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

Attachment D-4

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

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

If you answered “No” to both 1a and 1b, skip to question 33 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.”

Average daily attendance of participants

If you answered “0,” skip to question 33 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.”

Number of participants

If you answered “0,” skip to question 33 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.”

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

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

PRIMARILY social/recreational needs and SOME health/medical needs

EQUALLY social/recreational and health/medical needs

PRIMARILY health/medical needs and SOME social/recreational needs

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?

Yes

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

  Alzheimer’s disease or other dementias

HIV/AIDS   

Intellectual and other developmental disabilities

Multiple sclerosis

Parkinson’s disease

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

Severe mental illness

Traumatic brain injury

Other (please specify) ____________________________________________________

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

MARK ONLY ONE ANSWER

Private, nonprofit

Private, for profit

Publicly traded company or limited liability company (LLC)

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.

Yes

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. 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
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
c. Mental health services—target participants' mental, emotional, psychological, or psychiatric well-being and may include diagnosing, describing, evaluating, and treating mental conditions
d. Any therapeutic services—physical, occupational, or speech
e. Pharmacy services—including filling of or delivery of prescriptions
f. Dietary and nutritional services
g. Skilled nursing services—must be performed by an RN or LPN and are medical in nature
h. Transportation services for medical or dental appointments
i. Daily round trip transportation services to/from this center

Staff Profile

12. 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)
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

13. 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?

Yes

No

If you answered ‘No,” skip to question 15.

14. 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)
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, 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
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 center’s system
i. Not reported (race and ethnicity unknown)
TOTAL

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

16. 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
b. Female
TOTAL

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

17. 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
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
TOTAL

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

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.

	NUMBER OF PARTICIPANTS		NUMBER OF PARTICIPANTS
a. Alzheimer’s disease or other dementias		j. High blood pressure or hypertension
b. Arthritis		k. Human immunodeficiency virus (HIV)
c. Asthma		l. Intellectual or developmental disability
d. Cancer		m. Multiple sclerosis
e. Chronic kidney disease		n. Obesity o. Osteoporosis
f. COPD (chronic bronchitis or emphysema)		p. Parkinson’s disease
g. Depression		q. Severe mental illness, such as schizophrenia and psychosis
h. Diabetes i. Heart disease (for example, congestive heart failure, coronary or ischemic heart disease, heart attack, stroke)		r. Traumatic brain injury

19. 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
b. With eating, like cutting up food
c. With dressing
d. With bathing or showering
e. With using the bathroom (toileting)
f. With locomotion or walking- this includes using a cane, walker, or wheelchair and/or help from another person.

20. Of the participants currently enrolled at this center, how many have elected and are now receiving hospice care? If none, enter “0.” (Version B)

Number of participants

21. 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.”

Number of participants

22. 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

23. 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

If you answered “0,” skip to question 25.

24. 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.”

Number of participants

Record keeping

25. 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?

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.

MARK YES OR NO IN EACH ROW
	Yes	No
Physician
Pharmacy
Hospital

27. Advance directives are written documentation and may include health care proxies, durable power of attorney, living wills, do not resuscitate (DNR) orders, or physician or medical orders for life sustaining treatments (POLST or MOLST).

Does this center provide any information about advance directives to participants and/or their families? (Version B)

Yes

No

28. Does your state require your center to provide information to participants or their families about advance directives? (Version B)

Yes

No

Do not know

29. Does this adult day services center typically maintain documentation of participants’ advance directives or have documentation that an advance directive exists in participant files? (Version B)

Yes

No

If you answered “No,” skip to question 31.

30. Of the current participants, how many have documentation of an advance directive in their file? If none, enter “0.” (Version B)

Number of participants

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

31. 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	Yes No	Yes No
b. Dates of birth	Yes No	Yes No
c. Last four digits of Social Security numbers	Yes No	Yes No
d. Full Social Security numbers	Yes No	Yes No

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

Yes

No

Do not know

Contact Information

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

SELECT ALL THAT APPLY

Desktop or Laptop

Smartphone

Tablet

Other

No internet access at work

34. 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:

Your work telephone number, with extension:

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Your work e-mail address:

Your job title:

2016 National Study of

Long-Term Care Providers

Please tell us about your experience participating in this study

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