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 18

11/29/1989

: Table 18

Case ManagementEver received (several examples of case management are given in the instrument): yes/no2 Provided as part of residential environment: yes/no Provided by one agency or more than one Does agency mostly serve MR/DD/mental health Name of agency: __________ (write-in) Number of visits from agency in past 12 months
Mental Health ServicesReceived in past month any mental health program/day treatment program, or partial hospitalization for all/part of the day Number of days received Were services part of residential arrangement Visits in past month with mental health professional (i.e. psychologist, social worker, psychiatric nurse) or attended group sessions Number of visits/sessions Were services part of residential arrangement Hospitalized overnight in past year for mental health reasons: yes/no Number of times hospitalized (This information can be obtained in the NHIS core under "reasons for hospitalization" but may be added in this more specific format) Attend in past month adult day care program Number of days attended Were services part of residential arrangement
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 HMO Other No cost of 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 of 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)