HEDIS Supplement questions PHW Trainnig 06.22.2021 - Copy.docx

LTSS HEDIS Supplement Assessment Date:
Self-Efficacy 6 Item Scale:
Assessment of the member's self-reported activation or self-efficacy using a standardized tool.
Documentation that the member is too cognitively impaired to provide self-report meets the element.
Is member too cognitively impaired to provide self-report on a standardized tool? (YES or NO)
If no, we would like to know how confident you are in doing certain activities. For each of the following
questions, please choose the number that corresponds to your confidence that you can do the tasks
regularly at the present time.
1 represents "not at all confident" and 10 represents "totally confident".
How confident do you feel that you can keep the fatigue caused by your disease from interfering with
the things you want to do?
How confident do you feel that you can keep the physical discomfort or pain of your disease from
interfering with the things you want to do?