HEALTH CARE EXCEL

Medicare Quality Improvement Organization

PARTICIPANT EDUCATION EVALUATION

Medicare Outpatient Observation or Inpatient Admission? That is The Question! Internet Self Study

July 30, 2007 - June 30, 2008

Please rate the following statements according to the rating scale listed below. If the statement is not applicable, leave the response blank.

Evaluations and verification forms must be submitted by July 15, 2008 to receive CMEs, CNEs, or a certificate of participation.

Strongly Agree

Agree

Disagree

Strongly Disagree

1. The education provided clarification and guidance on key issues related to the determination of placement status, differentiating Medicare outpatient observation and inpatient guidelines.

4

3

2

1

2. I can describe key issues related to the determination of placement status.

4

3

2

1

3. I can compare the appropriateness of Medicare outpatient observation placement to inpatient admission.

4

3

2

1

4. The education was well organized.

4

3

2

1

5. The teaching methodologies met the need for the education.

4

3

2

1

6. The continuing education hours are applicable to my professional requirements. (If CE hours are not required, please leave blank.)

4

3

2

1

7. I can apply the content to my professional and/or clinical practice.

4

3

2

1

8. Overall, I am satisfied with the education.

4

3

2

1

Please rate the following items for Roland Grieb, MD, MHSA using the rating scale below.

Above Average

Average

Below Average

1. Subject Knowledge

3

2

1

2. Communication of Ideas and Concepts

3

2

1

3. Understanding of Audience Needs and Knowledge Base

3

2

1

4. Presentation Pace

3

2

1

5. Answered Questions

3

2

1

6. Objectivity (Did not promote product or service.)

3

2

1

Please explain Disagree, Strongly Disagree, or Below Average responses.

What was the most beneficial information?

Please list recommendations to improve this activity.

Do you have any recommendations for future education or speakers related to the Centers for Medicare & Medicaid Services HPMP special study? Please explain.

List one opportunity for improvement that you will implement in your practice or organization as a result of this education.

The password to open the verification form is 'observation.'

Thank you for completing the education. After submitting the evaluation, you will be directed to a verification form.

You must enter the educational password and return the completed verification form by fax to 812-232-6167, or by mail to HCE, P.O. Box 3713, Terre Haute, IN 47803-0713.

Or, you may return the electronic document to inhpmp@hce.org. A certificate of completion will be forwarded to you within 45 days of receipt of your documentation.

Questions may be directed to the Medicare QIO Provider Help Desk at 1-800-300-8190 or e-mail to inhpmp@hce.org.