Survey of Community Hospice Programs
This survey is part of a national effort to understand the existing relationships (if any) between VA facilities and community facilities providing hospice care. THANK YOU for completing the survey and for your participation in this important project.
INSTRUCTIONS:
Responses to this survey can be entered electronically or manually. (NOTE: In order to enter the data electronically, this form must be locked. To lock for data entry click on View, then on Toolbars and scroll down to Forms. Click on Forms to open the Forms toolbox. Click on the padlock icon to lock.)
- To respond electronically, click on the gray-shaded boxes representing your choices and, where indicated, type in written responses. When you have completed the survey, click on the Save icon on your toolbar. To return the survey, click on Forward and e-mail to
- To respond manually, print the survey, complete it as directed, and fax the completed survey to
- Do you ask every patient what his or her veteran status is?
___ Yes
___ No
- Do you receive referrals from VA facilities?
___ Yes
___ No
- If the answer to question # 2 is yes, how many veterans referred from VA facilities did you serve in the previous calendar year?
_____ Number served (from data logs or other source)
_____ Estimated number served
_____ We don't track referrals from VA facilities
- How many veterans referred from State Veterans Homes did you serve in calendar year 2002?
_____ Number served (from data logs or other source)
_____ Estimated number served
_____ We don't track referrals from State Veterans Homes
- We are trying to understand how community hospice agencies get paid for the services they provide to veterans that have been referred to them by VA providers. Please rank the payors listed below by the frequency with which you are reimbursed where 1 = most frequent source of reimbursement.
______ Medicare
______ Medicaid
______ TriCare /Champus
______ HMO
______ Private Insurances
______ Private pay
______ Fee-for-service basis contract with the VA facility
______ Free of charge (charity)
______ Other (list)
Additional comments:
- We are trying to determine how frequently community hospices are asked to donate their services to veterans who have been referred to them by VA providers. Please rank the type of reimbursement arrangements your agency has with VA providers where 1 = most frequent type of reimbursement arrangement.
______ Per Diem
______ Fee-for-service basis
______ Sharing agreement
______ Services were donated by the organization(s)
______ Private pay
Other (please describe)
Additional comments:
- We are trying to understand some of the existing community hospice-specific barriers to partnering with VA organizations. Please rate the following barriers from no barrier to major barrier.
| Factors related to community hospice-specific barriers in partnership with VA organizations |
No Barrier |
Minor Barrier |
Major Barrier |
Barrier |
| Community hospice staff have inadequate knowledge about VA policies and regulations |
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| Community hospice staff have inadequate knowledge about VA policies and regulations |
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| Community hospice staff have no knowledge of how to contact VA facility designated hospice point-of-contact |
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| Continuity of care issues (Community hospice has no mechanism for communicating status of referred veteran to VA staff) |
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| Lack of knowledge about certain illnesses that may be more common in veterans. (e.g., Post Traumatic Stress Disorder (PSDT), Agent Orange exposure, etc.) |
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Other barriers (please describe)
Additional comments:
- We are trying to understand some of the existing VA-specific barriers that community hospices have in partnering with VA organizations. Please rate the following barriers from no barrier to major barrier.
| Factors related to VA-specific barriers in partnering with VA organizations |
No Barrier |
Minor Barrier |
Barrier |
Major Barrier |
| VA staff have inadequate knowledge about the Medicare Hospice Benefit |
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| VA physician issues (DEA number, State license, 24/7 availability) |
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| Hospice unable to secure contract with VA facility |
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| VA determines the scope and frequency of hospice services rather than allowing the hospice to control the veteran's plan of care as related to the terminal illness. |
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| VA payment issues (no mechanism to bill VA for veterans not eligible for the Medicare hospice benefit) |
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| Defining responsibilities for medications, treatments, medical equipment, and transportation |
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| Continuity of care issues (no designated VA contact; VA changes plan of care without notifying hospice; veteran is admitted to VA facility without knowledge of hospice) |
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Other barriers (please describe)
Additional comments:
- Do you do targeted outreach activities to veterans?
___ Yes
___ No
- If the answer to question #9 is yes, please rank the type of outreach activities your agency has done with VA providers where 1 = most frequent type of activity.
_____ Veteran-targeted education and training
_____ Veterans/family support groups
_____ Veteran-targeted publications
_____ Outreach to Veterans Service Organizations
_____ Media use (Public Service Announcements, articles, etc.)
_____ Other
Additional comments:
- Do you know who the designated community hospice ‘points-of-contact' (the VA provider you could call for hospice related questions regarding veterans you are serving) are for VA facilities in your service area?
___ Yes
___ No
- If the answer to #12 is yes, please list the hospices and contact names:
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VA |
NAME OF CONTACT |
TELEPHONE |
EMAIL |
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NAME OF CONTACT |
TELEPHONE |
EMAIL |
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NAME OF CONTACT |
TELEPHONE |
EMAIL |
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VA |
NAME OF CONTACT |
TELEPHONE |
EMAIL |
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VA |
NAME OF CONTACT |
TELEPHONE |
EMAIL |
- We are planning an effort to improve care of terminally ill veterans by increasing communication between VA facilities and community hospices. Can you please share with us the most difficult issues and the least difficult issues in referring and coordinating care for veterans who need home hospice care
Most difficult issues:
Least difficult issues:
- In your opinion, what specific resources will be helpful to you in facilitating quality end-of-life care for veterans who need hospice and palliative care services?
a.
b.
c.
d.
e.
- Would your organization be interested in participating in a statewide veterans' outreach/education program on improving access to end-of-life care for veterans?
___ Yes
___ No
Additional comments:
- Are there people in your organization who would be interested in participating (sitting on committees, become a local champion) in a statewide veterans' outreach/education program on improving access to end-of-life care for veterans?
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TELEPHONE |
EMAIL |
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NAME OF CONTACT |
TELEPHONE |
EMAIL |
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NAME OF CONTACT |
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NAME OF CONTACT |
TELEPHONE |
EMAIL |
Individual completing form: ________________________________________________
Your role in your organization: ______________________________________________
Organization name: _______________________________________________________
Organization address: _____________________________________________________
City: _______________________________ State:_ _____________ Zip: ___________
Phone: _______________________________ Fax: _____________________________
E-mail: _________________________________________________________________
Thank you for your help in this national effort to improve care for terminally ill veterans!
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