1I Attachment 1-I. Study 1 MEPS Abbreviated R2 Interview

Study 1 R2 Instrument

Universe: respondents whose household completed at least one monthly check-in

Form Approved
OMB No. 0935.0124
Exp. Date 1/31/2024

Step 1: Calendar (CA) Section

CA10. To answer the next set of questions, you will find it helpful to refer to records about the health care {you/{REFERENCE PERSON}/{your/{REFERENCE PERSON}’s} household} received in person, by phone, or by video since {START OF REFERENCE PERIOD}. Records that identify the place or person that provided the health care, the dates of health care visits, and any charges for the care will help answer the questions.

Any records you refer to should cover health care {since {START DATE OF REFERENCE PERIOD}/between {START DATE OF REFERENCE PERIOD} and {END DATE OF REFERENCE PERIOD}}.

Do you have any records you can use to help answer this next set of questions?

HAS RECORD KEEPING MATERIALS 1 CA25

FOR AT LEAST 1 PERSON

DOES NOT HAVE ANY RECORDS 2 Skip to step 3

WILL NOT USE RECORDS 3 Skip to step 3

CA25. Thanks for keeping these records. Let’s start by reviewing what records you have.

Starting with any record you’d like, please tell me who the record is for, and the type of record you’re looking at, such as a calendar, the MEPS Record Keeper, a provider or insurance statement, patient portal information, payment records, prescription records such as medicine bottles, or something else.

CONTINUE 1

CA30_01. {Do/Does} {you/{PERSON}} have a calendar with health entries?

YES, HAS CALENDAR WITH HEALTH CARE 1

ENTRIES FOR {PERSON}

NO, DOES NOT HAVE CALENDAR WITH HEALTH 2

CARE ENTRIES FOR {PERSON}

(Continue with CA30_02 to CA30_08.)

CAXX. Do any of these records cover health care events that happened since {DATE OF LAST MONTHLY CHECK-IN}, which is the last time you completed a monthly check-in?

YES 1

NO, DOES NOT HAVE ANY RECORDS FOR EVENTS 2 Skip to step 3

SINCE LAST MONTHLY CHECK-IN

(Continue with the rest of the CA section.)

Step 2: Event Roster (EV) Section – Entering New Events with Records

EV10. {INTERVIEWER: SELECT CORRECT PERSON FOR THIS EVENT.}

{{Next I’ll ask for some basic information about each of these health care visits since {DATE OF LAST MONTHLY CHECK-IN} where you have a record.}

Let’s {start/continue} with this {next} record. Please tell me who {(else)} this record is for.}

{FIRST NAME [MIDDLE NAME] LAST NAME 1 1

{FIRST NAME [MIDDLE NAME] LAST NAME 2 2

…

{FIRST NAME [MIDDLE NAME] LAST NAME 5 5

EV20. {Looking at show card EV-1{A/B}, at what type of place did {you/{PERSON}} receive the care?/

Looking at show card EV-1{A/B}, tell me if {you/{PERSON}} received the care at {a hospital/a hospital emergency room/home/a residential or long term care facility} or at some other type of place listed on the card?}

HOSPITAL INPATIENT STAY (HS) 1

HOSPITAL EMERGENCY ROOM (ER) 2

…

TELEHEALTH (TH) 10

(The rest of the EV section follows the standard flow for EE, EV, and PV.)

Step 3: Event Roster (EV) Section – Reviewing Monthly Check-in Entries

EVXX. Next, let’s focus on the health care events {you/{REFERENCE PERSON}/{your/{REFERENCE PERSON}’s} household} entered in the monthly check-in{s}.

{If you have any records for the health care events entered in the monthly check-in{s}, you will find it helpful to refer to them when answering the next set of questions.}

Let’s start with the {NUMBER OF EVENTS FOR PERSON 1} health care event{s} entered for {PERSON 1}.

{Now let’s review the {NUMBER OF EVENTS FOR PERSON N} health care event{s} entered for {PERSON N}.}

CONTINUE 1

EV20_REV. {I’m going to first ask a few more questions about/Now, let’s focus on} {your/{PERSON}’s} visit to {PROVIDER IN MONTHLY CHECK-IN} on {EVENT DATE IN MONTHLY CHECK-IN}.

PROBE AS NEEDED: The monthly check-in, shows that {you/{REFERENCE PERSON}} received care from {PROVIDER IN MONTHLY CHECK-IN} on {EVENT DATE IN MONTHLY CHECK-IN} for {REASON IN MONTHLY CHECK-IN}.

CONTINUE 1

EV20. {Looking at show card EV-1{A/B}, at what type of place did {you/{PERSON}} receive the care?/

Looking at show card EV-1{A/B}, tell me if {you/{PERSON}} received the care at {a hospital/a hospital emergency room/home/a residential or long term care facility} or at some other type of place listed on the card?}

HOSPITAL INPATIENT STAY (HS) 1

HOSPITAL EMERGENCY ROOM (ER) 2

…

TELEHEALTH (TH) 10

(The rest of the EV section follows the standard flow for EE, EV, and PV. Repeat the loop for each person and each event entered in the monthly check-ins, starting with EV20_REV.)

Step 4: Provider Probes (PP) – Family Subunit

PP_NEW. The next set of questions {help make sure we haven’t missed any additional health care for any of the/ ask about health care received by the} people living here.

The next set of questions {help make sure we haven’t missed any additional health care for {any of the people living here/you}/{ask about health care received by {the people living here}/{you}. {Earlier you mentioned that {DISPLAY NAME 1} {DISPLAY NAME 2} {DISPLAY NAME 3} {and DISPLAY NAME N} had some health care visits that we haven’t yet talked about. I can collect that information during these next series of questions}

{As I ask the questions, please look at the corresponding show cards and think about {any additional} health care {you/each person} received in person or in real-time telehealth interactions by phone or video. / As I ask the questions, please look at the corresponding show cards. For now, I’d like you to think about {yourself/you/{REFERENCE PERSON}} {and {your/his/her} {spouse/partner}}/ {and {your/his/her} children} when answering. We’ll cover the other household members next. }

Looking at card PP-X, {since {START DATE}/between {START DATE} and {END DATE}}, {have/has} {DISPLAY FAMILY SUBUNIT NAMES} received any type of care in a hospital, emergency room, hospital outpatient department, doctor’s or specialist’s office, health clinic, urgent care center, or any other type of medical office{, other than what we already talked about}?

YES 1

NO 2

REFUSED RF

DON’T KNOW DK

SHOW CARD TEXT:

PP #	Original	New
1	-Admitted to the hospital for one or more nights	Received care in places such as… -Hospital
2	-Any type of care received in a hospital emergency room	-Emergency room
3	Same-day care received at a hospital outpatient department such as... -Surgery Centers -Cancer Treatment Centers -Physical Therapy and Rehabilitation Centers -Cardiology Centers -Obesity Treatment Centers -Radiology and Imaging Centers	-Hospital outpatient department such as surgery centers, cancer treatment centers, physical therapy and rehabilitation centers, or any other same-day outpatient department
4	Primary care doctor such as... -General Practitioner -Internist -Pediatrician -Family Medicine Provider -Medical Doctor	-Doctor’s or specialist’s office such as care from a doctor, nurse, physician’s assistant or other health care professional at a primary care provider, internist, pediatrician, cardiologist, dermatologist, allergist, or any other type of medical provider’s or specialist’s office
9	Such as... -Walk-in Urgent Care -Retail Clinic – in a pharmacy -Retail Clinic – in a grocery store -Family Planning Center -College or University Clinic -Employer Clinic -Free Clinic -Infirmary -Other type of Health Clinic	-Health clinic or urgent care center such as walk-in urgent care, a retail clinic in a pharmacy or grocery store, a clinic on a campus or at an employer, or any other type of health clinic
5	Such as... -Orthopedist -Cardiologist -Dermatologist -Oncologist -Neurologist -Gynecologist -Allergist -Gastroenterologist -Surgeon -Kidney specialist (Nephrologist) -Radiologist -Ear, nose and throat specialist (Otorhinolaryngologist) -Urologist -Podiatrist -Audiologist -Any other type of medical specialist	(SEE ABOVE)
8	Such as... -Nurse (RN, LPN, PHN, BSN) -Nurse practitioner -Nurse’s aide -Physician’s assistant (PA) -Midwife -Health aide	(SEE ABOVE)

PP_NEW. Looking at card PP-X, {since {START DATE}/between {START DATE} and {END DATE}}, {have/has} {DISPLAY FAMILY SUBUNIT NAMES} seen any type of dental care provider, or any type of vision or eye care provider{, other than what we already talked about}?

YES 1

NO 2

REFUSED RF

DON’T KNOW DK

SHOW CARD TEXT:

PP #	Original	New
6	Such as... -Dentists -Oral Surgeons -Orthodontists -Dental Assistants -Dental Hygienists -Pediatric Dentists -Endodontists -Periodontists -Dental Technicians -Other Type of Dental Care Providers	Dental care provider such as… -Dentist -Oral Surgeon -Orthodontist -Dental Hygienist -Other Type of Dental Care Provider
12	Such as... -Optometrist -Ophthalmologist -Vision Technician -Optician -Orthoptist -Other Eye Care Professional	Vision or eye care provider such as… -Optometrist -Ophthalmologist -Vision Technician -Optician -Other Eye Care Professional

PP_NEW. Looking at card PP-X, {since {START DATE}/between {START DATE} and {END DATE}}, {have/has} {DISPLAY FAMILY SUBUNIT NAMES} seen any type of mental health professional or any other type of therapist such as a physical therapist, occupational therapist, speech therapist or chiropractor{, other than what we already talked about}?

YES 1

NO 2

REFUSED RF

DON’T KNOW DK

SHOW CARD TEXT:

PP #	Original	New
6	Such as... -Psychiatrist -Psychologist -Licensed Clinical Social Worker -Mental Health Therapist -Counselor -Psychiatric Social Worker -Other Mental Health Professional	Mental health professional or any other type of therapist such as… -Psychiatrist -Psychologist -Counselor -Licensed Clinical or Psychiatric Social Worker
11	Such as... -Physical Therapist -Occupational Therapist -Speech Therapist -Chiropractor -Physiatrist -Behavioral Therapist -Other type of Therapist	-Physical Therapist -Occupational Therapist -Chiropractor

PP_10. Looking at card PP-10, [{since {START DATE}/between {START DATE} and {END DATE}}], {have/has} {DISPLAY FAMILY SUBUNIT NAME} been to any medical lab or testing facility for bloodwork, x-rays or other tests{, other than what we already talked about}?

YES 1

NO 2

REFUSED RF

DON’T KNOW DK

SHOW CARD TEXT:

PP #	Original	New
10	Such as... -Independent Medical Lab -Testing Facility Lab	(No changes)

PP_13. Looking at card PP-13, [{since {START DATE}/between {START DATE} and {END DATE}}], {have/has} {DISPLAY FAMILY SUBUNIT NAMES} received any care from someone who practices alternative care such as acupuncture, homeopathic care, massage therapy, hypnosis, or other treatments{, other than what we already talked about}?

YES 1

NO 2

REFUSED RF

DON’T KNOW DK

SHOW CARD TEXT:

PP #	Original	New
13	Such as... -Acupuncture -Homeopathic care -Massage therapy -Hypnosis -Naturopathic care -Herbalist -Other alternative care professional	(No changes)

PP_14. Now I would like you to think about care {DISPLAY FAMILY SUBUNIT NAMES} may have received at home. Please look at card PP-14. Because of a health problem, {since {START DATE}/between{START DATE} and {END DATE}}, {have/has} {DISPLAY FAMILY SUBUNIT NAMES} received any type of care at home, such as

… care from a home care nurse or any type of therapist or social worker?

… care from someone who helps with bathing, dressing, or taking medication?

… help with cooking or cleaning ?

… or companionship services?

YES 1

NO 2

REFUSED RF

DON’T KNOW DK

SHOW CARD TEXT:

PP #	Original	New
14	Care received from someone who visited your home, such as... Skilled Medical Care from - -a home care nurse, -any type of therapist, -a social worker, -anyone else providing nursing or medical care Personal Care Services such as help with - -bathing, -dressing, -taking medication Household Chore Services -help with cooking -help with cleaning Companionship Services such as - -reading, -talking, -going for a walk or drive Any Other Type of Home Care	(No changes)

PP_15. Now let’s talk about health care provided in a residential setting. {Earlier we discussed that {DISPLAY NAMES FROM RE350 WITH VISIT OF LESS THAN 100 DAYS}{was/were} institutionalized in a facility for less than 100 days. If {he/she/they} received care in a residential health care facility, I can record that care now.} Looking at card PP-15, {since {START DATE}/between {START DATE} and {END DATE}}, {have/has} {DISPLAY FAMILY SUBUNIT NAMES} received any type of care in a residential rehabilitation or treatment facility, such as for rehab after surgery, hospice or respite care, mental health treatment, or treatment for drug, alcohol or other addiction?

YES 1

NO 2

REFUSED RF

DON’T KNOW DK

SHOW CARD TEXT:

PP #	Original	New
15	Residential or long-term care received at places such as... -Nursing Home for Rehabilitation Services -Inpatient Rehabilitation Facility or Convalescent home -Hospice Care -Respite Care -Mental Health Treatment Center -Drug and Alcohol Treatment Center -Addiction Treatment Center -Eating Disorder Treatment Center -Other Treatment Center	(No changes)

Step 5: Provider Probes (PP) – Non-Family Subunit

(Same language as Step 4 except with non-family subunit members.)

Attachment 1I: Study 1 R2 Instrument 1I-10