National Study of Long-Term Care Providers--2016 Adult D

Data Collection for the Residential Care Community and Adult Day Services Center Components of the National Study of Long-term Care Providers

Att D-3 _2016 ADSC questions Version A 031816

2016 Adult Day Services Center Questions-Version A

OMB: 0920-0943

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Attachment D-3

National Study of Long-Term Care Providers----2016 Adult Day Services Center Questions-Version A


Form Approved

OMB No. 0920-0943

Exp. Date XX/XX/XXXX

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 …

MARK YES OR NO IN EACH ROW


Yes

No

a. licensed or certified by the State specifically to provide adult day services?

Shape1

Shape2

b. authorized or otherwise set up to participate in Medicaid?

Shape3

Shape4

If you answered “No” to both 1a and 1b, skip to question 35 on page X.

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.”

Shape5 Average daily attendance of participants

If you answered “0,” skip to question 35 on page X.

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

Shape6 Number of participants

If you answered “0,” skip to question 35 on page X.

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.”

Shape7 Maximum number of participants allowed





5. Which one of the following best describes the participant needs that the services of this center are designed to meet?

MARK ONLY ONE ANSWER

Shape8 ONLY social/recreational needs—NO health/medical needs.

Shape9 PRIMARILY social/recreational needs and SOME health/medical needs

Shape10 EQUALLY social/recreational and health/medical needs

Shape11 PRIMARILY health/medical needs and SOME social/recreational needs

Shape12 ONLY health/medical needs— NO social/recreational needs



6. Is this a specialized center that serves only participants with a particular diagnosis, condition, or disability?

Shape13 Yes

Shape14 No

If you answered “No,” skip to question 8.


7. In which of the following diagnoses, conditions, or disabilities does this center specialize?


SELECT ALL THAT APPLY


 Shape15 Alzheimer’s disease or other dementias

Shape16 HIV/AIDS   

Shape17 Intellectual and other developmental disabilities

Shape18 Multiple sclerosis

Shape19 Parkinson’s disease

Shape20 Post-stroke physical and/or mental impairments with a need for rehabilitative therapies

Shape21 Severe mental illness

Shape22 Traumatic brain injury

Shape23 Other (please specify) ____________________________________________________

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

MARK ONLY ONE ANSWER

Shape24 Private, nonprofit

Shape25 Private, for profit

Shape26 Publicly traded company or limited liability company (LLC)

Shape27 Government—federal, state, county, or local



9. 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.

Shape28 Yes

Shape29 No



















10. 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%. Enter “0” for any sources that do not apply.

a. Medicaid (include revenue from Medicaid waivers, Medicaid managed care, or California regional centers)

%

b. Medicare

c. Older Americans Act

d. Veteran’s Administration

%


e. Other federal, state or local government

%

f. Out-of-pocket payment by the participant or family

%

g. Private insurance

%

h. Other source

%

TOTAL

%

NOTE: Your entries should add up to 100%.

Services Offered

11. Fall risk assessment tools often address gait, mobility, strength, balance, cognition, vision, medications, and environmental factors. Examples of tools include but are not limited to CDC’s “Stopping Elderly Accidents, Deaths & Injuries” or STEADI; Timed Up and Go or TUG test; 30-second chair stand test; and 4-stage balance test. Does this center typically evaluate each participant’s risk for falling using any fall risk assessment tool? (Version A)

Shape30 Yes, as a standard practice with every participant

Shape31 Case-by-case depending on each participant

Shape32 No

12. Fall reduction interventions may include but are not limited to environmental safety measures; medication reconciliation; exercise, gait, or balance training; and participant or family education. Does this center currently use any formal falls reduction interventions? (Version A)

Shape33 Yes

Shape34 No















13. For each service listed below, MARK ALL THAT APPLY.

Service

This adult day services center. . .

Provides the service by paid center employees

Arranges for the service to be provided by outside service providers

Refers participants or family to outside service providers

Does not provide, arrange, or refer for this service

a. Hospice services

Shape35

Shape36

Shape37

Shape38

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

Shape39

Shape40

Shape41

Shape42

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

Shape43

Shape44

Shape45

Shape46

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

Shape47

Shape48

Shape49

Shape50

e. Pharmacy services—including filling of or delivery of prescriptions

Shape51

Shape52

Shape53

Shape54

f. Dietary and nutritional services

Shape55

Shape56

Shape57

Shape58

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

Shape59

Shape60

Shape61

Shape62

h. Transportation services for medical or dental appointments

Shape63

Shape64

Shape65

Shape66

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

Shape67

Shape68

Shape69

Shape70




Staff Profile



14. An individual is considered an employee if the center is required to issue a Form W-2 federal tax form on their behalf. For each staff type below, indicate whether or not this center currently has any full-time employees or part-time employees. Enter “0” for any categories with no employees.


Number of Full-Time Employees


Number of Part-Time Employees

a. Registered nurses (RNs)

Shape71


Shape72

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

Shape73


Shape74

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

Shape75


Shape76

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

Shape77


Shape78

e. Activities directors or activities staff

Shape79


Shape80


15. Contract or agency staff refer to individuals or organization staff under contract with and working at this center but are not directly employed by the center.

Does this center have any nursing, aide, social work, or activities contract or agency staff?


Shape81 Yes

Shape82 No

If you answered ‘No,” skip to question 17.


16. For each staff type below, indicate whether or not this center currently has any full-time contract or agency staff or part-time contract or agency staff. Enter “0” for any categories with no contract or agency staff.


Number of Full-Time contract or agency staff


Number of Part-Time contract or agency staff

a. Registered nurses (RNs)

Shape83


Shape84

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

Shape85


Shape86

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

Shape87


Shape88

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

Shape89


Shape90

e. Activities directors or activities staff

Shape91


Shape92




Participant Profile

17. Of the participants currently enrolled at this center, what is the racial-ethnic breakdown? Count each participant only once. Enter “0” for any categories with no participants.


NUMBER OF PARTICIPANTS

a. Hispanic or Latino, of any race

Shape93

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

Shape94

c. Asian, not Hispanic or Latino

Shape95

d. Black, not Hispanic or Latino

Shape96

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

Shape97

f. White, not Hispanic or Latino

Shape98

g. Two or more races, not Hispanic or Latino

Shape99

h. Some other category reported in this center’s system

Shape100

i. Not reported (race and ethnicity unknown)

Shape101

TOTAL

Shape102

NOTE: Total should be the same as the number of participants provided in question 3.

18. Of the participants currently enrolled at this center, what is the sex breakdown? Enter “0” for any categories with no participants.


NUMBER OF PARTICIPANTS

a. Male

Shape103

b. Female

Shape104

TOTAL

Shape105

NOTE: Total should be the same as the number of participants provided in question 3.




19. Of the participants currently enrolled at this center, what is the age breakdown? Enter “0” for any categories with no participants.


NUMBER OF PARTICIPANTS

a. 17 years or younger

Shape106

b. 1844 years

Shape107

c. 4554 years

Shape108

d. 5564 years

Shape109

e. 6574 years

Shape110

f. 7584 years

Shape111

g. 85 years or older

Shape112

TOTAL

Shape113

NOTE: Total should be the same as the number of participants provided in question 3.



20. 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.


NUMBER OF PARTICIPANTS


NUMBER OF PARTICIPANTS


a. Alzheimer’s disease or other dementias

Shape114

j. High blood pressure or hypertension

Shape115

b. Arthritis

Shape116

k. Human immunodeficiency virus (HIV)

Shape117

c. Asthma

Shape118

l. Intellectual or developmental disability

Shape119

d. Cancer

Shape120

m. Multiple sclerosis

Shape121

e. Chronic kidney disease

Shape122

n. Obesity


o. Osteoporosis


Shape123

Shape124

f. COPD (chronic bronchitis or emphysema)

Shape125

p. Parkinson’s disease

Shape126

g. Depression

Shape127

q. Severe mental illness, such as

schizophrenia and psychosis

Shape128

h. Diabetes



i. Heart disease (for example, congestive heart failure, coronary or ischemic heart disease, heart attack, stroke)

Shape129

Shape130

r. Traumatic brain injury

Shape131



21. Assistance refers to needing any help or supervision from another person, or use of assistive devices.

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.


NUMBER OF PARTICIPANTS

a. With transferring in and out of a chair

Shape132

b. With eating, like cutting up food

Shape133

c. With dressing

Shape134

d. With bathing or showering

Shape135

e. With using the bathroom (toileting)

Shape136

f. With locomotion or walking- this includes using a cane, walker, or wheelchair and/or help from another person.

Shape137


22. Of the participants currently enrolled at this center, how many live in each of the following places? (Version A)


NUMBER OF PARTICIPANTS

a. Private residence (house or apartment)

Shape138

b. Assisted living or similar residential care community


Shape139



c. Nursing home or other institutional setting


Shape140



d. Some other place


Shape141



If you answered “0” to 22a, skip to question 24.




23. Of the participants currently enrolled at this center who live in a private residence, how many live with each of the following people? Assign each participant to only one category. Enter “0” for any categories with no participants. (Version A)


NUMBER OF PARTICIPANTS

a. Alone

Shape142

b. With relative (such as a spouse, partner, adult child including son or daughter-in-law, parent, or other relative

Shape143

c. With non-relative(s)

Shape144


24. During the last 30 days, for how many of the participants currently enrolled at this adult day services center, did Medicaid pay for some or all of their services received at this center? (Please include any participants that received funding from Medicaid waivers, or Medicaid managed care, or any of the California regional centers). If none, enter “0.”

Shape145 Number of participants

25. 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.”

Shape146 Number of participants

26. 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.”

Shape147 Number of participants

If you answered “0,” skip to question 28.


27. Of the participants who were discharged from an overnight hospital stay in the last 90 days, about how many of those participants were re-admitted to the hospital for an overnight stay within 30 days of their hospital discharge? If none, enter “0.”

Shape148 Number of participants

28. As best you know, about how many of your current participants had a fall in the last 90 days?  Please include falls that occur in your center or off-site, whether or not the participant was injured, and whether or not anyone saw the participant fall or caught them. Please just count one fall per participant who fell, even if the participant fell more than one time.   If one of your participants fell during the last 90 days, but is currently in the hospital or rehabilitation facility, please include that person in your count. If no participants had a fall, enter “0.” (Version A)

Shape149 Number of participants

If you answered “0,” skip to question 30.


29. As best you know, of the participants who fell in the last 90 days, about how many are in each of the following categories? If a participant had more than one fall in the last 90 days, count only their most serious fall. Enter “0” for any categories with no participants. (Version A)


NUMBER OF

PARTICIPANTS

a. had a fall resulting in some kind of injury, such as a broken bone (for example in a wrist, arm, or ankle), hip fracture, or head injury

Shape150

b. had a fall that did not result in some kind of injury

Shape151



NOTE: Total should be the same as provided in question 28.


TOTAL Shape152

30. As best you know, of the participants who fell in the last 90 days, about how many went to a hospital emergency department or were hospitalized as a result of the fall? Include hospital admissions and observation stays. If a participant had more than one fall in the last 90 days, count only their most serious fall. If none, enter “0.” (Version A)

Shape153 Number of participants


Record keeping

31. An Electronic Health Record (EHR) 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?

Shape154 Yes

Shape155 No

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

MARK YES OR NO IN EACH ROW


Yes

No

  1. Physician

Shape156

Shape157

  1. Pharmacy

Shape158

Shape159

  1. Hospital

Shape160

Shape161






The following questions ask for information to help inform planning for future waves of NSLTCP.


33. The National Center for Health Statistics (NCHS) links person-level survey data with health records from other data sources, such as Medicare or Medicaid data.  Linking allows NCHS to better understand the services participants of centers use.  In order to link in future surveys, we would need the information below about your current participants.  We would use this information for research purposes only.  Federal laws authorize NCHS to ask for this information and require us to keep it strictly private. 


To help NCHS plan for future surveys, please answer the following questions:  For each item below, in Column 1 indicate whether or not this center has this information about its current participants.  For each “yes” in column 1, in Column 2 indicate whether or not this center is willing to provide this information about participants.



Column 1

This community has…

Column 2

I would be willing to provide…

a. Full names

Shape163 Shape162 Shape164 Yes

Shape165 No

Shape166 Yes

Shape167 No

b. Dates of birth

Shape168 Shape169 Yes

Shape170 No

Shape171 Yes

Shape172 No

c. Last four digits of Social Security numbers

Shape173 Shape174 Yes

Shape175 No

Shape176 Yes

Shape177 No

d. Full Social Security numbers

Shape178 Shape179 Yes

Shape180 No

Shape181 Yes

Shape182 No

34. Is this adult day services center a Health Insurance Portability and Accountability Act- (HIPAA-) covered entity?


Shape183 Yes

Shape184 No

Shape185 Do not know

Contact Information

35. In which of the following ways do you have internet access at work?

SELECT ALL THAT APPLY


Shape186 Desktop or Laptop

Shape187 Smartphone

Shape188 Tablet

Shape189 Other

Shape190 No internet access at work





36. We would like to keep your name, telephone number, work e-mail address, and job title for possible future contact related to participation in current and future NSLTCP waves. Your contact information will be kept confidential and will not be shared with anyone outside this project team.

PLEASE PRINT

Your full name:

Shape191

Your work telephone number, with extension:

( )

Shape192

Your work e-mail address:

Shape193

Your job title:

Shape194



2016 National Study of

Long-Term Care Providers


Please tell us about your experience participating in this study


If you have additional comments, concerns, or suggestions for improving our survey, please let us know! You can write your comments in the box below and submit them with your completed questionnaire in the enclosed postage-paid return envelope.

Shape195















Thank you for your participation and feedback.


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