Design for Survey of Persons with Mental Retardation and Developmental Disabilities: Summary of Recommendations for Survey Questions and Screening Criteria. Design for Survey of Persons with Mental Retardation and Developmental Disabilities: Summary of Recommendations for Survey Questions and Screening Criteria : Table 17

11/29/1989

: Table 17

NHIS CoreOvernight hospital stays (13-month period) Date of admission Number of nights spent Reason for hospitalization Whether surgery was performed Name/address of hospital Doctor visits (2-week period) Date of visit Setting Physician specialty Whether surgery was performed Location (city, county, state) Also collected: number of times family member received health care/medical advice/prescription/test results over telephone Number of medical doctor/assistant visits in past 12 months
Additional Questions on FrequencyNumber of times in nursing home/convalescent home/similar place Total number of nights in nursing home/convalescent home/similar place Number of dental visits Number of emergency room/emergency treatment center visits Frequency of purchases: Prescription drugs OTC medications Incontinence supplies Other Frequency of therapy: Physical Occupational Speech/hearing
Payment ModeWho paid/is expected to pay for costs of services: Sample member/family Medicare/medicare HMO Medicaid Veteran's benefits CHAMPUS/CHAMPVA Private insurance/non-Medicare HM Other No cost to sample member/family/third party Any costs incurred by sample member/family: yes/no Total paid by sample member/family excluding insurance paybacks
Satisfaction with ServicesFor each service: very satisfied, satisfied, neither satisfied or dissatisfied, dissatisfied, very dissatisfied Reason for dissatisfaction: For each service: very satisfied, satisfied, neither satisfied or dissatisfied, dissatisfied, very dissatisfied Why dissatisfied: Receives too little/too much of service Service is not appropriate to needs Not reliable Not timely Too expensive Problem with provider's attitude Problem with transportation Other __________ (specify)