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-4_ 2016 ADSC questions Version B 031816

2016 Adult Day Services Center Questionnaire-Version B

OMB: 0920-0943

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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?

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 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.”

Shape5 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.”

Shape6 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.”

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. 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

Shape30

Shape31

Shape32

Shape33

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

Shape34

Shape35

Shape36

Shape37

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

Shape38

Shape39

Shape40

Shape41

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

Shape42

Shape43

Shape44

Shape45

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

Shape46

Shape47

Shape48

Shape49

f. Dietary and nutritional services

Shape50

Shape51

Shape52

Shape53

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

Shape54

Shape55

Shape56

Shape57

h. Transportation services for medical or dental appointments

Shape58

Shape59

Shape60

Shape61

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

Shape62

Shape63

Shape64

Shape65




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)

Shape66


Shape67

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

Shape68


Shape69

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

Shape70


Shape71

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

Shape72


Shape73

e. Activities directors or activities staff

Shape74


Shape75


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?


Shape76 Yes

Shape77 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)

Shape78


Shape79

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

Shape80


Shape81

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

Shape82


Shape83

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

Shape84


Shape85

e. Activities directors or activities staff

Shape86


Shape87




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

Shape88

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

Shape89

c. Asian, not Hispanic or Latino

Shape90

d. Black, not Hispanic or Latino

Shape91

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

Shape92

f. White, not Hispanic or Latino

Shape93

g. Two or more races, not Hispanic or Latino

Shape94

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

Shape95

i. Not reported (race and ethnicity unknown)

Shape96

TOTAL

Shape97

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

Shape98

b. Female

Shape99

TOTAL

Shape100

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

Shape101

b. 1844 years

Shape102

c. 4554 years

Shape103

d. 5564 years

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e. 6574 years

Shape105

f. 7584 years

Shape106

g. 85 years or older

Shape107

TOTAL

Shape108

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

Shape109

j. High blood pressure or hypertension

Shape110

b. Arthritis

Shape111

k. Human immunodeficiency virus (HIV)

Shape112

c. Asthma

Shape113

l. Intellectual or developmental disability

Shape114

d. Cancer

Shape115

m. Multiple sclerosis

Shape116

e. Chronic kidney disease

Shape117

n. Obesity


o. Osteoporosis


Shape118

Shape119

f. COPD (chronic bronchitis or emphysema)

Shape120

p. Parkinson’s disease

Shape121

g. Depression

Shape122

q. Severe mental illness, such as

schizophrenia and psychosis

Shape123

h. Diabetes



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

Shape124

Shape125

r. Traumatic brain injury

Shape126



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

Shape127

b. With eating, like cutting up food

Shape128

c. With dressing

Shape129

d. With bathing or showering

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e. With using the bathroom (toileting)

Shape131

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

Shape132


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)

Shape133 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.”

Shape134 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.”

Shape135 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.”

Shape136 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.”

Shape137 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?

Shape138 Yes

Shape139 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

  1. Physician

Shape140

Shape141

  1. Pharmacy

Shape142

Shape143

  1. Hospital

Shape144

Shape145



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)


Shape146 Yes

Shape147 No



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

Shape148 Yes

Shape149 No

Shape150 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)

Shape151 Yes

Shape152 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)



Shape153 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

Shape155 Shape154 Shape156 Yes

Shape157 No

Shape158 Yes

Shape159 No

b. Dates of birth

Shape160 Shape161 Yes

Shape162 No

Shape163 Yes

Shape164 No

c. Last four digits of Social Security numbers

Shape165 Shape166 Yes

Shape167 No

Shape168 Yes

Shape169 No

d. Full Social Security numbers

Shape170 Shape171 Yes

Shape172 No

Shape173 Yes

Shape174 No

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


Shape175 Yes

Shape176 No

Shape177 Do not know



Contact Information

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

SELECT ALL THAT APPLY


Shape178 Desktop or Laptop

Shape179 Smartphone

Shape180 Tablet

Shape181 Other

Shape182 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:

Shape183

Your work telephone number, with extension:

( )

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Your work e-mail address:

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Your job title:

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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.

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Thank you for your participation and feedback.


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