ADSC Questions

Attachment B-1

National Study of Long-Term Care Providers----2014 Adult Day Services Center Questions

OMB No. 0920-0943

Exp. Date 07/31/2015

NOTICE – Public reporting burden of this collection of information is estimated to average 30 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0943).

Assurance of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Background Information

1. Is this adult day services center …

a. Licensed or certified by the State specifically to provide adult day services Yes No

b. Authorized or otherwise set up to participate in Medicaid Yes No

If you answered “No” to both 1a and 1b, skip to Question 27.

2. Based on a typical week, what is the approximate average daily attendance at this adult day services center at this location? If none, enter “0.”

Average daily attendance of participants If you answered “0,” skip to Question 27.

3. What is the total number of participants currently enrolled at this adult day services center at this location? If none, enter “0.”

Number of participants If you answered “0,” skip to Question 27.

4. What is the maximum number of participants allowed at this adult day services center at this location? This may be called the allowable daily capacity and is usually determined by law or by fire code, but may also be a program decision. If none, enter “0.”

Maximum number of participants allowed

5. What is the type of ownership of this adult day services center?

Private, nonprofit; Private, for profit; Publicly traded company or limited liability company (LLC); or Government—federal, state, county, or local

6. Is this center owned by a person, group, or organization that owns or manages two or more adult day services centers? This may include a corporate chain.

Yes No

7. During the last 30 days, for how many of this adult day services center’s participants did Medicaid pay for some or all of their services at this center? If none, enter “0.”

Number of participants

8. What is the total number of years this center has been operating as an adult day services center at this location? MARK ONLY ONE ANSWER

Less than 1 year; 1 to 4 years; 5 to 9 years; 10 to 19 years; or 20 or more years

9. Of this center’s revenue from paid participant fees, about what percentage comes from each of the following sources? Your entries should add up to 100%.

a. Medicaid (including Medicaid managed care programs) %

b. Medicare %

c. Other government %

d. Out-of-pocket payment by the participant or family %

e. Private insurance %

f. Other source %

10. As a part of the admission process, does this adult day services center . . .

a. screen participants for depression with a standardized tool or scale? Yes No

b. accept results from depression screenings performed by other health care providers?

Yes No

11. Does this adult day services center offer any disease-specific programs for participants with the following conditions?

These programs may include one or more of the following services—education, physical activity, diet/nutrition, medication management, or weight management.

a. Alzheimer’s disease and other dementias Yes No

b. Cardiovascular disease (e.g., heart disease, stroke, high blood pressure) Yes No

c. Depression Yes No

d. Diabetes Yes No

Services Offered

12. For each row, mark if this adult day services center provides the service by . . . (MARK ALL THAT APPLY)

• Paid center employees

• Arranging for and paying outside vendors

• Arranging for outside vendors paid by others

• Referral

• NONE OF THESE APPLY/NOT PROVIDED

a. Routine and emergency dental services by a licensed dentist

b. Hospice services

c. Social work services—provided by licensed social workers or persons with a bachelor’s or master’s degree in social work, and include an array of services such as psychosocial assessment, individual or group counseling, and referral services

d. Mental health services—target participants' mental, emotional, psychological, or psychiatric well-being and include diagnosing, describing, evaluating, and treating mental conditions

e. Any therapeutic services—physical, occupational, or speech

f. Pharmacy services—including filling of and delivery of prescriptions

g. Podiatry services

h. Skilled nursing services—must be performed by an RN or LPN and are medical in nature

i. Transportation services for medical or dental appointments

j. Transportation services for social and recreational activities, or shopping

k. Daily round trip transportation services to/from this center

Staff Profile

13a. What is the maximum number of hours per week that part-time staff can work at this adult day services center?

hours per week.

13b. What is the minimum number of hours per week that full-time staff can work at this adult day services center?

hours per week.

14. For each category of staff listed below, please indicate the number of staff that currently work at this adult day services center full-time and part-time. Please include:

• both full-time and part-time adult day service center employees (an individual is considered a center employee if the center is required to issue a Form W-2 on their behalf), and

• other individuals or organization staff under contract with and working at this adult day services center full-time and part-time.

Enter “0” for any categories with no employees or staff.

Number of Full-Time Staff Number of Part-Time Staff

a. Registered nurses (RNs)

b. Licensed practical nurses (LPNs)/Licensed vocational nurses (LVNs)

c. Certified nursing assistants, nursing assistants, home health aides, home care aides, personal care aides, personal care assistants, and medication technicians or medication aides

d. Social workers—licensed social workers or persons with a bachelor’s or master’s degree in social work

e. Activities directors or activities staff

Participant Profile

15. Of the participants currently enrolled at this center, how many are in each of the following categories? Count each participant only once. Enter “0” for any categories with no participants.

a. Hispanic or Latino, of any race

b. American Indian or Alaska Native, not Hispanic or Latino

c. Asian, not Hispanic or Latino

d. Black, not Hispanic or Latino

e. Native Hawaiian or Other Pacific Islander, not Hispanic or Latino

f. White, not Hispanic or Latino

g. Two or more races, not Hispanic or Latino

h. Some other category reported in this residential care community’s system

i. Not reported (race and ethnicity unknown)

16. Of the participants currently enrolled at this center, how many are in each of the following categories? Enter “0” for any categories with no participants.

a. Male

b. Female

17. Of the participants currently enrolled at this center, how many are in each of the following age categories? Enter “0” for any categories with no participants.

a. 17 years or younger

b. 18–44 years

c. 45–54 years

d. 55–64 years

e. 65–74 years

f. 75–84 years

g. 85 years or older

18. Of the participants currently enrolled at this center, about how many have been diagnosed with each of the following conditions? Enter “0” for any categories with no participants.

a. Alzheimer’s disease or other dementias

b. Intellectual/ developmental disability

c. Severe mental illness

d. Depression

e. Cardiovascular disease (e.g., heart disease, stroke, high blood pressure)

f. Diabetes

19. Assistance refers to needing any help or supervision from another person, or use of special equipment. Of the participants currently enrolled at this center, about how many now need any assistance at their usual residence or this center in each of the following activities? Enter “0” for any categories with no participants.

a. With transferring in and out of a chair

b. With eating, like cutting up food

c. With dressing

d. With bathing or showering

e. In using the bathroom (toileting)

f. With walking

20. Of the participants currently enrolled at this center, about how many were discharged from an overnight hospital stay in the last 90 days? Exclude trips to the hospital emergency department that did not result in an overnight hospital stay. If none, enter “0.”

Number of participants

21. Of the participants currently enrolled at this center, about how many were treated in a hospital emergency department in the last 90 days? If none, enter “0.”

Number of participants

22. Of the participants currently enrolled at this center, about how many had any fall in the last 90 days? Include onsite and offsite falls. If none, enter “0.”

Number of participants

23. For about how many of the current participants does this adult day services center provide medication-related services, such as storing medications; administering medications; or providing assistance to participants with self-administration of medications? If none, enter “0.”

Number of participants

24. Of those participants who stopped using this adult day services center in the last 12 months, did any leave because the cost of attending the center, including meals and services required to meet their needs, exceeded their ability to pay?

Yes No

Record keeping

25. An Electronic Health Record is a computerized version of the participant’s health and personal information used in the management of the participant’s health care. Other than for accounting or billing purposes, does this adult day services center use Electronic Health Records?

Yes No

26. Does this adult day services center’s computerized system support electronic health information exchange with each of the following providers? Do not include faxing.

a. Physician Yes No

b. Pharmacy Yes No

c. Hospital Yes No

Contact Information

27. In case we need to reach you, please provide your name, telephone number, work e-mail address, and job title. Your contact information will be kept confidential and will not be shared with anyone outside the project team.