Protocol - Quality of Care - Children

The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Health Plan Survey 4.0 Child Medicaid Questionnaire

Survey Instructions

Answer each question by marking the box to the left of your answer.

You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

Yes → If Yes, go to # 1 on page 1

Please answer the questions for the child listed on the envelope. Please do not answer for any other children.

1. Our records show that your child is now in {INSERT HEALTH PLAN NAME}. Is that right?

1[ ]Yes → If Yes, go to # 3

2[ ]No

2. What is the name of your child’s health plan?

Please print:_______________________ __________________________________

Your Child’s Health Care in the Last 6 Months

These questions ask about your child’s health care. Do not include care your child got when he or she stayed overnight in a hospital. Do not include the times your child went for dental care visits.

3. In the last 6 months, did your child have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?

1[ ]Yes

2[ ]No → If No, go to #5

4. In the last 6 months, when your child needed care right away, how often did your child get care as soon as you thought he or she needed?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

5. In the last 6 months, not counting the times your child needed care right away, did you make any appointments for your child’s health care at a doctor’s office or clinic?

1[ ]Yes

2[ ]No → If No, go to #7

6. In the last 6 months, not counting the times your child needed care right away, how often did you get an appointment for health care at a doctor’s office or clinic as soon as you thought your child needed?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

7. In the last 6 months, not counting the times your child went to an emergency room, how many times did he or she go to a doctor’s office or clinic to get health care?

[ ] None→ If None, go to #9 on page 4 [If items CC5-CC7 or CC5-CC18 are included: go to #CC5; if only items CC8-CC18 are included: go to #CC8]

[ ] 1

[ ] 2

[ ] 3

[ ] 4

[ ] 5 to 9

[ ] 10 or more

CC1. In the last 6 months, how often did you have your questions answered by your child’s doctors or other health providers?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

CC2. Choices for your child’s treatment or health care can include choices about medicine, surgery, or other treatment. In the last 6 months, did your child’s doctor or other health provider tell you there was more than one choice for your child’s treatment or health care?

1[ ]Yes

2[ ]No → If No, go to #8

CC3. In the last 6 months, did your child’s doctor or other health provider talk with you about the pros and cons of each choice for your child’s treatment or health care?

1[ ]Yes

2[ ]No

CC4. In the last 6 months, when there was more than one choice for your child’s treatment or health care, did your child’s doctor or other health provider ask you which choice was best for your child?

1[ ]Yes

2[ ]No

8. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your child’s health care in the last 6 months?

0[ ]Worst health care possible

1[ ]

2[ ]

3[ ]

4[ ]

5[ ]

6[ ]

7[ ]

8[ ]

9[ ]

10[ ]Best health care possible

CC5. Is your child now enrolled in any kind of school or daycare?

1[ ]Yes

2[ ]No → If No, go to #9 on page 4 [If items CC8-CC18 are included: go to #CC8]

CC6. In the last 6 months, did you need your child’s doctors or other health providers to contact a school or daycare center about your child’s health or health care?

1[ ]Yes

2[ ]No → If No, go to #9 on page 4 [If items CC8-CC18 are included: go to #CC8]

CC7. In the last 6 months, did you get the help you needed from your child’s doctors or other health providers in contacting your child’s school or daycare?

1[ ]Yes

2[ ]No

Option: Insert additional questions about general health care here.

Specialized Services

CC8. Special medical equipment or devices include a walker, wheelchair, nebulizer, feeding tubes, or oxygen equipment. In the last 6 months, did you get or try to get any special medical equipment or devices for your child?

1[ ]Yes

2[ ]No → If No, go to #CC11

CC9. In the last 6 months, how often was it easy to get special medical equipment or devices for your child?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

CC10. Did anyone from your child’s health plan, doctor’s office, or clinic help you get special medical equipment or devices for your child?

1[ ]Yes

2[ ]No

CC11. In the last 6 months, did you get or try to get special therapy such as physical, occupational, or speech therapy for your child?

1[ ]Yes

2[ ]No→ If No, go to #CC14

CC12. In the last 6 months, how often was it easy to get this therapy for your child?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

CC13. Did anyone from your child’s health plan, doctor’s office, or clinic help you get this therapy for your child?

1[ ]Yes

2[ ]No

CC14. In the last 6 months, did you get or try to get treatment or counseling for your child for an emotional, developmental, or behavioral problem?

1[ ]Yes

2[ ]No → If No, go to #CC17

CC15. In the last 6 months, how often was it easy to get this treatment or counseling for your child?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

CC16. Did anyone from your child’s health plan, doctor’s office, or clinic help you get this treatment or counseling for your child?

1[ ]Yes

2[ ]No

CC17. In the last 6 months, did your child get care from more than one kind of health care provider or use more than one kind of health care service?

1[ ]Yes

2[ ]No → If No, go to #9

CC18. In the last 6 months, did anyone from your child’s health plan, doctor’s office, or clinic help coordinate your child’s care among these different providers or services?

1[ ]Yes

2[ ]No

Your Child’s Personal Doctor

9. A personal doctor is the one your child would see if he or she needs a check-up or gets sick or hurt. Does your child have a personal doctor?

1[ ]Yes

2[ ]No → If No, go to #19 on page 6

10. In the last 6 months, how many times did your child visit his or her personal doctor for care?

[ ] None → If None, go to #18

[ ] 1

[ ] 2

[ ] 3

[ ] 4

[ ] 5 to 9

[ ] 10 or more

11. In the last 6 months, how often did your child’s personal doctor explain things in a way that was easy to understand?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

12. In the last 6 months, how often did your child’s personal doctor listen carefully to you?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

13. In the last 6 months, how often did your child’s personal doctor show respect for what you had to say?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

14. Is your child able to talk with doctors about his or her health care?

1[ ]Yes

2[ ]No → If No, go to #16

15. In the last 6 months, how often did your child’s personal doctor explain things in a way that was easy for your child to understand?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

16. In the last 6 months, how often did your child’s personal doctor spend enough time with your child?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

17. In the last 6 months, did your child’s personal doctor talk with you about how your child is feeling, growing, or behaving?

1[ ]Yes

2[ ]No

18. Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your child’s personal doctor?

0[ ]Worst personal doctor possible

1[ ]

2[ ]

3[ ]

4[ ]

5[ ]

6[ ]

7[ ]

8[ ]

9[ ]

10[ ]Best personal doctor possible

CC19. Does your child have any medical, behavioral, or other health conditions that have lasted for more than 3 months?

1[ ]Yes

2[ ]No → If No, go to #19

CC20. Does your child’s personal doctor understand how these medical, behavioral, or other health conditions affect your child’s day-to-day life?

1[ ]Yes

2[ ]No

CC21. Does your child’s personal doctor understand how your child’s medical, behavioral, or other health conditions affect your family’s day-to-day life?

1[ ]Yes

2[ ]No

Option: Insert additional questions about personal doctor here.

Getting Health Care From a Specialist

When you answer the next questions, do not include dental visits or care your child got when he or she stayed overnight in a hospital.

19. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 6 months, did you try to make any appointments for your child to see a specialist?

1[ ]Yes

2[ ]No → If No, go to #23

20. In the last 6 months, how often was it easy to get appointments for your child with specialists?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

21. How many specialists has your child seen in the last 6 months?

[ ] 0 None → If None, go to #23

[ ] 1 specialist

[ ] 2

[ ] 3

[ ] 4

[ ] 5 or more specialists

22. We want to know your rating of the specialist your child saw most often in the last 6 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist?

0[ ]Worst specialist possible

1[ ]

2[ ]

3[ ]

4[ ]

5[ ]

6[ ]

7[ ]

8[ ]

9[ ]

10[ ]Best specialist possible

Option: Insert additional questions about specialist care here.

Your Child’s Health Plan

The next questions ask about your experience with your child’s health plan.

23. In the last 6 months, did you try to get any kind of care, tests, or treatment for your child through his or her health plan?

1[ ]Yes

2[ ]No → If No, go to #25

24. In the last 6 months, how often was it easy to get the care, tests, or treatment you thought your child needed through his or her health plan?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

25. In the last 6 months, did you try to get information or help from customer service at your child’s health plan?

1[ ]Yes

2[ ]No → If No, go to #28

26. In the last 6 months, how often did customer service at your child’s health plan give you the information or help you needed?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

27. In the last 6 months, how often did customer service staff at your child’s health plan treat you with courtesy and respect?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

28. In the last 6 months, did your child’s health plan give you any forms to fill out?

1[ ]Yes

2[ ]No → If No, go to #30

29. In the last 6 months, how often were the forms from your child’s health plan easy to fill out?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

30. Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your child’s health plan?

0[ ]Worst health plan possible

1[ ]

2[ ]

3[ ]

4[ ]

5[ ]

6[ ]

7[ ]

8[ ]

9[ ]

10[ ]Best health plan possible

Option: Insert additional questions about the health plan here.

Prescription Medicines

CC22. In the last 6 months, did you get or refill any prescription medicines for your child?

1[ ]Yes

2[ ]No → If No, go to # 31

CC23. In the last 6 months, how often was it easy to get prescription medicines for your child through his or her health plan?

1[ ]Never

2[ ]Sometimes

3[ ]Usually

4[ ]Always

CC24. Did anyone from your child’s health plan, doctor’s office, or clinic help you get your child’s prescription medicines?

1[ ]Yes

2[ ]No

About Your Child and You

31. In general, how would you rate your child’s overall health?

1[ ]Excellent

2[ ]Very Good

3[ ]Good

4[ ]Fair

5[ ]Poor

CC25. Does your child currently need or use medicine prescribed by a doctor (other than vitamins)?

1[ ]Yes

2[ ]No → If No, go to #CC28

CC26. Is this because of any medical, behavioral, or other health condition?

1[ ]Yes

2[ ]No → If No, go to #CC28

CC27. Is this a condition that has lasted or is expected to last for at least 12 months?

1[ ]Yes

2[ ]No

CC28. Does your child need or use more medical care, more mental health services, or more educational services than is usual for most children of the same age?

1[ ]Yes

2[ ]No → If No, go to #CC31

CC29. Is this because of any medical, behavioral, or other health condition?

1[ ]Yes

2[ ]No → If No, go to #CC31

CC30. Is this a condition that has lasted or is expected to last for at least 12 months?

1[ ]Yes

2[ ]No

CC31. Is your child limited or prevented in any way in his or her ability to do the things most children of the same age can do?

1[ ]Yes

2[ ]No → If No, go to #CC34

CC32. Is this because of any medical, behavioral, or other health condition?

1[ ]Yes

2[ ]No → If No, go to #CC34

CC33. Is this a condition that has lasted or is expected to last for at least 12 months?

1[ ]Yes

2[ ]No

CC34. Does your child need or get special therapy such as physical, occupational, or speech therapy?

1[ ]Yes

2[ ]No → If No, go to #CC37

CC35. Is this because of any medical, behavioral, or other health condition?

1[ ]Yes

2[ ]No → If No, go to #CC37

CC36. Is this a condition that has lasted or is expected to last for at least 12 months?

1[ ]Yes

2[ ]No

CC37. Does your child have any kind of emotional, developmental, or behavioral problem for which he or she needs or gets treatment or counseling?

1[ ]Yes

2[ ]No→ If No, go to #32

CC38. Has this problem lasted or is it expected to last for at least 12 months?

1[ ]Yes

2[ ]No

32. What is your child’s age?

1[ ]Less than 1 year old

______ YEARS OLD (write in)

33. Is your child male or female?

1[ ]Male

2[ ]Female

34. Is your child of Hispanic or Latino origin or descent?

1[ ]Yes, Hispanic or Latino

2[ ]No, not Hispanic or Latino

35. What is your child’s race? Please mark one or more.

1[ ]White

2[ ]Black or African-American

3[ ]Asian

4[ ]Native Hawaiian or other Pacific Islander

5[ ]American Indian or Alaska Native

6[ ]Other

36. What is your age?

0[ ]Under 18

1[ ]18 to 24

2[ ]25 to 34

3[ ]35 to 44

4[ ]45 to 54

5[ ]55 to 64

6[ ]65 to 74

7[ ]75 or older

37. Are you male or female?

1[ ]Male

2[ ]Female

38. What is the highest grade or level of school that you have completed?

1[ ]8th grade or less

2[ ]Some high school, but did not graduate

3[ ]High school graduate or GED

4[ ]Some college or 2-year degree

5[ ]4-year college graduate

6[ ]More than 4-year college degree

39. How are you related to the child?

1[ ]Mother or father

2[ ]Grandparent

3[ ]Aunt or uncle

4[ ]Older sibling

5[ ]Other relative

6[ ]Legal guardian

40. Did someone help you complete this survey?

1[ ]Yes

2[ ]No → Thank you. Please return the completed survey in the postage-paid envelope.