Form #3 Form #3 Patient-Family-caregiver Interview Tool (Drivers)

Patient/Family/Caregiver Interview (Drivers)

Hospital Name:
Interviewer Name:
Date of Interview:
Case #:
Mode of Interview:	In hospital Over the phone Other _____________________________________________
Person(s) interviewed (check all that apply):	Patient Family/Caregiver Other _____________________________________________
Date of first admission:
Date of readmission:
Description of Strategy/Quality Improvement Being Tested (during QI cycles):

Purpose:	The purpose of the patient & family/caregiver interview(s) is to obtain the patient and family/caregiver perspectives, in their own words, of the initial hospitalization and the readmission.
Sample Size:	10-20 cases – until themes converge and very little new information is being learned (same patients for whom you did chart reviews).
Selection Criteria:	Patient with primary insurance Medicaid who had a readmission within 30 days of a previous admission. Patient is still in hospital or 7 or fewer days since discharge. Speak directly with patient when possible AND with concerned family member/caregiver whom patient allows to talk on his/her behalf. Records review has been conducted.
Conduct:	Patient and family/caregiver interviews can be completed while the patient is still in hospital, if appropriate given his/her circumstances and the timing is convenient; if not, conducting the interview over the phone is fine. Interviews with patient and family/caregiver can occur simultaneously or separately. The interview style should be conversational and allowing the interviewee to express his/herself rather than following strict adherence to the questions – the interview tool is provided more as a guide to this interview than as a survey tool. Only read the questions (not the answer choices) to avoid leading respondents to a particular answer.
Time:	10 minutes maximum per interview.
Patient Consent: Interviewer: “I understand you were recently in the hospital at least twice in the past month. The hospital and the doctors and nurses that take care of you are working to improve how we take care of people after they leave the hospital. Since you were recently in the hospital and then admitted again to the hospital soon after you got out the first time, we would like to hear more about what happened with you between those two hospitalizations. By talking to patients like you, we can improve the care we give to patients after they leave the hospital. I have a few questions for you that will take about 10 minutes. Is that okay with you?” Yes No... Reason, if provided: ______________________________________________________

Family/Caregiver Consent:

Interviewer: “[insert name of patient] was recently in the hospital at least twice in the past month. The hospital and the doctors and nurses that take care of him/her are working to improve how we take care of people after they leave the hospital. We would like to hear more about what happened with [insert name of patient] between those two hospitalizations. By talking to family members or caretakers like you, we can improve the care we give to patients after they leave the hospital. I have a few questions for you that will take about 10 minutes. Is that okay with you?”

Yes No... Reason, if provided: ______________________________________________________

General/Overall
Are you comfortable speaking in English?	yes no (provide interpreter)
Where do you go when you have to see the doctor?	Community health center Hospital-based clinic VA clinic Emergency department Other _______________________________ Unknown
Do you have a specific doctor there who you see most of the time?	yes no For interviewer: is this the same provider documented in the medical record? yes no
Do you have any other doctors that take care of you?	yes no
4a. If yes, do you know their specialties (for example, cardiologist, endocrinology, immunology)
Tell me why you were first admitted to the hospital on [insert date].
Where were you living before you went into the hospital on [insert date]?	Own home Home with home health Relative/caregiver home Rehabilitation facility Nursing home/long-term care facility Home with hospice Shelter Other _______________________________
Where were you staying right after you left the hospital the first time?	Own home Home with home health Relative/caregiver home Rehabilitation facility Nursing home/long-term care facility Home with hospice Shelter Other _______________________________ Unknown
8. Were you involved in discussions with your doctors and nurses about a plan for when you left the hospital?	yes no If yes, describe:
Did you feel that you knew how to take care of yourself when you left the hospital?	yes no Comments:
10. Were all your questions about leaving the hospital answered to your satisfaction?	yes no Comments:
11. Did you receive any information about who to call if you had questions or problems?	yes no Comments:
12. Did you receive any information about new medicines you needed to take?	yes no Comments:
13. Did you receive any information about how to take care of yourself after your hospitalization?	yes no Comments:
14. Did a doctor or nurse make any appointment for you, or help you make an appointment, to see your main doctor soon after you left the hospital?	yes no Comments:
Did [insert strategy being tested] happen? TO BE ASKED DURING QI CYCLES	yes no
15a. If yes, it what ways was it helpful or not helpful to you?
Time Between Admissions
Did you see a doctor or nurse between the time you left the hospital the first time and the time you were admitted again to the hospital?	yes no Comments:
16a. If yes, what was the name of the doctor?
16b. If yes, what did you discuss with the doctor?
16c. If yes, please describe in what ways it was helpful to you or not helpful to you.
Describe any problems you had making the appointment for that doctor’s visit or getting to that appointment.
Second Hospitalization
Tell me about why you came back to the hospital the second time. Prompt for family, social, economic, logistical, psychological (anxiety), clinical reasons that they returned; the circumstances and the chief complaint, in the patient’s or family’s/caregiver’s own words.
Where were you living before you went into the hospital the second time?	Own home Home with home health Relative/caretaker home Rehabilitation facility Nursing home/long-term care facility Home with hospice Shelter Other _______________________________
Did [insert strategy being tested] happen? TO BE ASKED DURING QI CYCLES	yes no
20a. If yes, it what ways was it helpful or not helpful to you?
Where were you staying right after you left the hospital the second time (if patient has been discharged)?	Not yet discharged Own home Home with home health Relative/caretaker home Rehabilitation facility Nursing home/long-term care facility Home with hospice Shelter Other _______________________________
Following Doctors’ Suggestions
Do you feel that you know how to take care of yourself when you leave the hospital?	Yes No Comment:
Do you have any trouble paying for medications?	Yes No Comment:
Do you have any trouble getting to the drugstore to pick up your medications?	Yes No Comment:
Are you supposed to follow any doctor’s recommendations for your health, like a special diet, or exercises, or not smoking?	Yes No Comment:
25a. If yes, do you have any ideas for helping to make it easier for you to follow these recommendations?
How can we improve how we help you or others prepare to leave the hospital?
Is there anything else you would like to tell us about your experience?

Patient/Family/Caregiver Interview (Drivers) Page 7

Adapted from STAAR Readmissions Diagnostic Tool