtain data from all sample facilities. 3. Field Representative I Code 

Continue with Item 6, NAME VERIFICATION. I 

I 

112 
---- -----

----

----

Section C- QUESTIONS ABOUT THE FACILITY 

Before I begin the interview, I’d like to take a moment to explain the purpose of the survey. I believe you 

(received/did not receive) the letter from the National Center for Health Statistics. 

If administrator did not receive the letter, hand him/her a copy. Allow him/her to read it through briefly. 

As it says in the letter, the purpose of this survey is to collect baselina information ebout hospices and 

home health agencies such as yours. The information you provida is strictly confidential and will be used 

only by persons involvad in the survey and only for the purposes of tha survey. 

1a.	 Does this facility currantly provide home health or ~ 01 � Yas 

hospice cara services? I 02n No I 

b. Did this facility provide home health or hospice care ~ 01 � Yes - GO to item lC services	 to patients during tha last 12 months? I 02 � No - SKIP to item ld 

C.	 During the past 12 months, what was the number of I 

home health and the number of hospice care I Number of home health patients 

patienta served by this facility? I 0000� None 1 

Use the combined category if the respondent cannot 

prov!de separate numbers for home health and hospica 

I 99s9� Don’t know 

t-–.-----------––––– -— 

patients OR if the faci/ity had patienta who received both 

home health and hospice care. 

I 

Number of hospice patients 

1 0000 � None 

e9ss � Don’t know ,1 

I 

I Number of patients who were served as 

I BOTH hospice and home haalth patients 

I (DO ~T INCLUDE IN NUMBERS ABOVE) 

~---–- —’--- ____ ______ _______ 

I 0000 � None I [ 9999 � Don’t know 

d.	 Does this facility currently have any active home [ 01 � Yas – GO to item fe haalth or hospice care patienta? I 02 � No - SKIP to CHECK /TEM A 

e.	 What is the number of homa health and the number 1 

of hospice care patients currantly being served by I Number of home health patients 

this facility? ~ 0000� None 

Use the combined category if the respondent cannot 

provide separate numbers for home health and hospice 

; 9999� Don’t 

i----------------

know 

-----------–––- -

patients OR if the facility has patients who receive both 

home health and hosDice care. I Number of hospice patients 

~ 0000 � None 

I 9999� Don’t know 

p--- ______________ _________ _ 

I


I Number of patients currently served as


I BOTH hospice and home health patients


I (DO~TINCLUOEIN NUMBERS ABOVE)


I 0000 � None I 

, wwnDon’tknow 

1 

Refer to items la, lb, and Id. 

CHECK 

ITEM A 

I 

I 

I 

I 

01� If la, lb, and Id are all marked “No,u THIS FACILITY IS 

OUT OF SCOPE FOR THE SURVEY’. THANK THE 

RESPONDENTAND END THE INTERVIEW 

I 02 n Other - GO to item 2a I 

2a. What isthetype ofownersfdp ofthisfacilityas I partnership, corporation 

HAND FLASHCARD 1 I 

I 01� FOR PROFIT - Includes individual or private, 

shown on this card? I 

I 02 � NONPROFIT - Includes church-related, nonprofit 

Mark (X) only ONE box. I corporation, othar nonprofit ownership 

[


I 03 � STATE OR LOCAL GOVERNMENT - Includes State:


1 county, city, city-county, hospital district or authority


I I 04 � FEDERAL GOVERNMENT - Includes USPHS, Armed
 I


t Forces, Vetarans Administration


I I 05 � Other - Specify ? I 

I I


I I
 I 

I 

b. Is this facility operatad by a hospital? I

I 

01 � Yss 

I 02 � No 1 

c. Is this facility operatad by a nursing home? I 01 � Yes 

I 02 tl No I 

d. Is (Name of facifily) a mamber of a group of facilities I 01 � Yes- Confirrue with item 2e operating under one ganaral authority or general I
 ownership? I oz � No - SK/P to item 3


I e. What is the name of the parent organization? I Parent organization 

I I


t


I I


I 1 

Page 2 FORMHHC5-1(5.27.92) 

113 
Section C- QUESTIONS ABOUT THE FACILITY- Continued 

I Is this facility certified under Medicare as a Home , 01•l Yes Health Agency? I

1 02 � No 

I 03 •l Certification pending 

I. Is this facility certified under Medicare as a Hospice? I 01 •l Yes [ 

I 02 � No 

I 03 •l Certifisstion pending 

I.	 IS this facility certifiad under Madicaid as a Home I 01 •l Yes Health Agency? 

r

I 

02 � No 

I 03 •l Certification oendirm 

h Is this facility certified under Medicaid as a Hospice?	 I 

1 07 •l Yes 

I 02a No 

! 03 •l Certification pending 1 

i.	 Doas this facility provide bereavement care to the I

I 01 •l Yes families of the patients you serve? I 02 � No $ 

>. Doss this facility provide pastoral sare? I

I 01 � Yes 

I 02 � No 

How many persons served your facikity as vraluntears I 

during the last 7 days? I 

1 Number 

I 00 � None 

What is your name, title, and telephone number? ~Respondent name 

I 

I Title 

I

IAreacode Number 

I 

TO complete this survey. 1will need a kist of all currant home health and hospice patients. and a 

list of all home health and hospica discharges within the past year. From thesa 3ists, I will draw a 

sample of 6 current patiente and 6 discharged patients. 

e.	 From whom shall 1obtain tha list of current I Neme 

patients? I 

r 

, Title 

1will need these patiants’ medisal racords and tha ~ 

cooperation of a staff member best acquainted with 

these patients in order to obtein tha information on ~ 

this quaationnaire. I 

Hand the administrator a copy of the current patient I

I 01 � Yes -GO to item 9a questkvm.wre. AIIow him/her

and

to examine it br!efly. 

Retrieve I 02 � No - Determine which staff member wotdd have this the questionnaire continue reading. I knowledge and anter the name and title below. z 

I will not be contacting or interviewing the patients 1 

in anyway. 1will depend on your staff to consult the \ 

madiaal records. 

; Name b.	 Would [person named in item 8a) know which staff 

member I should interview for those patients ! 

selectad for tha sample? I Title 

t 

I a. From whom shall I obtain the list of discharges? ,DSame as 8a 

! 

I Name 

i Title I 

I will need the help of a staff person familiar with j 

the discharge records to aid me in completing the ,


information raquested in this queetionnaira. 1 01� Yes - GO to item 70 below


02 Q No - Determine which staff member would hava tfda Hand the administrator a copy of the discharged patient [ &now/edge and enter the name and titla balow, ~ questionnaire. Allow him/her to examine it briefly. I Retrieve the questionnaire and continue reading. I 

b.	 Would (person named in item 9a) know which staff I 

mambsr I should interviaw for those discharges that ~Name 

fall into the sample? t 

I Title 

I 

HAND FLASHCARD 2 ~ Name 

I [0. I also need this information about your staff. From 

whom shall I obtcin this information? : Title 

I 

Refer to item 10. ! 

I 01 � Respondent will provide information - GO to itam 71 

CHECK [ 02a Other - Leave a copy of Form FfHCS-7A, Facility TEM B I Staff Worksheet (and self-addressed, stamped I envelope) with respondent. SKIP to item 12 I 

!M HHCS-1(5.27.921 Page 3 

114 
11. HAND FLASHCARD z Number of Number of 

Please provide the information mquestedabout the number of employees full-time staff full-time 

of this facility, the hours worked, and the number of visits made during (35+ hours per budgeted 

your last paypen-od for each type of employee listed, even if the number is week) on your positions that 

zero. Do not include vohrssteers in these numbers. payroll are vacant 

What are the dates 

of your last pay 

pariod? ~ la) (b) 

‘hysicians 

Registered nurses 

.icensed practical or vocational nurses 

Uursing aides and attendants 

iome heelth aides 

{omemakers/Personal caretaker —.. . 

)ieticians/Nutritionists 

occupational therapists 

;peech pathologist and audiologists 

‘hyaical therapist 

;ocial workers 

1 

iealth educators I I *astoral/Bereavement staff 

idminiatratorloirector 

:ase managerlCase coordinator {Not RNs or Social Workers) 

secretarial/Clerical I 

)ther health personnel - Specify~ . . I 

)ther personnel - Specify z 

I 

12. Thank you for your time. I will ba checking with you before I Ieeve to sey NOTES 

good-bye. 

At this time, could you introduce me to (Names ofpersonfs) listed in items 8a, 

8b, 9a and 9b). 

Number of Number of T;tal hours 

part-time staff part-time worked by all 

(less than 35 budgeted full-time and 

hours per positions that part-time staff 

week) on your are vacant 

payroll pay%li’’%ing 

you::.tdpay 

Total hours of service Total number 

provided by staff not on of viaits mada 

your payroll during your last during your 

pay period. (For example, last:;~:tfiod 

temporary employment 

servicee, visiting nurse payroll and 

services, and other contract nonpr~tl 

services) 

(cl I (d) I . (e) I (fl I k!] 

I 
OMB No, 0920.0296 Approval Expires 06/30i95 

1 FOflM HHCS-l A U.S.OEPART~;R;;:;FcT;~~::;: 1.Facility name 2. Controlnumber 3. Dates ofyourlaat payperiod (5.27.92) 

FACILITY STAFF WORKSHEET Month I Oay I Year II Month Oay Yaar 

— 

NATIONAL HOME AND HOSPICE CARE SURVEY I 

INSTRUCTIONS Number of Number of Number of Number of Total hours Total hours of sarvice Total numbar 

(1) the full-time staff full-time part-time etaff part-time worked by all provided by staff not on of visits made Enter dates of your last pay per;od in ifam 3. (35+ hours per budgeted Oesathan 35 budgeted full-time and your payroll during your last during your (2) For each cetegory /Lsted be/ow, enter the information requested about the steff of this weak) on your positions that hours per poeitionsthat part-time staff pay period. (Examplex Iast#; :t~iod 

facility. Enter zero if appropriate. Please fi// all of cohrnrrrs a through g for all categories. payroll are vacant week) on your are vacant temporary employment i 

[3) Do not include volunteers In drese numbers, I payroll	 pay%fil;ing servicas, visitino nursa payroll and 

you;: ~tdpay services, and othe; contract no~fm#l 

~4j Return the form in the attached po~tage paid envelope. Itwould be hefpful /f you could eervlcas) complete and return the form wlthtn the next TWO DAYS, la) lb) (c) (d) [e) [9) 

I 

Licensed 

Physicians 

Registered 

practical 

nurees 

or vocational nurees 

d

Nursing aides and attendante 

Home health aides 

Homemekers/Personal caretaker 

Dietitians/Nutritionists 

Occupational therapies 

Speech pathologists and audiologists 

Physical therapists 

Social workers 

Health educators 

Pastoral/Bereavement staff 

Administrator/Director 

Case manager/Case coordinator (Not RNs or Social Workers) 

Secretarial/Clerical


Other health personnel - Specify ?

Other personnel-Specify z


=1=1= 

*U.S. GOVEF3M5XT PRINTING OFFICE: 1992-648-072/60111 
01

02

03

04

05

06

OMB No. 0920-0296 Approval Expires 06/30/S 

m7y41HCS-2	 NOTSCE - Public reporting burden for tirk collection of information is estimated 

to average 20 minutes per response. Send comments regardiqg this burden 

estimate or any other aspect of tfrts collection of information, including 

suggestions for raducing thfs burden to PHS Reports Clearance Officec AITN 

PRA Hubert H, Humphrey Bldg., Rm. 721-R 200 Independence Ave., SW: 

U.S. DEPARTMENT OF COMMERCE 

BUREAUOFTHECENSUS ACTINGASCOLLECTINGAGENTFORTHE 

DEPARTMENT OF HEALTH ANO HUMAN SERVICES U.S. PUaLIC HEALTH SERVICE CENTSRSFORDISEASECONTROL NAn0t4ALCENTERFORHEALTHsmrsnca 

CURRENT PATIENT 

SAMPLING LIST 

NATIONAL HOME AND 

HOSPICE CARE SURVEY 

1. Field representative name 

1. Respondent name 

READ INTRODUCTION -

Washington, DC 20201, and to the Office of Management and Budget; Papenvork 

Reduction Projact (0920.0298); Waahirrgton, DC 20503. Information contained on this form which would permit identification of any individual or establishment. 

has been collected with a guarantee that it will be held in strict confidence, will 

be used for purposes stated for this study, and will not be disclosed or released 

to others without the consent of the individual or establishment in accordance 

with Section 30S(d) of the Public Health Se!vice Actf42 USC242m). 

~Code 2. Date of listing 

I


I I


4. Respondent title 

I 

[n order to obtain national level data about the patiants of hospices and home health agencies 

such as this one, we are collecting information about a sample of currant patiants. This 

information and tha list of namas you provide will be held in strict corrfidance and will be used 

ONLY by persons involved in tha survey and only for the purposes of the survey. Please give me 

the names of all current patients; that is, all patients on the rolls of this facility as of midnight 

last night, so that I may select the sample. 

FOLLOW 

STEP 1. 

STEP 2. 

STEP 3. 

STEP 4. 

STEP 5. 

STEP 6. 

STEP 7. 

THE STEPS BELOW TO LIST CURRENT PATIENTS -

Start listing the patients on line number 1 on page 3 of this form. List the patients consecutively in 

the order in which they are given to you. Be sure to complete the “Page of Page” item. 

NOTE - If the facrlity supp/ies an appropriate M that you can use, do not transcribe tha 

information onto the sampling list(s). If you can kaa this list, attach it to this form; write the 

control number and facility name on each page oft : e list. In either case, number the patients on 

the provided list; and go to step 2. 

Review the list. Verifi that all eligible patients have been listed. Delete any duplicate entries and 

any patients that do not meet the definition of a current patient. Renumber the lines if you add or 

delete any names. 

Enter thetotal number ofpatients listed. . . . . . . . . . . . . . . . . . . . . . . . . 

IMPORTANT - This number is vital for estimation purposes. Number 

Look at the Sample Selection Table. Find the number in the column labeled “Total # listed” that 

matches the total number of patienta [iated. 

Circle the line numbers on the listing sheets that correspond to those in the columns labeled 

“Sample line numbers.” 

Enter the amount of circled line numbers on the listing sheets. . . . . . . . 

Number 

The current patients to be sampled are those listed on lines with a circled line number. Enter the 

line number and the name or other identifier of each sampled patient below. Use this information 

to complete Section B of a Form HHCS-3, Current Patient Questionnaire, for each sampled patient. 

Line number Current patient identifier 

SAMPLING LIST FINAL STATUS 

•l Complete listing


•l Partial listing as of / /


� Refused listing information


� Listing records not available


•l No current patients


� Other - Specify


117 
01

02

03

04

05

06

07

08

09

PAGE — I OF_ PAGES

CURRENT PATlENT SAMPLING LIST 

Line 

number Patient neme (or other identifier) 

(a) (b) 

–, 

I I 

I 

I i I 

I I I 

I 11I I 

I 12 I I 

I 13 I I 

I 14 I I 

16 

17 

18 

19 

20 

21 ,

I 22 I I 

I 23! I 

24 

25 

26 

27 

29 

30 

37 

32 

33 

34 

35 

36 

37 

38 

39 

I 40 I I 

41 

42 

43 

44 

45 

46 

I 491 I 

118 
OMB No. 0920-0298 Approval Expires 06/30/S5 

m1M92iHCS-4 

U.S. DEPARTMENT OF COMMERCE 

BUREAUOF THE CENSUS 

ACTING AS COLLECTINGAGENT FOR THE 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

U.S. PUBLIC HEALTH SERVICE 

CENTEFISFOR DISEASECONTROL NATIONAL CENTERFORHEALTHSTATISTICS 

DISCHARGED PATIENT 

SAMPLING LIST 

NATIONAL HOME AND 

HOSPICE CARE SURVEY 

1. Field representative name 

L Respondent name 

i. Reference period for discharged sample 

NOTICE - Public reporting burden for this colk?ction of information is estimated 

to average 30 minutes per response. Send comments reg?rdlqg this burden 

estimate or any other aspect of this collection of information, including 

suggestions for reducing this burden to PHS Reports Clearance Omcer; AlTN: 

PRA Hubert H. Humphrey Bldg., Rm. 721-B; 204 Independence Ave., SW: 

Washington, DC 20201, and to the Office of Management and Bydget: Paperwork Red”ctio” pro@t (rrg20.029B); Washington. DC 20503. bIfOrfRatlOn contained on 

this form which would permit identification of any individual or establishment 

has been collected with a guarantee that it will be held in strict confidence, will 

be used for purposes stated for this study, and will not be disclosed or released 

to others without the consent of the individual or establishment in accordance 

with Section 30S(d) of the Public Health Service Act (42 USC 242m). 

~Code 2. Date of listing 

I 

I 

4. Respondent title 

I 

Month / Dsy / Year ,0 Momh / Day I War 

READ INTRODUCTION -

in order to obtain national level data about discharged patiants of hoapicaa and home health 

agencies suoh as this ona, wa ara collecting information about a eample of discharges. This 

information and tha fist of namee you provide will ba bald in strict confidence and will be usad 

ONLY by persons involved in the survey and only for tha purposes of tha survey. Pleasa give me the 

names of all patiants discharged alive or deceased from (See item 5 for reference period) and their 

specific dates of discharge. If any patient was discharged more than onca during the referenca 

pariod, giva me their name and the discharga date for EACH time they were discharged. Be sure to 

inchrda the name and discharge date for patients currently being sewed by your facility who ware 

also discharged from (First and /ast day of reference period), so that I may select the sampla. 

FOLLOW 

STEP 1. 

STEP 2. 

STEP 3. 

STEP 4. 

STEP 5. 

STEP 6. 

STEP 7. 

THE STEPS BELOW TO LIST DISCHARGED PATIENTS -

Start listing the patients on line number 1 on page 3 of this form. List the patients consecutively in 

the order in which they are given to you. Be sure to complete the “Page of Page” item. 

NOTE – If the facility supplies an appropriate list that you can use, do not transcribe the 

information onto the sampling list(s). If you can kaep this list, attach it to this form; write the 

control number and facility name on each page of the list. In either caae, number the discharges 

on the provided list; and go to step 2. 

Review the list. Verify that all eligibla discharges hava been listed. Delete any duplicate


discharges and any discharge that does not fall into the reference period. [f both the patient name


and date of discharge are the same, probe to determine if it is a duplicate entry. Renumber the


lines if you add or delete any namea.


Enter the total number of discharges listed. . . . . . . . . . . . . . . . . . . . . . .


IMPORTANT - Ttris numbar is vital for estimation purposas. Number


Look at the Sample Selection Table. Find the number in the column labeled “Total # listed” that 

matches the total number of discharges listed. 

Circle the line numbers on the listing sheets that correspond to those in the columns labeled 

“Sample line numbers.” 

Enter the amount of circled line numbers on the listing sheets. . . . . . . . 

Number 

The discharged patienta to be aampied are those listed on lines with a circled line number. Enter 

the line number, name or other identifier, and discharge date of each sampled patient below, Use 

this information to complete Section B of a Form HHCS-5, Discharged Patient Questionnaire, for 

each sampled patient, Discharge date 

Line number Discharged patient identified (Month/Day flear) 

SAMPLING LIST FINAL STATUS 

01� Complete listing 

02Cl Partial listing / /_tO / / 

03� Refused Iiating information 

04� Listing records not available 

os� No discharges 

os� Other - Specify 

119 
01

02

03

04

05

06

07

08

09

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

PAGE &OF _ PAGES 

DISCHARGED PATlENT SAMPLING LIST 

Line Discharge date 

number Patient name (or other identifier) (Month/DayiYear) 

[a) (b) (c) 

36’


37


38


39


40


I 41 I I I


43


44


45


46


47


48


49


50


FORMHHCS-4{521.92) Page 3


120 
01

02

03

04

05

06

07

08

09

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

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39

40

41

42

43

44

45

46

47

48

49

50

OMB No, 0920.029S Approval Expires 06i30/95 PAGE _ OF _ PAGES 

FORM HHCS-6 U.S. DEPART$JR~j::F\:~#:::: A. c~”tr~l number C. Sampling list type (5.26.92) Mark (X) one 

•l Current patient

SAMPLING LIST (Do not complete 

CONTINUATION SHEET B. Facility name column (c)) 

a Discharged patient 

IMPORTANT- Add appropriate first digit to preprinted line numbars. 

Line 

number Patient name (or other identifier) Oischarge date 

(Month/DayNear) 

(a) (b] (c) 

121 
--- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ---

---- -- ----- ----- ----- ----- ----- ---

DRM Hkics-3 

!-5-92) 

U.S. DEPARTMENT OF COMMERCE 

BUREAU OFTHECENSUS 

ACTINGAS COLLECTINGAGENTFORTHE 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

U.S. PUBLIC HEALTHSERVICE 

CENTERSFORDISEMECONTROL NATIONAL CENTER FOR HEALTHSTATISTICS 

CURRENT PATIENT 

QUESTIONNAIRE 

NATIONAL HOME AND 

HOSPICE CARE SURVEY 

OMB No. 0920-0298 Approval Expires 06/30/95 

NOTICE - Public reporting burden for this collection of information is estimated 

to average 10 minutes per response. Send comments regarding this burden 

aatimate or any other aspaot of this collection of information, including 

suggestions for reducing this burden to PHS Reports Clearance Officer; AITN 

PRk Hubert H. Humphrey Bldg., Rm. 721-B; 200 Independence Ave.t SW; 

Washington, DC 20201, and to the Office of Management and Budget; Paperwork 

Reduction Project (0920-0298): Washington, DC 20503. Information contained on 

this form which would permit identification of any individual or establishment 

has been collected with a guarantee that it will be held in strict confidence, wUI 

be used for purposes *ated for this study, and will not be disclosed or released 

to others without the consent.of the individual or establishment in accordance 

with Section 308(d) of the Public Health Sewice Act (42 USC 242mL 

S@ion A - ADMINISTRATIVE INFORMATION 

1.	 Field representative name 2. FR code 3. Date of interview 

Month/Dayflear 

I I / / 

Section B- PATIENT INFORMATION 

1. Patient name or other identifier , 2. Patient line number I .First	 . , Ml. , Last 

I I I 

Section C - RESPONDENT INFORMATION 

la. Respondent name 

--——- -— 

b. Title 

c. Providedanswersforitemsmtom �l.Provided answers for all items 

Za. Respondent name 

———- --—- --—- - ——-— ----—— -—--—— 

b. Title 

—— 

c.	 Provided answersforitems UtoU 

Seotion D - STATUS OF INTERVIEW 

01 •l Complete 06 D Assessment Only


02 III Partial 07 � Other noninterview - Specify ~


03 � Selected in error


04 � Refused


05 •l Unable to locate record


NOTES 

122 
Read to each new respondent. 

In order to obtain national level data about tha patients of hoapicas and home health agencies such aa this 

one, we are collecting information about a sample of currant stiants. I will be askhtg questions about the 

background, heaith status, treatment, social contacts, and bi“Fmg information for each sampiad patient. 

The information ou rovide wili be heid in @riot confidena and will IW used ONLY by persons involved in the 

survey andonly~rti!e purposes of the survey. 

In answaring these questions, it is especially important to locate the information in the patient’a medical 

record. Do you have the mediml file(s) and reoord(s) for (Read name(s) of selected current patient(s))? 

[f not, ask the respondent to get iflhem prior to be inning the interview. Fill sections A and Bon the front of all the current


patient forms whale the respondent gets the recor f s. If no record is available for a patient, try to obtain as much


information as possible from whatever administrative records are availab/e and,/or from the respondent’s memory.


1 

. What is. . .’a sex? I 01 � Male 

I 02 D Female I 

. What is.. .’s date of bhth?	 1 Age (at admission) I 

1 Month Day Year 

I OR 

1 I Years Months 

HAND FLASHCARD 1. 

I

I 01 D White 

a.	 Which of these best describes. . .*s rata? I 02 � Black 

I 03 � American indian, Eskimo, Aleut 

I

Mark (X) only one box. I 04 � Asian, Pac”ticIslander 

I oi5� Other - Specify 

I 99 � Don’t know I 

b. Is . . . of Hispanic origin? I 01Cl Yes i 

I 02� No 

I as � Don’t know I 

,. what is.. .’s cumnt marital status? I

I 01 � Married 

I 02� Widowad Mark (X) only one box. I 03D ~vorced I

I oh� Separated 

I 05 � Never Married 

I 

I as � Don’t know

HAND FLASHCARD 2. I 01 � Private residence 

;a. wham is . . . cumntiy Iiving? I 

I 

02 n Rented room, boarding house 

osO Retirement home 

I os� Health facil” (including mental health 

?

Mark (X) only one box. 1

I 04 D Board and care or residential care facility 

I facility) - SK P to item 6 Introduction 

1 N � Other- Speci@ ~ I 

I 

I 

b. h . . . living with family mambars, nonfamily ~ 01 � With family members 

membars, both famiiy and nonfamily members, , 02 n With nonfamily members or alone? I 03� With both family members and nonfamily members 

I


I 04 � Alone


Read the introductory paragraph for t~e Social Security Number only once for each respondent. 

AS part of this suwe , we would iike to have . . .‘s Social Security Number. Provision of this number is 

voluntaW and prow“Jmg or not providing ‘ the number will have no affaot in anyway on. . .’a benefi~. This 

numbar will be uaefui in conducting future foiiowup studies. It wiil be used to match against the wtal 

statistics racords maintained by the National Center for Health Statistics. This information is coiiacted under 

the authority of Saction 303 of the Public Health Service Act. 

i.	 What is...’ s Social Sacur-@ Number? 

[ n’sru~ru?ei-l I I I I I


I 97 � Refused


I 990 Don’t know
 !


123 

,, 

,-
--

HAND FLASHCARD 3.


7. Who referred . . . to thisfacility7 

Mark (X) all that apply.


PROBE: Any other sources?


1


I 

, 

I 

1

1 

, 

I 

1


I


,


I 

I


010 Self/Family 

02 ❑ Nursing home 

m a Hospital 

CMn Physician 

05a Health department 

0s •l Social service agency 

w a Other- Specify 

es a Don’t know 

8.	 What was the date of. . .’s most- ~ recentadmission with your facdKy, , 

that is, the date on which . . . was 

a=d:ted for the current ●pieodo of ,

Ei3TEI 

I


I


I


I


9a.	 According to. . .“? medioel record, 1,


whet ware the primary and other I
 diagnoses at the time of that


(admissiomks.sessmant)? Plmwe ~
 provido tho ICD-9-CM code if one is 

●vailable. ~ 

PROBE: Any other diagnoses?	 I


I


I


1


I


I


1 

1


I


I


1


~ f#E’Jc: Refer to item 8. 

I 

1 

b.	 According to. . .“s medical records, I 

what are. . .“s CURRENT primary 

and other diagnoses? Please provide ; 

the ICD-9-CM code if one is I 

available. I


I 

PROBE: Any other diagnoses? I 

I


I


00~ Only an assessment was done for this patient 

(patient was not provided services by this facility) 

w O No diagnosis ICD-9-CMcodes 

Written form if available 

Primaw 1 -— ●-— 

Othem: 2 —--—’- -

3 —--—, — -

4 ——— —,- — 

5 ———-~..—. — 

6 -———~ —-

01❑ Box 00 is NOT marked -Go to item 96


02 ❑ Box 00 is marked - END THE INTERVIEW 

Complate sections C and Don the cover. 

00❑ NO dia9nosis 

Written form. 

ICD-S-CM codes 

if available 

prima~ 1 —- —-~ —— 

Others: z ——— —,- -

3 —--—~— - 1


I


I 4 ——— —,- —


I


I 5 ————~- -
 I


1 6
 I ——— —,- —


10.	 What type of care is. . . currently I


receiving from your facility? Is it I 01 ❑ Home health care


home health care, hospice careor I 02 D Hospice care
 other care? ~ 03❑ Other - Speciti 

Mark (X) all that apply. , 

1la. Does . . . have a primary caregiver? I


I 01•l Yes 

1 020 No....... 

1
 SKIP to item 12


~ 99 ❑ Don’t know }


I


b. Does . . . usually live with (hid?ier) 1

I 01Cl Yes primary caregiver? I 020No 

~ ss ❑ Don’t know 

3RM HHC5-3 (5-592) rage 

124 
I
 HAND FL4SHCARD 4. I


,


1c.	 What is the relationsWlp of the primary caregiver I


to.. .?
 i
I


Mark (X) only one box, I


I


[


I


I


‘ I

I


I


i
I


I


I


I


I


1


HAND FtiSHCARD 5.	 I


I


12. Which of thase aids doas. . . currantly use? ~ 

Mark (X) all that apply. I


I


PROBE:Any othar aids? ~ 

I


I


~ 

I


I


~ 

I


I


I


I


I


\ 

I


,
 For items 13a-14b, refer to item 12. ~ 

Be.	 Does.. . have any difficuky in seeing (when I


wearing glasses)? 1


I


, 

1


HAND FLASHCARD 6. I


I


b.ls. ..’ s s“ight (when wearing glasses) partially, I


saveraly, or completely impaired as defined on
 ~
 this card?
 I


I


I


14s.Does. . . have any difficulty in hearing (when I


wearing a hearing aid)? 1


i


~ 

I


I


I


HAND FLASHCARD 7.	 I


I


b.ls...’ s hearing (when wearing a hearing aid) ~


partially, severely, or completely impaired, as I


dafined on this card? I


I


I


I


sge 4


01•l Spouse


02Cl Parent


030 Child


04a Daughter/Son-in-law


05� Othar relative - Specify z


os � Neighbor


07� Friend


08� Volunteer group


08D Other - Specify ~


99� Don’t know 

01U Eya glasses (including contact lenses) 

02� Dentures (full or pattial) 

03� Hearing aid


04� Wheelchair


05•l Cane


os� Walker


07� Crutches


os� Brace (any type)


oe•l Oxygen


10� Hospital bed


11a Commode


32n Other aids or devices -


w � NO aids used


m � Don’t know


01Cl Yes


020 No . . . . . . . . . . . . . . . . . . . . . .


Specify ~ 

03� Not applicable (e.g., comatose) SKIP to item 14a 

waDon’t know . . . . . . . . . . . . . . . } 

01 � Partially impaired 

o?� severely impaired 

03 � Completely lost, blind 

99a Don’t know 

01•l Yes


020 No, . . . . . . . . . . . . . . . .. . . . . .


03� Not applicable (e.g., comatose) SKIP to item 15


wODon’t know . . . . . . . . . . . . . . . }


01 � partially impaired 

02D Severely impaired 

03� Completely lost, deaf 

9s� Don’t know 

.-,.. . ,,,,- . ,. . rumn nrwa-s W-Z 

125


,. 
--

--

---- -----

i HAND FLASHCARD 8. I No 

15.	 Does. . . currently receive personal help FROM 

1 Yes does not Unable to Don’t know


YOUR FACILITY in any of the following activities 

I

, receives help receive help do/Doesn’t do


as defined on this card I


I


Mark (X) one box for each activiiy.	 I


1
 a. Bathing or showering? I 010 02 � 03n S9cl 

b. Dressing? :

I 01c1 02 •1 030 99a 

I


c. Eating? 1 01c1 02 � 03 � 3s0 

I


d.	 Transferring in or out of beds or chairs? I 01•1 02El 03 � 3s0


I


e. We[king? I

I 01c1 020 03cl 99 c1 

1


f.	 Using the toilet room? I 01•1 020 03•1 Ssa 

, 

16s. Does . . . have an oatomy, an indwelling catheter I
 or similar device? I 01•l Yes 

I 020 No...... 

I

[ ss � Don’t know 1SKIP to item 17


b.	 Doss . . . receive personal help FROM YOUR 1


FACILITY in caring for this device? I 01Cl Yes


I 02aNo


I


, w a Don’t know


I


17.	 Doss. . . currently havo any difficulty in 1


controlling (hi@13ar) bowels? [ 010 Yes


1 02DN0 

j 030 Not applicable (e.g., infant, has a colostomy) 

I as o Don’t know


I


18. DOSS . . . currently have any difficulty in I


controlling	 (hi@her) bladder? ‘ 010 Yes
 I


I 020No 

I 03� Not applicable (e.g., infant, has an indwelling catheter) 

i sea Don’t know
 1


f 

HAND FL4SHCARD 9. I


No
 I Yes does not Unable to


19. Doss . . . receive personal help FROM YOUR I receives help receive help dolDoesn’t do Don’t know


FACIIXW in any of the follow-rig activities I


I


Mark (X) one box for each activity. I


I


I


a. Doing Iight housework? I 01•1 02c1 03c1 S9Cl


1


I


b. Managing money? I 01•1 020 030 99a 

I


c. Shopping for groceries or clothes? I

I 01•1 02c1 03 •1 99 � 

I !. d.	 Using the telephone (dialing or receiving calls)? I 01•1 02a 03•1 99c1


1


I
 a. Preparing meaIs? I 01 •1 02c1 030 9s0 

I


f. Taking medications? I 

I 01•1 02•1 03•1 9s0 

NOTES 

UHM ....—- (3-5-321 Page nnlA-3 
1
 HAND FIASHCARD 10. 1


I


Ja. During your last billing period, wWlchof these 1


services were provided to. . . BY YOUR FACILITY? I


I


Mark (X) all that apply. I


I


PROBE: Any other sewicss? I


I


I


I


I


I


I


I


I


I


I


1


I 

I


I


1


I


I


I


I


I


I


HAND FLASHCARD 11.	 I


,


b. WMch of these service providers FROM YOUR I


01Q Skilled nursing services


02 •! Personal care


03 •l Social Services


04 •l Counseling


05 � Medications


os� Physical therapy


07 ~ Homemaker/Compenion services


08D Respite care


090 Referral services


100 .ietaw and nutritional services


11� Physician services


12 n High tech care (e.g., IV therapy)


13 � Occupational therapy/Vocational therapy


14 � Speach therapy/Audtology


15 D Transportation


16 � Enteroatomal therapy


17 D Meals on wheels


m D Other services- Speciti jZ


00 � None 

01 � Registered nurses


02a Licensed practical or vocational nurses


FACILF1’Yvisited . . . during your last billing period? ,

1 03� Nursing aides and attendants

,
 Mark (X) all that apply. I


PROBE: Any other providers?	 I 

I 

, 

I 

I


I


04� Home health aides 

05 � Homemakers/Personal caretakers


~ I_JSocial workers


07 � Physical therapists


08 � Phvsiciana


09 D Occupational therapists


10 � Speech pathologists and audiologists


II � Dietitians/Nutritionists


12 ~ Health educators


13 •l Volunteers


14 � Other providers - Speciw z
 .’ 

1 00D None
 I


!1. How many visits were made to. . . during your I


tactbilling period? 1 

Number of visits
 I


1


I 00.O None 

‘ 96a 24 hour care
 I


I 99u Don’t know


I


!2s. For your last billing period, what was the total I


charge billed for. . .’s care, including all charges .00 for services, drugs and special medical supplies? ~ $ •1

! 96a Was nOt a patient during laSt billing period -

I SKIP to item 23


I


, 00a No charge was made for care - END INTERVIEW.


I Complete sections C and D on the front of this form.


/ 99 � Don’t know- Skip to item 23


b.	 What time period does this charge cover? !mTom 

! 99 U Don’t know (not billed yet, etc.) 

Ige6 FORM HHCS-3 (55-92) 

127


/ 

... 
,.— 

HAND FLASHCARD 12. { 

I 01 � Private insurance 

!3. What are ALL the (expected) sources of I 02Cl Own incom~, fami[y sup ort, Social Security payment for the amount billed? I benefits, retirement fun (fs 

Mark (X) all that apply. I 03Cl Supplemental Security Income (SS1) I 04 � Medicare I 

PROBE:Any other sources of payment? I 05 n Medicaid 

i 06a Other government assistance or welfare 

I 

I 07U Religious organizations, foundations, agencies 

I 08 � VA contract, . oensions, .
 or other VA compensation

I 09 � Payment source not yet determined
 I


I 10 � Other - SpeciW ~


I


~ 99 H Don’t know 

t 

HAND FLASHCARD 12. I 

I 01 •l Private insurance 

!4. What was the PRIMARY (expeoted) source of I 02 � own income, famil sup ort, Social Security 

payment (for this billhrhen billed)? I benefits, retirernen?’fun& 

Mark (X) only one box. ~ 03 � Supplemental Security Income (SS1) 

I 04 D Medicare 

I 05� Medicaid 

~ 06 � Other government assistance or welfare 

; 07a Religious organizations, foundations, agencies 

1 os � VA contract, pensions, or other VA compensation 

~ 08 � Payment source not yet determined 

I 10� Other- Speci~ ~ 

I 

I 

I 

I


I S9� Don’t know


FILL SECTIONS C AND D ON THE COVER OF THIS FORM. 

JOTES 

‘. 

IRMHHCS-3(5-5-92} Pagt 

128 
-----

----- ---

---- ---- ---- ---- ---- -- ---- ---- ----

I 

ym12)HHcs-5 . . 

., 

U.S. DEPARTMENTOF COMMERCE 

BUREAUOF THE CENSUS 

ACTINGASCOLLEcTiN13AGENTFORTHE 

DEPARTMENTOF HEALTHAND HUMAN SERVICES 

U.S. PUBLICHEALTHSERVICE 

CENTERS FOR OISEASE CONTROL NATIONAL CENTER FOR HEALTH STATISTICS 

DISCHARGED PATlENT 

QUESTIONNAIRE 

NATIONAL HOME AND 

HOSPICE CARE SURVEY 

Section A­

‘. Field representative name 

Section B1. Patient name or other identifier 

First I Ml. I Last 

I I 

I I 

-. .- .. a--- . . - . --.-..,-- UMtI No. UYZU-UZYMApprovat txpwes utwwsb 

NOTICE - Public reporting burden for this collection of information is eetimeted 

to average 10 minutes per response. Send comments regarding this burden 

estimate or any other aspect of this collection of information, including 

suggestions for reducing this burden to PHS Repotis Clearance Officer; AlTN: 

PRA Hubert H. Humphrey Bldg., Rm. 721-B; 200 Independence Ave., SW: 

Washington, DC 20201, and to the Office of Management and Budget; Paperwork 

Reduction Project (0920-0298); Washington, DC 20503. Information contained on 

this form which would permit identification of any individual or establishment 

has been collected with a guarantee that itwill be held in strict confidence, will 

be used for purposes stated for this study, end will not be disclosed or released 

to others without the consent of the individual or establishment in accordance 

with Section 308(d) of the Public Health Service Act (42 USC 242m). 

ADMINISTRATIVE INFORMATION 

2.	 FR code 3. Date of interview 

Month/Day/Year 

/ / 

PATIENT INFORMATION 

2.	 Patient line number 3. Date of Discharge 

MorrthJDayjYear 

// 

Section C - RESPONDENT INFORMATION 

‘a. Respondent name 

---— _____ —--— --—- -— ————- —--— ———————-- —---- ——--- ----— —-. 

b. Title 

c. Providedan.swersforiternsmtom •l Provided answers for all items 

!a. Respondent name 

-— -——- ——-- --—- ---— --—- ——-— —--

b. Title 

. . ProvidedanswersforitemsUtoU 

Section D - STATUS OF INTERVIEW 

OI� Complete 06H Assessment only


02 •l Partial 07 •l Other nonintewiew - Specify ~


03 •l Selected in error


04 •l Refused


05 � Unable to locate record


JOTES 

129 

,= 

/’ 

i 
I

Read to each new respondent. 

In order to obtain nationaI IeveI data about patients who are discharged from hospices and home health 

agencies such as this one, we are collecting information ebout a sample of diachar$es. I will be asking 

questions about the background, haalth status, treatment, social contacts, and biIlmg information for each 

sampled discharge. 

The information ou rovide wiII be heId in strict confidence and will be used ONLY by persons involved in the 

survey and only {Eor t e purposes of the survey. 

In answering these questions, it is especially important to locata the information in the patient’s medical 

record. Do you have the medical file(s) and record(s) for (Read name(s) of selected discharged patient(s))? 

If not, ask the respondent to qet itjthem prior to beginning the interview. Fill sections A and B on the front of all the 

discharged patient forms whale the respondent ets the records. If no record is available for a patient, try to obtain as 

much information as possible from whatever a1?ministrative records are available and/or from the respondent’s memory. 

I . What was.. .’s sex? I 01 � Male 

I 02 � Female

1 

.. What was. . .’s date of birth?	 I Age (at admission) I 

1 Month Day Year 

I OR


I Years Months


HAND FL4SHCARD 1. I

I 01 � White 

la. Which of these best described . . .-e race? I 02 � Black 

I 03 � American Indian, Eskimo, Aleut 

i

Mark (X) oniy one box. I 04 � Asian, Pacific Islander 

1 05 � Other- Speci& 

I 9s � Don’t know 

I 

b. Was... of Hispanic origin? I 01 Cl Yes I


I 02 � No


I 99 � Don’t know I 

L What was. ..’ s marital status at the time of 

I

I 01� Married 

discharga? I 02 � Widowed 

Mark (X) only one box. I 03 � D!vorced 

I

I 04 � Separated 

I 05 � Never Marriad 

I 99 � Don’t know I 

HAND FLWHCARD 2. I

I 01 � Private residence 

ia.	 During the episode of cara that ended on (date ~ 02 � Rentad room, boarding house 

of discharge), where was . . . living? I 

03 � Retirement home 

Mark (X) only one box. I 05 � Health facility (including mental health 

[ facility) - SKIP to iterq 6 Introduction 

I 

I 

06 � Other - Specify ~ 

I 

I 04 � Board and care or residential care facility 

I 

b.	 Was... living with family members, nonfamily ~ 01 n With family members members, both family and nonfami[y members, I 02 � With nonfamily members or alone? 

I 03 � With both family members and nonfamily members 

I 

I 04 � Alone 

Read the introductory paragraph for the Social Security Number only once for each respondent, 

As part of this curve.$ we would like to have.. .’s Social Security Number. Provision of this numbar is 

voluntary and prow mg or not providing the number will have no effect in any way on . . .’s benefits. This 

number will be usefui in conducting future foiiowup studies. It will be used to metch againat the vital 

statistics records maintained by the National Center for Health Statistics. This information is collected under 

the authority of Saction 306 of the Public Health Service Act. 

E. What was. . .*s Social Security Number? 

1

! rrrrm-~

97 � Refused 

I 99 � Don’t know 

I . v.”.. . . . . . . .,-. .

130 
HAND FLASHCARD 3. 

7. Who referred . . . to this facility? 

Mark (X) all that app/y. 

PROBE: Any other sources? 

8.	 What was the date of. . .*s 

admissionfor the eriod of care 

I 

I 

, 

I 

~ 

I 

I 

1 

I 

, 

I 

I 

I 

OICl SeIf/Family 

02 � Nursing home 

03 n Hospital 

04 n Physician 

05a Health department 

06 D !%Ck31 SW’VkX agency 

07 � Other - Specify 

99 � Don’t know 

which ended on (8 ate of discharge)? 

im 

I 

I 00 � Only an assessment was done for this patient


I (patient was not provided services by this facility)


9a. Accordingto.. .’s medical record, I 00n No diagnosis ICD-9-CM codes 

what were the primary and other I Written form if available 

diagnoses at the time of.. .’s I 

admission that ended with this I Primary: 1 ———— .—— (dIsc~arge/assessment)? Plqase 

~v~~$~l~he ‘CD-9=M code ‘f one is I &her~ * . 1. ——— —.— — 

I PROBE: Any other diagnoses? I 3 ————. —— I 

I 4 ———— .——
 I


I


I 5 ———— .——


I


I 6 ———— .——
 I


,


CHECK Refer to item 8. 

1 01 � BOX ()() k NOT markad - Go to item 9b 

ITEM A ~ 02 � Box 00 is marked - END THE INTERVIEW. 

I 

b. According to.. .’s madical records, ~ 

what were. . .’s primary and other 

diagnoses at the time of discharge - ~ 

that is, on (Date of discharge)? Please , 

provide the ICD-9-CM code if one is , 

available. I 

I PROBE: Any other diagnoses? I 

c. Why was. . . dkcharged? 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

~ 

, 

I 

1 

I 

I 

I 

1 

I 

, 

I 

10.	 What type of care was . . . receiving ~ 

at the time of discharge? Was it 

home health care, hospice care or I 

other care? 1 

-----Mar+{)() aiithatqc@y7-”--.--”””-””--~-”-”’-—--

IRM HHcS-5 K-5-92) 

Complete sections C and D on the cover. 

00� No diagnosis ICD-9-CM codes 

Written form if available 

primaV 1 ——— _.— — 

Others z ———— .—— 

3 ——— —. —...— 

4 ———— .—— 

5 ———— .—— 

6 ———— -—— 

01 � Recovered 

02 � Stabilized 

03 � Moved out of district 

04 � Deceased 

05 � Admitted to hospital inpatient servica 

060 Admitted to nursing home 

07 � Other - Specify 

S9 � Don’t know 

o, � Home health care 

02 � Hospice care 

03 � Other - Spaciw 

‘“’---”-- ’”-–—-——--—--’–”-’- ”-”-”’”--’-”-” “-”-”””—--—-”-

Page 

131 
1 

1118.Did . . . have a primary caregiver? I 

t 

~ 

I 

b. Did... usually live with (his/her) primary ~ caregiver? I 

1

1 

HAND FIASHCARD 4. I 

~ c.	 What was the relationship of the primary 

caregiver to. . .? I 

I 

Mark (X) only one box. ~ 

I 

I 

~ 

I 

I 

I 

01 •l Yes 

020 No...... SKIP to<INSTRUCTION BOX 

99 � Don’t know 1 above Jtem 72 

01•l Yes 

020No 

99 � Don’t know 

01 � Spouse 

02•l Parent 

03 � Child 

04 � Daughter/Son-in-law 

05 � Other relative - Specify 

06 � Neighbor 

07 � Friend 

08 � IVolunteer group 

09 � Other - SpeciYy 

99 � Don’t know 

INSTRUCTION For items 72 through 19, use the phrase “AT THE TIME OF DISCHARGE if the patient was discharged 

BOX alive. Use the phrase “IMMEDIATELY PRIOR TO DISCHARGE if the patient was discharged dead, 

1 HAND FLASHCARD 5. I 

~ 112. The following questions refer to the patient’s 

status (at the time of dischargefimmediately prior , 

to discharge) on (Date of discharge). I 

1 (At the time of dischargefimmadiately prior to I 

discharge), which of these aids did.. . regularly , 

use? I 

1 Mark (X) all that apply.	 1 

, 

PROBE:Any other aids? I 

I 

~ 

I 

I 

I 

1 

I 

I 

For items 13a-14b, rafer to item 72.	 I 

I 

113a.(At the time of discharge/immediately prior to I 

discharge), did . . . have any difficulty in seeing ~ 

(when waaring gIasses)? I 

I 

HAND FLASHCARD 6. I 

I 

b.	 Was...’ s sight (whan wearing glassea) partially, I 

severeIy, or completely impaired as defined on ~ 

this card? I 

I 

114a. (At the time of discharge/immediately prior to I 

I discharge), did . . . have any difficulty in haaring 

(when wearing a hearing aid)? I 

~ 

I 

I 

HAND FLASHCARD 7. f 

b.	 Was. ..’ s hearing (when wearing a haaring aid) I 

partially, severely, or completely impaired, as I

I defined on this card? [

I 

Page 4 

01 � Eye glasses (including contact lenses) 

w � Dentures (full or partial) 

03 � Hearing aid 

04 � Wheelchair 

05 •l Cane 

06 � Walker 

07 � Crutches 

os � Brace (any type) 

09 � Oxygen 

10 � Hospital bed


11 � Commode


12 � Other aids or devices - Specify ~


00 � No aids used


99 � Don’t know


01 •l Yes 

02DNo............cc...,. . . . 

03a Not applicable (e.g., comatose) SKIP to item 14a 

wDDon’t know . . . . . . . . . . . . . . . J 

01 � Partially impaired 

02 � Severely impaired 

03a Completely lost, blind 

99 H Don’t know 

01•l Yes 

020 No . . . . . . . . . . . . . . . . . . . . . .


03 � Not applicable (e.g., comatose) SKIP to item 15


waDon’tknow . . . . . . . . . . . . . . . }


01 � Partially impaired 

02 � Severely impaired 

03 � Completely lost, deaf 

99 � Don’t know 

FORM HHC6.S (5-5-921 

132 
--

I


HAND FLASHCARD 8. I


I Yes . ‘0 - Unable to Don’t know 5. (At the time of dischargefimmediately prior to I received help “d n:$- do/Didn’t do 

discharge), did . . . receive personal help FROM I


YOUR FACILITY in any of the following activities I
 as defined on this card I


I


Mark (X) one box for each activity. I


1


a. Bathing or showering7 I 01 •1 02 � 03 •1 99 � I


I
 b. Dressing? I 01 •1 02•1 03•1 99•1 

I


c. Eating7 I 01•1 02 •1 03 •1 99 •1 

, 

I


d. Transferring in or out of beds or cheirs7 I 01 � 02 •l 03 •1 99 � I


e. Walking? I 

I 01 •1 02 •1 03 � 99 •1 

I


f. Using the toilet room? I 01•1 02 � 03 � 99 •1 

6a.	 (At the time of dischergefimmediately prior to I


discharge), did... have an ostomy, an indwelling , 01� Yes


catheter or similar device? I 020 No...... SK,Ptoitem77 

[ 99 � Don’t know } 

b. Did . . . receive personal help FROM YOUR I


FACILITY in caring for this device? I 01•l Yes 

I 02nN0 

I
 99 � Don’t know
 I


1


7.	 (At the time of discharge/immediately prior to I


discharge), did . . . have any difficulty in I 01� Yes


controlling (his/her) bowels? 1 020No


~ 03 � Not applicable (e.g., infant, had a colostomy) 

I 99 � Don’t know


I


I
 8.	 (At the time of discharge/immediately prior to 

discharge), did. . . have any difficulty controlling 1 01•l Yes 

(his/her) bladder7 ~ 020No 

I 03� Not applicable (e.g., infant, had an indwelling catheter) 

1 99 � Don’t know 

HAND FLASHCARD 9. I


I Yes No Unable to 

9. (At the time of dischargefimmediately prior to I received help did not receive do/Didn’t do Don’t know 

discharge), did... receive personal help FROM help 

YOUR FACILITY in any of the foIloiwing activities- I


I


Mark (X) one box for each activity. 1


I


a.	 Doing light housework? I 01 � 02 � 03 � 99 •1


I


1


b. Managing money? I 01 •1 02,Q. 03 � 99 � I


c. Shopping for groceries or clothes? I 

I 01 •1 02 •1 03 •1 990


i


d.	 Using the telephone (dialing or receiving calls)? I 01 n 02 •1 03 � 99 •1


I


I


e. Preparing meaIs7 I 01 •1 02 � 03 � 99 � 

I


I
 f. Taking medications? I 01 •1 02 •1 03 •1 99 •1 

40TES 

)RM HHCS.5 (5.5-92) Page 

133


,,-
HAND FLASHCARD 10. 

I 

I o! � Skilled nursing services ] 

!08. During the billing period that included (Date of j 02 •l Personal cere 

discharge), which of these Services were 

provided to. . . BY YOUR FACILKY? 

I 

I 

03 El Social services 

04 � Counseling 

Mark (X) all that app/y. ~ 

I 

05 � Medications 

06 � Physical therapy 

PROBE:Any other services? I 07 � Homemaker/Companion services 

~ os � Respite care 

I 09 � Referral services


1 10 � ~etary and nutritional services


I

1 11 � Physician services 

I 12 � High tech cara (e.g., IV therapy) 

I 13 � occupational therapyjVocational therapy 

~ 14 � Speech therapy/Audiology


1 15 � Transportation


I 16 � Enterostomal therapy
 I


1 17 � Meals on wheels


I IS � Other services- Speci$’ ~


I


I


I 

1 00� None 

I 

HAND FLASHCARD 11. ,

I 01� Registered nurses 

b.	 During the billing period that included (Date of I 02 � Licensed practical or vocational nurses 

discharge), which of these service providers FROM ,

I 03 � Nursing aides and attendants 

YOUR FACILITY visited ...? , 04 � Home health aides 

Mark (X) all that apply. I 05 � Homemakers/Peraonal caretakers 

1 oa � Social workers

I PROBE:Any other providers? , 07 � Physical therapista 

I os � Physician 

I 09 � Occupational therapists
 I


, 10Q Spaech pathologists and audiologists


I II � Dietitians/Nutritionists


I 12 � Health educators


I


, 130 Volunteers


I 14a Other providers- Specifi z
 I


I 

I 

‘ 00� None 

I 

21. How many visits were made to. . . during tha I 

billing	 period that inckded (Date of discharge)? 1 

1 Number of visits 

I


I 00 � None


1 96 � 24 hour care


I 99 � Don’t know


1


Z2a. For the billing period that included (Date of I 

discharge), what was the total charge bilIed I 

for.. .’s care including all charges made for 1$ �.00

drugs, services and special medical supplies? 1 

I 00 � NO charge was made for care - END INTERVIEW. 

I Complete sections C and D on the front of th{s form. 

I 

I w � Don’t know- Skip to item 23 

1 

b. What time period does this charge cover? lmTom ~

99 Q Don’t know (not billed yet, etc.)

I 

‘age 6 FORM HHC3-5 (54 

134 
HAND FLASHCARD Ii?. 

3.	 What were ALL the (expected) sources of 

payment for the amount billed? 

Mark (X) all that apply. 

PROBE: Any other sources of payment? 

HAND FLASHCARD 12. 

,4. What was the PRIMARY (expected) source of 

payment (for this billmhen billad)? 

Mark (X) only ona box. 

FILL SECTIONS C AND 

IOTES 

. .. . . . . . . :. )NM HHCS.5 (5-5-S2) 

1 

I 

, 

I 

I 

I 

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I 

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I 

I 

I 

I 

I 

~ 

I 

I 

I 

~ 

I 

I 

1

I 

~ 

I 

I 

[ 

I 

I 

~ 

I 

1. 

I 

I 

I 

I 

I 

01 •l Private insurance 

02 •l	 Own income, family sup ort, Social Security 

benefits, retirement fun (/’s 

03 •l Supplemental Security Income (SS1) 

04� Medicare 

05 � Medicaid 

06 � other government assistance or welfare 

07 � Religious organizations, foundations, agencies 

os � VA contract, pensions, or other VA compensation 

0s � payment source not yat determined 

10a Other- Spaci& jzJ 

9s � Don’t know 

OI � Private insurance 

02 � Own income, famil sup on, Social Security 

benefits, retiremen/’fun& 

03 � Supplemental Security Income (SS1) 

04 � Medicare 

05 � Medicaid 

os � Other government assistance or walfare 

07 � Religious organizations, foundations, agencies 

os � VA contract, pensions, or other VA compensation 

os � Payment source not yet determined 

10 � Other- Speci~ ~ 

S9� Don’t know 

D ON THE COVER OF THIS FORM. 

m.-. . rage I 
FORM Htics-20 

(5-22-92) 

U.S. DEPARTMENT OF COMMERCE 

BUREAU OF THE CENSUS


ACTING AS COLLECTING AGENT FOR THE “


DEPARTMENT OF HEALTH AND HUMAN SERVICES


U.S. PUBLIC HEALTH SERVICE


CENTERS
 FOR DISEASE CONTROL 

NATIONAL CENTER FOR HEALTH STATISTICS


FLASHCARD BOOKLET


NATIONAL HOME AND


HOSPICE CARE SURVEY


I 

I 

I 

i 

f 

I


I


I


I


I


i


I


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i


I


I


I


I


I


I


f


i


I


I


i


I


I


f 

I


I


I


I


r


I


I


I


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i


I


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I


136 
FACILITY CARD 1


1.	 FOR PROFIT- includes individual or private, partnership, 

corporation 

2.	 NONPROFIT - includes church-related, nonprofit corporation, 

other nonprofit ownership 

3.	 STATE OR LOCAL GOVERNMENT- includes State, county, 

city, city-county, hospital 

district or authority 

4. FEDERAL GOVERNMENT - includes USPHS, Armed Forces, 

1 Veterans Administration 

5. OTHER 

FORM HHCS-20 (5-22-92) Page 2 

137 
FACILITY CARD 2 

EMPLOYEES ON PAYROLL (as of last pay period 

Full-time (35 or more hours per week) 

Employed


Budgeted vacant positions


Part-time (less than 35 hours per week)


Employed


Budgeted vacant positions


SERVICES PROVIDED DURING THE LAST PAY PERIOD


Total hours worked by full-time and part-time


Total hours of service provided by those not


Total visits made


TYPE OF EMPLOYEE


Physicians


Registered nurses


Licensed practical or vocational nurses


Nursing aides and attendants


Home health aides


Homemakers/Personal caretakers


Dietitians/Nutritionists


Occupational therapists


Speech pathologists and audiologists


Physical therapists


Social workers


Health educators


Pastoral/Bereavement staff


Administrator/Director


Case manager/Case coordinator


Secretarial/Clerical 

Other health personnel 

Other personnel 

FORM HHCS-20 (5-22-92) Page 3


138


staff 

on your payroll 

FACILITY


CARD 1


[Left)


FACILITY


CARD 2


(Right)
 ~__-d _---,. 

f 

1


r 

r 

I


I


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I 

I


i 

t 

1 

I


I 

I


13 \


Ig


.= 

[ 

i 

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I 

I 

I 

I 

I


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I


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\ i 
PATIENT CARD 1 

1. White 

2. Black 

3. American Indian, Eskimo, Aleut 

4. Asian, Pacific Islander 

FORM HHCS-20 (5-22-92) Psge 4 

139 
PATIENT CARD 2 

1.	 PRIVATE RESIDENCE - house or apartment, rented or 

owned 

2.	 RENTED ROOM, BOARDING HOUSE- room or boarding


house open to anyone as defined by the landlord for rental


payment


3.	 RETIREMENT HOME - a retirement facility that provides


room and board to elderly or impaired persons; often includes


a separate hospice wing or unit that provides nursing,


medical, personal care, etc., to those needing it 

PATlENT 

CARD1 

(Left} 

PATIENT 

y?!?.. r 

I 

I


I


I€

[€

I


I 

I 

4.	 BOARD AND CARE OR RESIDENTIAL CARE FACILITY - a 

facility having three beds or”more and that provides personal I€ care or supervision to its residents, not just room and board I€

(for example, help with bathing, dressing, eating, walking,


shopping, or corresponding)


5.	 OTHER TYPE OF HEALTH FACILITY (including menta!


health facility) - other facility or institution that provides


lodging, board, and social and physical care including the


recording of health information, dietary supervision and


supervised hygienic services for three or more patients not


related to the operator


6. OTHER 

FORM HHCS-20 (5-22-92) Page 5€

140


I 

1 

i pm=-.€

I


1- ‘% ‘-”€ [~

I.~1: 101% 

lb 

@ 

1:
 l=
 IQ
 1-
 1


I€

I€

1€

I€

I€

I€

I€

I€

I€

[ 

I€

I€

I€

I€

I€

I€

I€

h 
1. 

2. 

3. 

4. 

5. 

6. 

7. 

FORM HHCS-20 (5-22-92) 

PATIENT CARD 3 

SelflFamily 

Nursing home 

Hospital 

Physician 

Health department 

Social service agency 

Other 

Page 6


141

1. 

2. 

3.


4. 

5. 

6. 

7.


8.


9. 

FORM HHCS-20 [5-22-92] 

142 

PATIENT CARD 4 

Spouse


Parent


Child


Daughter- or son-in-law


Other relative


Neighbor


Friend


Volunteer group


Other


Page 7 

PATIENT 

CARD3 

(Left) 

PATIENT 

CARD4 

(Right} ~-- d_- ,--­

1 

I 

[ 

I 

I 

I 

I 

I 

/ 

I 

I 

i 

I 

i 

I 

I 

I 

I 

I 

I 

1 
1.€

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

10. 

11. 

12. 

PATlENT CARD 5 

Eye glasses (including contact lenses)


Dentures (full or partial)


Hearing aid


Wheelchair


Cane


Walker


Crutches


Brace (any type)


Oxygen


Hospital bed


Commode


Other aids or devices


FORM HHCS-20 (5-22-92) Page 8 

143€
------ ---

1 

PATlENT CARD 6


I


1. PARTIALLY IMPAIRED - cannot read newspaper print but 

can watch television 8 to 12 feet 

away 

2.	 SEVERELY IMPAIRED - cannot watch TV 8 to 12 feet away,


but can recognize the features of


familiar persons if they are within 2


to 3 feet 

3. COMPLETELY LOST, BLIND 

PATIENT 

CARD5 

(Left] 

PATlENT 

;;;:; 

r 

r 

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1= 

; 

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FORM HHCS-20 (5-22-92) Page 9	 i


1


I


144

PATIENT CARD 7€

r 1	 1. PARTIALLY IMPAIRED - can hear MOST of the things a 

I

1 ‘person “says 

2. SEVERELY IMPAIRED - can hear only a few words a person 

says or loud noises 

3. COMPLETELY LOST, DEAF 

FORM HHCS-20 (5-22-92) Page 10 

145 
----

PATlENT CARD 8 

a.	 BATHING or SHOWERING - washing the whole body; 

includes the process of getting in or out of tub/shower 

b.	 DRESSING - getting clothes from closets/drawers and putting 

them on. Includes managing buttons, zippers, and other 

fasteners; excludes tying shoes 

‘c.	 EATING - getting food from plate to mouth; excludes 

assistance with cutting meat or buttering bread 

d.	 TRANSFERRING IN OR OUT OF BEDS OR CHAIRS -

getting into and out of bed or getting into and out of a 

chair/wheelchair 

e.	 WALKING - moving from one place to another by advancing 

the feet and legs in turn at a moderate pace 

f.	 USING THE TOILET ROOM - going to the toilet, transferring 

on and off the toilet, cleaning self after elimination and PATIE~ arranging clothes; excludes bowel and bladder functioning :.;: i’ 

PATIENT


CARD 8


~ (Right]


..


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1


i


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I


FORM HHCS-20 (5-22-92) Pam 11


146

a. Doing light housework 

b. Managing money 

c. Shopping for groceries or clothes 

d.	 Using the telephone (diaIing or 

receiving calls) 

e. Preparing meals 

f. Taking medication 

FORM HHCS-20 (5-22-92) Page 12 

147

-----

PATlENT CARD 10


1.


2. 

3. 

4. 

5.


6.


7.


8. 

9. 

10. 

11. 

12. 

13. 

14. 

15. 

16. 

17. 

18. 

SKILLED NURSING SERVICES - coordination by an R.N. or an L.P.N. of a 

care plan; e.g., catheterization, injection 

PERSONAL CARE - aid in bathing, dressing, using the toilet, getting in and 

out of bed, eating, or walking 

SOCIAL SERVICES - counseling, advocacy coordination, information, 

referrals; e.g., legal aid, job, housing assistance 

COUNSELING - counseling and/or therapy that assists the patient in 

minimizing stresses and problems that arise from social, economical, or 

psychological situations and that assists the patient in maximizing positive 

aspects and opportunities for growth 

MEDICATIONS - providing prescription medication 

PHYSICAL THERAPY - from a certified or licensed physical therapist; 

treatment to restore function, relieve pain 

HOMEMAKEIVCOMPANION SERVICES - services that are necessary for 

maintaining a safe and healthy home environment for the patient (e.g., 

cleaning the patient’s kitchen, doing personal laundry, preparing meals) and 

other services to enable the patient to remain at home 

RESPITE CARE - care provided to the patient in the home or inpatient 

setting to relieve the family or primary caregiver, due to family psychological 

problems, caregiver fatigue, or required short-term absence of the caregiver 

REFERRAL SERVICES - referral to other sources for services that are not 

provided by the facility 

DIETARY AND NUTRITIONAL SERVICES - direct counseling by a trained 

nutritionist; does NOT include supervision of special diets 

PHYSICIAN SERVICES - evaluation and/or treatment from a licensed M.D. 

(not including psychiatrist), D. O., or physician associate 

HIGH TECH CARE - specialized care, in the home: examples include; 

respirator/ventilation therapy, IV therapy, chemotherapy, renal dialysis, etc. 

OCCUPATIONAL THERAPY/VOCATIONAL THERAPY - from a registered 

or licensed occupational therapist; special restorative treatment 

SPEECH THERAPY/AUDIOLOGY - evaluation, treatment, and monitoring 

of specific communication disorder(s) 

TRANSPORTATION - provision of transportation 

ENTEROSTOMAL THERAPY - therapy designed to teach the proper 

method of caring for an ostomy site or caring for an ostomy site 

MEALS ON WHEELS - program that provides regular delivery of food to 

elderly and handicapped persons with limited mobility. Often provided 

through a volunteer network 

OTHER SERVICES 

FORM HHCS20 (5-22-92) Page 13 

148 

PATlENT 

CARD 10 

~ (flight] -. 

I 

I 

I 

I 

I 

i 

f 
PATlENT CARD 11€ I I 

I 1= 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

10. 

la. 

12. 

13. 

14. 

Registered nurses€

Licensed practical or vocational nurses€

Nursing aides and attendants€

Home heaith aides 

Homemakers/Personal caretakers€

Social workers€

Physical therapists€

Physicians€

Occupational therapists 

Speech pathologists and audiologists 

Dietitians/Nutritionists 

HeaIth educators 

Volunteers 

Other providers 

FORM HHCS-20 (5-22-92) Pan- 1A 149 
-----

. I 

PATlENT CARD 12 I


1. Private insurance 

2.	 Own income, family support, Social Security 

benefits, retirement funds 

3. Supplemental Security Income (SS1) 

4. Medicare 

5.	 Medicaid 

Other government assistance or welfare 

7. Religious organizations, foundations, agencies 

8.	 VA contract, pension, or other VA compensation 

9= Payment source not yet determined 

10. Other 

PATIENT


:;%.: 11


PATIENT


CARD 12


(Right]
 -. r 

I


I


FORM HHCS-20 (5-22-92) Page 15


I


1


150

II 

,1 

1991


JANUARY 

SMTWTFS 

o12345

67~ 9101112 

13 14 15 16 17 18 19 

20@22 23 24 25 26 

27 28 29 30 31 

FEBRUARY 

SMTWTFS 

12 

3456789 

10 11 12 13 14 15 16 

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HHCS-20 (5-22-92) Page 16 

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--- -- ----

1

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13

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15

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17

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19

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21

22

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47

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------ ----- -----------------------------------

5

10

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25

30

SAMPLE SELECTION TABLE [ 1 ,3,000 1 

Total # Listed Sample Line Numbers
 .- - - - - - - .-

1 

1 2 

1 2 3 

1 2 3 4 

1 2 3 4 

1 2 3 4 5 6 

1 2 3 4 5 6 

2 3 4 5 6 7 

1 2 3 4 5 6 

2 3 4 5 6 7 

2 3 4 5 6 7 

2 4 6 8 12 

1 3 5 7 9 11 

1 3 5 7 9 11 

3 5 7 9 11 13 

1 3 5 7 9 11 

2 4 6 8 10 12 

3 6 9 12 18 

2 5 8 11 14 17 

2 5 8 11 14 17 

4 7 10 13 16 19 

2 5 8 11 14 17 

2 5 8 11 14 17 

4 8 12 16 24 

5 9 13 17 21 25 

4 8 12 16 20 24 

2 6 10 14 18 22 

4 8 12 16 20 24 

2 6 10 14 18 22 

3 8 13 18 23 28 

5 10 15 20 30 

2 7 12 17 22 27 

6 11 16 21 26 31 

4 9 14 19 24 29 

4 9 14 19 24 29 

6 12 18 24 36 

6 12 18 24 30 36 

4 10 16 22 28 34 

2 8 14 20 26 32 

4 10 16 22 28 34 

1 7 13 19 25 31 

2 9 16 23 3,0 37 

3 10 17 24 31 38 

4 11 18 25 32 39 

2 9 16 23 30 37 

1 8 15 22 29 36 

5 12 19 26 33 40 

7 15 23 31 39 47 

4 12 20 28 36 44 

6 14 22 30 38 46 

NOTE This Is the first page of sample selsotion table [1-3,000] “U.S. Govemmml PrintingOfflca 1994– 301.01900010 153 
Reviews of€

I New Reports€

From the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics 

National Hospital Discharge Survey: 

Annual Summary, 1991


Series 13-114 

(PHS) 93-1775 

Authors: Graves, E.J. and Kozak, L.J. 

For information contact: 

Kathy Brannan


Scientific and Technical Information Branch


6525 Belcrest Road, Rm. 1064


Hyattsville, MD 20782


Tel: (301) 436-8500


An estimated 31.1 million 

patients, excluding newborn infants, 

were discharged from short-stay 

non-Federal hospitals in the United 

States in 1991. This and other 

inpatient data are presented in a new 

report from the National Center for 

Health Statistics (NCHS). 

Inpatients in 1991 used 199.1 

million days of hospital care. The 

average length of stay was 6.4 days 

and the discharge rate was 124.1 

discharges per 1,000 civilian 

population. These statistics, along 

with other inpatient data by 

diagnosis, procedures, sex, age, and 

geographic region, are presented in 

the NCHS report, National Hospital 

Dischaqe Survey: Annual Summa~y, 

1991. 

Of the 31.1 million patients 

discharged, 68 percent underwent one 

or more surgical, diagnostic, or 

therapeutic procedures. 

Approximately 14 percent of all 

surgical procedures and 20 percent of 

all nonsurgical procedures were 

performed on patients 75 years of age 

and over. 

According to the report, 165,000 

patients with a diagnosis of human 

immunodeficiency virus (HIV) 

infection were discharged from 

short-stay hospitals in 1991. This 

figure contrasts sharply with the 

10,000 HIV patients discharged in 

1984, the first year that HIV 

discharge statistics were collected for 

this study. 

Data on hospital discharges are 

collected thrbugh NCHS’ annual 

National Hospital Discharge Survey. 

Information is obtained from a 

national sample of the hospital 

records of discharged inpatients. 

Copies of this report can’ be 

obtained from the U.S. Government 

Printing Office by using the order 

form on the back of this release. 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

Centers 

National 

for Disease 

Center for 

Control 

Health 

and 

Statistics 

Prevention CENTERS 

cm FOR OISEASE CONTROL 

AND PREVENTION 

\ 
-------- -------- -------- --------

Mail to: Publication Order Form Superimem%nt of Gocwents 

Government Printing Offfce 

Washington, D.C, 20402 

n — YIN, please send me copies of National Hospital Discharge Survey: Annual Summary, 1991

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Vital and Health Statistics 

series descriptions . 

SERIES 1.	 Programs and Collection Procedures—These reports 

describe the data collection programs of the National Center 

for Health Statistics. They include descriptions of the 

methods used to collect and process the data, definitions, 

and other material necessary for understanding the data. 

SERIES 2.	 Data Evaluation and Methods Research-These reports 

are studies of new statistical methods and include analytical 

techniques, objective evaluations of reliability of collected 

data, and contributions to statistical theory. These studies 

also include experimental tests of new survey methods and 

comparisons of U.S. methodology with those of other 

countries. 

SERIES 3.	 Analytical and Epidemioiogical Studies-These reports 

present analytical or interpretive studies based on vital and 

health statistics. These reports carry the analyses further then 

the exposito~ types of reports in the other series. 

SERIES 4.	 Documents and Committee Reports-These are final 

repotis of major committees concerned with vital end health 

statistics and documents such as recommended model vital 

registration laws and revised birth and death certificates. 

SERIES 5.	 International Vital and Health Statistics Reports-These 

reports are analytical or descriptive reports that compare U.S. 

vital and health statistic with those of other countries or 

present other international data of relevance to the health 

statistics system of the United States. 

SERIES 6.	 Cognition and Survey Measurement—These reports are 

from the National laboratory for Collaborative Research in 

Cognition and Survey Measurement. They use methods of 

cognitive science to design, evaluate, and test survey 

instruments, 

SERIES 10.	 Data From the National Health Interview Survey-These 

reports contain statistics on illness; unintentional injuries; 

dieabil~ use of hospital, medical, and other health services 

and a wide range of special current health topics covering 

many aspects of health behaviors, health status, and health 

care utilization. They are based on data collected in a 

continuing national household interview survey. 

SERIES 11, Data From the National Health Examination Survey, the 

Nstional Health and Nutrition Examination Surveys, and 

the Hispanic Health and Nutrition Examination Survey— 

Data from direct examination, testing, and measurement on 

representative samples of the civilian noninstitutionalized 

population provide the basis for (1) medically defined total 

prevalence of specific diseases or conditions in the United 

States and the distributions of the population with respect to 

physical, physiological, and psychological characteristics, 

and (2) analyses of trends and relationships among various 

measurements and between survey periods. 

SERIES 12.	 Data From the Institutionalized Population Surveys— 

Discontinued in 1975. Reports from these surveys are 

included in Series 13. 

SERIES 13.	 Data From the National Health Care Survey—These 

reports contain statistics on health resources and the public’s 

use of health care resources including ambulatory, hospital, 

and long-term care services based on data collected directly 

from health care providers and provider records. 

SERIES 14.	 Data on Health Resources: Manpower and FaciIities— 

Discontinued in 1990. Repotis on the numbers, geographic 

distribution, and characteristics of health resources are now 

included in Series 13. 

SERIES 15.	 Data From Special Surveys—These reports contain 

statistics on health and health-related topics collected in 

special surveys that are not part of the continuing data 

systems of the National Center for Health Statistics. 

SERIES 16.	 Compilations of Advance Data From Vital and Health 

Statistics-Advance Data Repotis provide early release of 

information from the National Center for Health Statistics’ 

health and demographic surveys. They are compiled in the 

order in which they are published. Some of these releases 

may be followed by detailed repotts in Series 10-13. 

SERIES 20.	 Data on Mortality-These repor(s contain statistics on 

mortalii that are not included in regular, annual, or monthly 

reports. Special analyses by cause of death, age, other 

demographic variables, and geographic and trend analyses 

are included. 

SERIES 21. Data on Natality, Marriage, and Divorce-These reports 

contain statistics on natality, marriage, and divorce that are 

not included in regular, annual, or monthly reports. Special 

analyses by health and demographic variables and 

geographic and trend analyses are included. 

SERIES 22.	 Data From the National Mortality and Natality SurveyeDiscontinued in 1975. Reports from these sample surveys, 

based on vital records, are now published in Series 20 or 21. 

SERIES 23. Data From the National Survey of Fsmily Growth-These 

reports contain statistics on factors that affect birth rates, 

including contraception, infertility, cohabitation, marriage, 

divorce, and remarriag~ adoption; use of medical care for 

family planning and infertilii and related maternal and infant 

health topics. These statistics are based on national surveys 

of childbearing age. 

SERIES 24.	 Compilations of Data on Natality, Mortality, Marriage, 

Divorce, and Induced Terminations of Pregnancy— 

These include advance reports of births, deaths, marriages, 

and divorces based on final data from the National Vital 

Statistics System that were published as supplements to the 

kkmt/r/y Vial Statistics Report (MVSR). These reports provide 

highlights and summaries of detailed data subsequently 

published in Vita/ Statistics of the Ufrited States. Other 

supplements to the MVSR published here provide selected 

findings based on final data from the National Viial Statistics 

System and may be followed by detailed reports in Series 20 

or 21. 

For answers to questions about this report or for a list of reports published 

in these series, contact 

Data Dissemination Branch


National Center for Health Statistics


Centers for Disease Control and Prevention 

Public Health Service 

6525 Belcrest Road, Room 1064 

Hyattsville, MD 20782 

(301) 436-6500 
, DEPARTMENT OF


HEALTH 8LHUMAN SERVICES


Public Health Service


Centers for Disease Control and Prevention


National Center for Health Statistics


6525 Belcrest Road


Hyattsville, Maryland 20782


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DHHS Publication No. (PHS) 94-1309, Series 1, No. 33 

4-0792 (9/94)