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This survey is part of a national effort to understand the existing relationships (if any) between VA facilities and community agencies providing hospice care to VETERANS WHO ARE ENROLLED IN THE VETERANS HEALTH CARE SYSTEM. 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 in the designated fields, 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 and complete it as directed. Write any comments on the backs of the survey pages. Fax the completed survey to ______________________, making sure you fax both sides of the pages if you have included comments.
- Do you refer terminally ill veterans who are patients in your VA facility to community hospice agencies?
____ Yes
____ No
If you have NOT referred enrolled veterans to any community hospices, please state why not (and please go to question 8).
We don't refer enrolled veterans to community hospices because
- How many veterans did you refer to community hospice(s) in the last calendar year?
____ Number referred (from data logs or other source)
____ Estimated number referred
____ We don't track referrals to community hospices
Additional comments:
- In the past year, to which of the following community agencies and VA facilities have you referred veterans for hospice or palliative care services?
| Hospice Agency or VA Facility |
Never |
Rarely |
Somewhat Often |
Very Often |
| Community hospice agency for home-based care |
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| Community hospice agency for inpatient-based care (e.g., care provided by a hospice agency in a hospice inpatient unit or in a non-VA nursing home) |
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| Community Home Health Agency |
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| VA designated inpatient hospice unit |
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| VA Medical Center |
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| VA Nursing Home Unit |
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| State Veterans Home |
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Other (list):
Additional comments:
- For those veterans you refer to community hospices, does your VA facility pay the hospices for the services they provide if the veteran is uninsured or underinsured?
____ Yes
____ No
Additional comments:
- Please rank order the frequency of ways in which community hospices are paid for services they provide to veterans you refer to them where 1 = most frequent type of payment.
____ Per Diem
____ Fee-for-service basis
____ Sharing agreement
____ Private pay
____ None (no payments made for hospice services)
____ Other (please describe)
Other (please describe):
Additional comments:
- Please rank order the payors listed below by the frequency with which community hospices are paid for the services they provide to veterans you refer to them where 1 = most frequent source of payment.
____ Medicare
____ Medicaid
____ TriCare / Champus
____ HMO
____ Private Insurances
____ Hospice has contract with the VA facility
____ Private pay (veteran pays out of pocket)
____ VA does not purchase hospice services
Other (please describe):
Additional comments:
- We are trying to understand some of the legal/regulatory barriers that exist between community hospices and VA facilities. Please rate the following barriers from no barrier to major barrier.
| Factors related to some of the legal/regulatory barriers that exist between community hospices and VA facilities |
No Barrier |
Minor Barrier |
Barrier |
Major Barrier |
| VA policies regarding accreditation requirements (JCAHO, CHAP, etc.) |
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| VA contracting policies and regulations |
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| Some hospices require a primary caregiver in the home who is able to assume responsibility for most of the patient's care. |
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| Some hospices require too much documentation to certify the 6 month prognosis. |
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| Some hospices limit the type of treatments patients can get, especially if they are considered to be "curative" or "aggressive." |
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| Hospices are required to provide medications, DME and biologicals related to the terminal illness. |
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| Veterans enrolled in community hospice have to revoke hospice to be admitted to a VA facility. |
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| Other legal/regulatory barriers you have encountered (please describe): |
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Additional comments:
- We are trying to understand VA staff perceptions about the quality of care community hospices provide to veterans. Please rate the following items on a scale of poor to excellent.
| Factors related to the quality of care provided to veterans by community hospices
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Poor |
Somewhat Good |
Good |
Excellent |
| Communication between community hospice and VA staff |
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| Case management assistance for outpatient cases |
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| Quality of care delivered |
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| Support to veterans and families |
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| Support to VA facility and staff |
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| Ability of hospice to provide care that meets the unique needs of veterans at the end of life |
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Additional comments:
- We are trying to understand VA staff perceptions of why community hospices may have problems working with them. Please rate the following factors from no barrier to major barrier.
| Factors related to VA staff perceptions of why community hospices may have problems working with them |
No Barrier |
Minor Barrier |
Barrier |
Major Barrier |
| VA staff do not communicate effectively with community hospice staff. |
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| VA staff do not understand the Medicare Hospice Benefit. |
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| VA physicians do not have DEA numbers. |
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| VA physicians are not always available 24/7 to respond to community hospice staff who are caring for their veteran patients. |
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| VA facilities do not reimburse community hospices for the services they provide. |
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| Community hospice medical director / physicians are not available to coordinate care for veterans after hours. |
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Other barriers you have encountered (please describe):
Additional comments:
- Please help us understand how hospice/palliative care is introduced to veterans in your facility who are terminally ill by putting in rank order the modes of communication listed below where 1 = most frequently used mode of communication.
____ Conversation between physician and veteran about prognosis and care options
____ Education of patient and family by other VA staff about prognosis and care options
____ Patient/family initiate discussion about prognosis and care options
____ Hospice brochures/other communication materials
Other (please describe):
Additional comments:
- Do you know the name of community hospice providers you should call for referrals or hospice-related questions regarding veterans you are serving?
____ Yes
____ No
If the answer to #12 is yes, please list the hospices and contact names:
| a. |
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HOSPICE |
NAME OF CONTACT |
TELEPHONE |
EMAIL |
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| b. |
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HOSPICE |
NAME OF CONTACT |
TELEPHONE |
EMAIL |
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| c. |
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HOSPICE |
NAME OF CONTACT |
TELEPHONE |
EMAIL |
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| d. |
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HOSPICE |
NAME OF CONTACT |
TELEPHONE |
EMAIL |
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| e. |
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HOSPICE |
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.
a. Most difficult issues:
b. Least difficult issues:
- In your opinion, please list specific resources that will be helpful to you in facilitating quality end-of-life care for veterans who need hospice and palliative care services in the community.
a.
b.
c.
d.
e.
Please provide any other comments:
Please list the names and contact information for persons at your facility who would be interested in participating (sitting on committees, becoming a local champion) in a statewide veterans' outreach/education program on improving access to end-of-life care for veterans.
| a. |
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NAME |
TELEPHONE |
EMAIL |
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| b. |
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NAME |
TELEPHONE |
EMAIL |
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| c. |
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NAME |
TELEPHONE |
EMAIL |
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Name of VA staff person completing form: _____________________________________
Your role in your organization: ______________________________________________
VA Facility name: _______________________________________________________
VA Facility 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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