Palliative Care Survey ⋆ Four Seasons

Thank you for completing the Palliative Care Survey!

We are currently conducting a survey regarding the Palliative Care services you are either currently receiving or have received in the recent past and would appreciate your feedback.

Please answer the questions in the form below. Your responses are anonymous and help us to improve the quality of care we provide. Thank you for taking the time to complete this survey. We are grateful for your feedback.

All of the questions in this survey will ask about your care from Four Seasons Palliative Care. If you need to, you can ask a family member or friend for help with this survey or ask them to complete the survey for you. If you are completing this survey for the patient, please remember that survey questions refer to the patient’s care. Unless a question says otherwise, please do not consider your own experiences in the answers you provide.

Palliative Care Survey

The Serious Illness Survey for Home-Based Programs assesses the experiences of patients who receive care from programs that provide serious illness care in patients’ homes. Access the complete set of survey resources, including guidance on administration, sampling, and analysis, at www.rand.org/Serious-Illness-Survey. For more information, contact seriousillness@rand.org. Survey development was funded by the Gordon and Betty Moore Foundation and carried out within the Quality Measurement and Improvement Program in RAND Health Care.

- Step 1 of 6

Your Care from This Program

People from this program may take your blood pressure, review your medicines, or talk with you about your symptoms. Visits with this program can be in your home, by video, or by phone. As you answer the questions in this survey, please think only about the care you received from Four Seasons Palliative Care.

1. In the last 3 months, how many times did someone from this program visit you at home? *

None
1 to 2 times
3 to 4 times
5 or 6 times
7 or more times

2. In the last 3 months, how many times did you talk to someone from this program on the phone or by video for questions or help with your care? *

None
1 to 2 times
3 to 4 times
5 to 6 times
7 or more times

3. In the last 3 months, how often did a person or persons from this program spend enough time with you?

Never
Sometimes
Usually
Always

4. In the last 3 months, how often did a person or persons from this program explain things to you in a way you could understand? *

Never
Sometimes
Usually
Always

5. In the last 3 months, how often did a person or persons from this program listen carefully to you? *

Never
Sometimes
Usually
Always

6. In the last 3 months, how often did you feel that people from this program cared about you as a whole person? *

Never
Sometimes
Usually
Always

7. In the last 3 months, how often did you feel heard and understood by a person or persons from this program? *

Never
Sometimes
Usually
Always

8. In the last 3 months, how often did a person or persons from this program seem to know the important information about your medical history? *

Never
Sometimes
Usually
Always

9. In the last 3 months, did someone from this program talk with you about the care or treatment you get from your other doctors or health care providers? *

Yes, definitely
Yes, somewhat
No

10. In the last 3 months, did someone from this program talk with you about all the medicines you are taking? *

Yes, definitely
Yes, somewhat
No
I do not take an medicines

11. Everyday activities include things like getting ready in the morning, getting meals, or going places in your community. In the last 3 months, did someone from this program talk with you about how to get help with everyday activities? *

Yes, definitely
Yes, somewhat
No
I did not want to talk with this program about getting help with everyday activities

Help in the Last 3 Months

12. In the last 3 months, when you contacted this program between visits for questions or help with your care, did you get the help you needed? *

Yes, definitely
Yes, somewhat
No
I did not contact this program between visits for questions or help with my care

13. In the last 3 months, did you have any pain? *

14. In the last 3 months, did you get as much help as you wanted for your pain?

Yes, definitely
Yes, somewhat
No
I did not want help for my pain

15. In the last 3 months, did you have any trouble breathing? *

16. In the last 3 months, did you get as much help as you wanted for your trouble breathing

Yes, definitely
Yes, somewhat
No
I did not want help for my breathing

17. In the last 3 months, did you have any feelings of anxiety or sadness? *

18. In the last 3 months, did you get as much help as you wanted for your feelings of anxiety and sadness?

Yes, definitely
Yes, somewhat
No
I did not want help for my breathing

Your Family Members or Friends

19. In the last 3 months, did you have family members or friends involved in your care? *

20. In the last 3 months, did people from this program involve your family members or friends in discussions about your health care as much as YOU wanted?

Yes, definitely
Yes, somewhat
No

21. In the last 3 months, did your family and friends get as much emotional support as THEY wanted from this program?

Yes, definitely
Yes, somewhat
No
My family members and friends did not want emotional support from this program

Planning Your Care

22. Did someone from this program ever talk with you about what you should do during a health emergency? *

Yes, definitely
Yes, somewhat
No

23. Did someone from this program ever talk with you about what is important in your life? *

Yes, definitely
Yes, somewhat
No

24. Did someone from this program ever talk with you about what your health care options would be if you got sicker? *

Yes, definitely
Yes, somewhat
No

25. On a scale of 0 to 10, where 0 is the worst care possible and 10 is the best, how would you rank the care you received from this program? *

0- Worst Care Possible
1
2
3
4
5
6
7
8
9
10- Best Care Possible

26. Would you recommend this program to you friends and family? *

Definitely no
Probably no
Probably yes
Definitely yes

About You (The Patient)

If you are completing this survey for the patient, please rememebr that the next set of questions refer to the patient.

27. Are you usually able to leave your home or a building to go outside, even if you use a cane, walker, or other people for support. *

Yes, by myself
Yes, with help
No

28. Are you usually able to get in and out of bed? *

Yes, by myself
Yes, with help
No

29. In general, how would you rate your physical health? *

Excellent
Very Good
Good
Fair
Poor

30. In general, how would you rate your mental or emotional health? *

Excellent
Very Good
Good
Fair
Poor

31. What is the highest grade or level of school you have completed? *

8th grade or less
Some high school but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

32. Are you of Hispanic, Latino, or Spanish origin or descent? *

No, not Hispanic/Latino/Spanish
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano/a/a
Yes, Cuban
Yes, other Spanish/Hispanic/Latino

33. What is your race? Please choose all that apply. *

White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Native or Alaska Native

34. What language do you mainly speak at home? *

English
Spanish
Other (Please list in the box below)

Other Language:

You may skip this if you selected "English" or "Spanish" in question 34.

35. Did someone help you complete this survey? Please choose all that apply. *

No, no one helped me complete this survey
Yes, they read the questions to me
Yes, they wrote down the answers I gave
Yes, they answered the questions for me
Yes, they translated the questions into my language
Yes, they helped in some other way

In thinking about your experience with this program, is there anything that is going well or that you wish would go differently? Please tell us about those experiences.

If you do not have anything further to add, you may skip this question.

Thank you for completing the Palliative Care Survey!

Your Care from This Program

Help in the Last 3 Months

Your Family Members or Friends

Planning Your Care

About You (The Patient)

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