VetExperOffice_Telehealth Services Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)

Telehealth_Survey Copy Deck_052118_V2

VetExperOffice_Telehealth Services Survey

OMB: 2900-0770

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6. Telehealth Services Email & Survey

Summary 2

Target Audiences 2

Experience Drivers 2

Notes 3

Telehealth Services Surveys 3

Telehealth Services Surveys Email Copy 3

Telehealth Services Surveys Pre-Header 4

Telehealth Services Surveys Reminder Email Copy 6

Telehealth Surveys Reminder Pre-Header 6

Telehealth Services Survey Rating Scale Questions 9

6.1 CVT Appointment Scheduling Survey 9

6.2 CVT VAMC or CBOC Appointment Survey 9

6.3 CVT Home or Mobile Appointment Survey 10

6.4 S&F VAMC or CBOC Appointment Survey 10

6.5 S&F Home or Mobile Appointment Survey 11

6.6 S&F Result Feedback Survey 11

6.7 Home Telehealth New Patient Care Survey 11

6.8 Home Telehealth Continuing Patient Survey 12

6.9 Home Telehealth Patient Graduation Survey 12

Telehealth Services Surveys – Open Text Question 13


Summary

This copy document provides email and survey copy for 9 distinct surveys measuring customer experience at key stages when using Telehealth services. These surveys are triggered within 3-4 days after the completion of the following events:


[6.1] CVT Appointment Scheduling Survey: Email survey sent after appointment has been scheduled.

[6.2] CVT VAMC or CBOC Appointment Survey: Email survey sent after appointment occurs.

[6.3] CVT Home or Mobile Appointment Survey: Email survey sent after appointment occurs.


[6.4] S&F VAMC or CBOC Appointment Survey: Email survey sent after appointment occurs.

[6.5] S&F Home or Mobile Appointment Survey: Email survey sent data has been submitted.

[6.6] S&F Result Feedback Survey: Email survey sent after results have been communicated.


[6.7] Home Telehealth New Patient Care Survey: Email survey sent after enrollment.

[6.8] Home Telehealth Continuing Patient Survey: Email survey sent after actively using the program.

[6.9] Home Telehealth Patient Graduation Survey: Email survey sent after disenrollment.




Target Audiences

To be included in the survey sample, respondents must be:

  1. Veterans who are enrolled in Telehealth outpatient services administered by the Veteran Health Administration (VHA).


Experience Drivers

The following annotations represent VE experience drivers and are mapped to each question. They are for reference ONLY. Do not place in Veteran view.

  1. EASE

  2. EFFECTIVENESS

  3. EMOTION

  4. TRUST


Notes

  1. Text with <carets> in the copy indicates a string from a database.

  2. Text with [brackets] indicates notes, comments, options, dummy text or annotates browser behaviors. [or] separates conditionals when there are choices. <NULL> indicates data does not exist.

  3. Margin comments call out details or issues that may require follow up or a discussion with a designer, developer, or writer.

  4. Headings label and demarcate sections of the experiences and separate surveys.

  5. All rating scale questions are 5-point RADIO buttons and permit only one response per question and are labeled as follows:



Telehealth Services Surveys

Telehealth Services Surveys Email Copy

[From:] Veterans Experience Office

[Subject 6.1] Telehealth Appointment Scheduling Survey – 2 minutes

[Subject 6.2] Telehealth at the Clinic Appointment Survey – 2 minutes

[Subject 6.3] Telehealth at Home or Mobile Appointment Survey – 2 minutes

[Subject 6.4] Telehealth Store & Forward at the Clinic Appointment Survey – 2 minutes

[Subject 6.5] Telehealth Store & Forward at Home or Mobile Appointment Survey – 2 minutes

[Subject 6.6] Telehealth Store & Forward Result Survey – 2 minutes

[Subject 6.7] Home Telehealth New Patient Care Survey – 2 minutes

[Subject 6.8] Home Telehealth Continuing Patient Survey – 2 minutes

[Subject 6.9] Home Telehealth Patient Graduation Survey – 2 minutes

Telehealth Services Surveys Pre-Header

[6.1] Tell us about your experience scheduling a telehealth appointment.

[6.2] Tell us about your recent telehealth appointment at <VAMC or CBOC Location>.

[6.3] Tell us about your recent telehealth appointment using your mobile phone, tablet or computer.

[6.4] Tell us about your experience during your recent Telehealth appointment capturing images or information about your health at < VAMC or CBOC Location >.

[6.5] Tell us about your recent Telehealth experience submitting photos or information on your mobile device.

[6.6] Tell us about the recent experience you had receiving the results of health information or images using Store and Forward Telehealth services.

[6.7] Tell us about your experience enrolling and getting prepared to start the Home Telehealth program.

[6.8] Tell us about your current experience as someone who engages in daily Home Telehealth monitoring services.

[6.9] Tell us about the experience you had completing the daily Home Telehealth monitoring services and graduating from the program.


[Header]

[Heading]

OMB Number: 2900-0770

Expiration: MM/DD/YYYY

Estimated Burden: 2 minutes


Your feedback is important to us. Please take two minutes to let us know how we are doing by answering this short survey about

[6.1] <your experience scheduling a VA telehealth appointment>.
[6.2] <your experience with your telehealth appointment at <VAMC or CBOC location>.

[6.3] <your experience with your telehealth appointment using mobile technology>.


[6.4] <your experience with your telehealth appointment capturing images or information about your health at <VAMC or CBOC location>.

[6.5] <your experience submitting images or information about your health on your mobile device>.

[6.6] <your experience receiving the results of health information or images using Store and Forward Telehealth services.>.

[6.7] <your experience enrolling and getting prepared to start the Home Telehealth program.>.

[6.8] <your experience engaging in daily Home Telehealth monitoring services.>.

[6.9] <your experience completing the daily Home Telehealth monitoring services and graduating from the program.>.


If you provide feedback, you may be contacted by VA. Serving you is our top priority.


[Take Survey]


Thank you,

Veterans Experience Office

Department of Veterans Affairs


[Footer]

If you wish to share your feedback, please do so by <date>.


The Veterans Crisis Line provides free, confidential support for Veterans in crisis and their families and friends. Dial 1 (800) 273-8255 (Press 1), or text 838255 to receive confidential support 24/7, (System of Records Notice VA158VA10NC5) Visit https://www.veteranscrisisline.net/ for more information. The National Call Center for Homeless Veterans (NCCHV) provides free, confidential support for Veterans who are homeless or at risk of homelessness—and their family members, friends and supporters. Veterans can make the call to or chat online with the National Call Center for Homeless Veterans, where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week. Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support. If you would like to opt out from receiving future surveys, please click here.

Unsubscribe from this VA Survey | VA Privacy Policy


Department of Veterans Affairs

Veterans Experience Office (30)

810 Vermont Avenue NW

Washington, DC 20420

Telehealth Services Surveys Reminder Email Copy

[Sent 1 week after initial email if there is no response]

[From:] Veterans Experience Office

[Subject 6.1] Telehealth Appointment Scheduling Survey Reminder – 2 minutes

[Subject 6.2] Telehealth at the Clinic Appointment Survey Reminder – 2 minutes

[Subject 6.3] Telehealth at Home or Mobile Appointment Survey Reminder – 2 minutes

[Subject 6.4] Telehealth Store & Forward at the Clinic Appointment Survey Reminder – 2 minutes

[Subject 6.5] Telehealth Store & Forward at Home or Mobile Appointment Survey Reminder – 2 minutes

[Subject 6.6] Telehealth Store & Forward Result Survey Reminder – 2 minutes

[Subject 6.7] Home Telehealth New Patient Care Survey Reminder – 2 minutes

[Subject 6.8] Home Telehealth Continuing Patient Survey Reminder – 2 minutes

[Subject 6.9] Home Telehealth Patient Graduation Survey Reminder – 2 minutes

Telehealth Surveys Reminder Pre-Header

[6.1] Tell us about your experience scheduling a telehealth appointment.

[6.2] Tell us about your recent telehealth appointment at <VAMC or CBOC Location>.

[6.3] Tell us about your recent telehealth appointment using your mobile phone, tablet or computer.

[6.4] Tell us about your experience during your recent Telehealth appointment capturing images or information about your health at < VAMC or CBOC Location >.

[6.5] Tell us about your recent Telehealth experience submitting photos or information on your mobile device.

[6.6] Tell us about the recent experience you had receiving the results of health information or images using Store and Froward Telehealth services.

[6.7] Tell us about your experience enrolling and getting prepared to start the Home Telehealth program.

[6.8] Tell us about your current experience as someone who engages in daily Home Telehealth monitoring services.

[6.9] Tell us about the experience you had completing the daily Home Telehealth monitoring services and graduating from the program.


[Header]

[Heading]

OMB Number: 2900-0770

Expiration: MM/DD/YYYY

Estimated Burden: 2 minutes


Your feedback is important to us. Please take two minutes to let us know how we are doing by answering this short survey about

[6.1] <your experience scheduling a VA telehealth appointment>.
[6.2] <your experience with your telehealth appointment at <VAMC or CBOC location>.
[6.3] <your experience with your telehealth appointment using mobile technology>.

[6.4] <your experience with your telehealth appointment capturing images or information about your health at <VAMC or CBOC location>.

[6.5] <your experience submitting images or information about your health on your mobile device>.

[6.6] <your experience the results of health information or images using Store and Forward Telehealth services.>.

[6.7] <your experience enrolling and getting prepared to start the Home Telehealth program.>.

[6.8] <your experience engaging in daily Home Telehealth monitoring services.>.

[6.9] <your experience completing the daily Home Telehealth monitoring services and graduating from the program.>.



If you provide feedback, you may be contacted by VA. Serving you is our top priority.


[Take Survey]


Thank you,

Veterans Experience Office

Department of Veterans Affairs


[Footer]

If you wish to share your feedback, please do so by <date>.


The Veterans Crisis Line provides free, confidential support for Veterans in crisis and their families and friends. Dial 1 (800) 273-8255 (Press 1), or text 838255 to receive confidential support 24/7, (System of Records Notice VA158VA10NC5) Visit https://www.veteranscrisisline.net/ for more information. The National Call Center for Homeless Veterans (NCCHV) provides free, confidential support for Veterans who are homeless or at risk of homelessness—and their family members, friends and supporters. Veterans can make the call to or chat online with the National Call Center for Homeless Veterans, where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week. Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support. If you would like to opt out from receiving future surveys, please click here.

Unsubscribe from this VA Survey | VA Privacy Policy


Department of Veterans Affairs

Veterans Experience Office (30)

810 Vermont Avenue NW

Washington, DC 20420


Telehealth Services Survey Rating Scale Questions



6.1 CVT Appointment Scheduling Survey

<h1> Tell us about your experience scheduling a telehealth appointment.</h1>


Please respond to the following statements on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree).

  1. I was given a choice between having my appointment in-person at a VA facility or through telehealth. (*Required) EFFECTIVENESS

  2. I got my appointment on a date and time that worked for me. (*Required) EASE

  3. When scheduling my appointment, I was treated with respect. (*Required) EMOTION

  4. It was clear before my appointment what to expect. (*Required) EFFECTIVENESS

  5. I trust telehealth as part of my overall VA healthcare. (*Required) TRUST



6.2 CVT VAMC or CBOC Appointment Survey

<h1> Tell us about your recent telehealth appointment at <VAMC or CBOC Location>. </h1>


Please respond to the following statements on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree).

  1. After I checked in for my appointment, the clinic staff explained how the video telehealth technology would work in a way that was easy to understand. (*Required) EFFECTIVENESS

  2. My provider explained things to me in a way that was easy to understand. (*Required) EASE

  3. My provider listened to me during the appointment in a caring manner. (*Required) EMOTION

  4. I was able to see the provider clearly by video. (*Required) EASE

  5. I was able to hear the provider clearly by video. (*Required) EASE

  6. The provider made me feel at ease by explaining every step they took during my appointment. (*Required) EMOTION

  7. Overall, I am satisfied with the video telehealth visit. (*Required) EASE

  8. After my appointment, I was clear on what my next steps were. (*Required) EFFECTIVENESS

  9. Telehealth reduces the need to travel long distances in order meet with my provider. (*Required) EFFECTIVENESS

  10. I trust telehealth as part of my overall VA healthcare. (*Required) TRUST



6.3 CVT Home or Mobile Appointment Survey

<h1> Tell us about your recent telehealth appointment using your mobile phone, tablet or computer.</h1>


Please respond to the following statements on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree).

  1. Connecting to my VA Video Connect appointment was easy. (*Required) EASE

  2. The VA staff gave me information about connecting to my video telehealth appointment. EFFECTIVENESS

  3. My provider listened to me during the appointment in a caring manner. (*Required) EMOTION

  4. My provider explained things to me in a way that was easy to understand. (*Required) EASE

  5. After my appointment, I was clear about my next steps of care. (*Required) EFFECTIVENESS

  6. The provider made me feel at ease by explaining every step they took during my appointment. (*Required) EMOTION

  7. Telehealth reduces the need to travel long distances in order meet with my provider. (*Required) EFFECTIVENESS

  8. I was able to see the provider clearly by video. (*Required) EASE

  9. I was able to hear the provider clearly by video. (*Required) EASE

  10. Overall, I am satisfied with the video telehealth visit. (*Required) EASE

  11. I trust telehealth as part of my overall VA healthcare. (*Required) TRUST



6.4 S&F VAMC or CBOC Appointment Survey

<h1> Tell us about your experience during your recent Telehealth appointment capturing images or information about your health at < VAMC or CBOC Location >.</h1>


Please respond to the following statements on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree).

  1. I found the exam process to be an easy experience. (*Required) EASE

  2. I felt comfortable during my exam appointment. (*Required) EMOTION

  3. The Telehealth staff explained what would happen to me during the exam in terms I could understand. (*Required) EFFECTIVENESS

  4. At the end of my exam appointment, I was told when I could expect my results. (*Required) EFFECTIVENESS

  5. I trust telehealth as part of my overall VA healthcare. (*Required) TRUST



6.5 S&F Home or Mobile Appointment Survey

<h1> Tell us about your recent Telehealth experience submitting photos or information on your mobile device.</h1>


Please respond to the following statements on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree).

  1. I found using my mobile device to capture my image or information to be an easy experience. (*Required) EASE

  2. I felt comfortable with using my mobile device to capture my image or information. (*Required) EMOTION

  3. The VA staff was helpful when showing me how to set up the tablet or app on my mobile device. EFFECTIVENESS

  4. After submitting my image or information, it was clear to me when I would expect my results. (*Required) EFFECTIVENESS

  5. I trust telehealth as part of my overall VA healthcare. (*Required) TRUST


6.6 S&F Result Feedback Survey

<h1> Tell us about the recent experience you had receiving the results of health information or images using Store and Froward Telehealth services.</h1>


Please respond to the following statements on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree).

  1. I received my exam results in a timely manner. (*Required) EASE

  2. The VA provider told me my exam results in a caring manner. (*Required) EMOTION

  3. The exam results were explained to me in terms I could understand. (*Required) EFFECTIVENESS

  4. When I needed a follow-up appointment, it was scheduled for me in a timely manner. (*Required) EASE

  5. I felt clear on my next steps after seeing my exam results. (*Required) EMOTION

  1. I trust telehealth as part of my overall VA healthcare. (*Required) TRUST


6.7 Home Telehealth New Patient Care Survey

<h1> Tell us about your experience enrolling and getting prepared to start the Home Telehealth program.</h1>



Please respond to the following statements on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree).

  1. My Care Coordinator clearly explained the home telehealth enrollment process to me. (*Required) EFFECTIVENESS

  2. My Care Coordinator listened to me in order to understand my unique healthcare needs. (*Required) EMOTION

  3. My Care Coordinator worked with me to address any questions or concerns I had before I started the home telehealth program. (*Required) EMOTION

  4. I understand how to take scheduled vitals (i.e. blood sugar, blood pressure, weight, etc.). (*Required) EFFECTIVENESS

  5. I find it easy to submit my vitals and answer the questions on my home monitor technology. (*Required) EASE

  1. I trust Home Telehealth program as part of my overall VA healthcare. (*Required) TRUST



6.8 Home Telehealth Continuing Patient Survey

<h1> Tell us about your current experience as someone who engages in daily Home Telehealth monitoring services.</h1>


Please respond to the following statements on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree).


  1. Submitting my vitals each day (i.e. blood sugar, blood pressure, weight, etc.) is a simple process. (*Required) EASE

  2. I know that when I submit my responses to questions and vitals, my Care Coordinator will review them. (*Required) EFFECTIVENESS

  3. I feel safe knowing that my Care Coordinator is monitoring my health. (*Required) EMOTION

  4. During phone calls, the care given by my Care Coordinator put me at ease.  EMOTION

  5. I trust Home Telehealth program as part of my overall VA healthcare. (*Required) TRUST


6.9 Home Telehealth Patient Graduation Survey

<h1> Tell us about the experience you had completing the daily Home Telehealth monitoring services and graduating from the program.</h1>


Please respond to the following statements on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree).

  1. I knew when I would complete my home telehealth program. (*Required) EFFECTIVENESS

  2. I understood the next steps to achieve my healthcare goals. (*Required) EFFECTIVENESS

  3. I felt supported throughout my home telehealth experience. (*Required) EMOTION

  4. I was able to accomplish my healthcare goals in a way that fit my lifestyle. (*Required) EASE

  5. I'm confident in being able to maintain my health post program. (*Required) EMOTION

  6. I trust Home Telehealth program as part of my overall VA healthcare. (*Required) TRUST

Telehealth Services Surveys – Open Text Question

Would you like to provide additional feedback with a concern, compliment, or recommendation about the experience of resolving your case? Please select from one of the following options. (*Required)


Use the text box below to enter details of the additional feedback (optional). Please do not include any personally identifiable information, Social Security Number, Veteran ID, or medical information, but do provide details about your experience.


[Drop down of feedback types] 

  1. Compliment 

  2. Concern 

  3. Recommendation 

  4. Will not provide feedback 

<Multi-line text box is optional>


❐ Please check this box if you would like to volunteer your demographic information to help VA better serve you, otherwise just click “Next” to submit your survey.


[Next]


The Veterans Crisis Line provides free, confidential support for Veterans in crisis and their families and friends. Dial 1 (800) 273-8255 (Press 1), or text 838255 to receive confidential support 24/7. Visit veteranscrisisline.net for more information.


[OMB Burden Response Copy]

We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of two minutes to review the instructions and complete this survey. The results of this survey will be used to inform opportunities for program improvement in the quality of VA services. Participation in this survey is voluntary and your decision not to respond will have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are authorizing VA database access to retrieve veteran contact information, to follow up with you accordingly for purposes of service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.


[Anonymity Disclaimer]

If you provide feedback, you may be contacted by VA. Serving you is our top priority.

[Footer]

Survey Support | Privacy Policy


Race, Ethnicity, and Gender Questions

<h1> Help VA Improve its Services</h1>


We are working to better understand our customers. The following questions are <bold>voluntary. By providing your data, your responses can help us improve VA care and services. Thank you for your participation.


  1. Are you Hispanic or Latino?

    1. Yes [go to Q #3]

    2. No [go to Q #2]

  2. What is your race? Select one or more.

    1. American Indian or Alaska Native

    2. Asian

    3. Black or African American 

    4. Native Hawaiian or Other Pacific Islander

    5. White

  3. How do you describe your gender?

    1. Male

    2. Female

    3. Non-Binary / Third Gender

    4. Prefer not to say

[Submit]

18

Last updated 5/14/18

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