| Hospice of New York Family Questionnaire |
| Questions marked by * are required. |
| 1. |
1. A clear explanation of what Services were available through hospice and how to access them was provided.
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| 2. |
2. The Hospice team was Available when needed.
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| 3. |
3. The Hospice team treated the patient and family with Care, Compassion, and Respect.
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| 4. |
4. The Hospice team was Skilled and Professional in meeting our needs.
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| 5. |
5. I was pleased with the Supplies and Durable Medical Equipment provided.
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| 6. |
6. I was pleased with the Home Health Aide services provided.
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| 7. |
7. The Hospice team responded to our needs in the Evening and on Weekends.
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| 8. |
8. I was pleased with the Pharmacy services.
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| 9. |
9. The patient’s pain was at a comfortable level within 48 hours after admission to hospice.
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| 10. |
10. I was pleased with how the patient’s other symptoms were managed. (I.e. nausea, vomiting, anxiety, etc.)
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| 11. |
11. The Hospice team involved the family/friends in the patient’s care.
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| 12. |
12. The Hospice team provided the education and training needed to assist the family in caring for the patient.
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| 13. |
13. I was pleased with the way Hospice listened to and answered our questions.
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| 14. |
14. I was pleased with the way Hospice honored and supported the personal wishes, spiritual beliefs and valued traditions of the patient and family.
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| 15. |
15. Hospice provided the emotional support needed to help me and my family prepare for the death of our loved one.
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| 16. |
16. Hospice staff provided emotional support to help me and my family cope at the time of the death of our loved one.
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| 17. |
17. I was provided information regarding continued bereavement contact and services following the death of our loved one.
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| 18. |
18. Hospice improved the patient’s Quality of Life.
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| 19. |
19. Overall, I am satisfied with the services provided by Hospice of New York.
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| 20. |
20. In your opinion, was the patient referred to hospice too early, at the right time, or too late during the course of his/her final illness?
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| 21. |
21. Did hospice provide you with adequate information about Advance Directives like a Health Care Proxy or Living Will?
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| 22. |
22. Where was the hospice care provided?
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| 23. |
23. Name of Facility? (Cont. from Question 22)
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| 24. |
24. Based on the care your family received, would you recommend Hospice services to others?
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| 25. |
Additional Comments(Please feel free to comment on any specific Hospice Team Member who significantly impacted your Hospice experience):
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| 26. |
Relationship to Patient:
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| 27. |
Date:
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| 28. |
Full Name (Optional):
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| 29. |
Email Address (Optional):
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