Research Triangle Institute
This instrument was developed for the National Study of Assisted Living for the Frail Elderly. The project was conducted by the Research Triangle Institute under contracts #HHS-100-94-0024 and #HHS-100-98-0013 for the Department of Health and Human Services' Office of Disability, Aging and Long-Term Care Policy. Additional funding was provided by American Association of Retired Persons, the Administration on Aging, the National Institute on Aging, and the Alzheimer's Association. For additional information about this project, visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The Project Officer was Gavin Kennedy.
This file is a recreation of the questions asked on the instrument. It is not an exact replica of the form itself. A copy of the instrument is available in a PDF version.
OMB Number 0990-0217
Expires: _______________
| Respondent ID Label |
Facility Name: _____________________________________________________________________
Name of Discharged Resident: _____________________________________________________________________
Interview Name: ________________________________________________ Interviewer ID#__________
Date of Inteview: Month_____/Day_____/Year_____
Start Time: _____:_____am/pm End Time: _____:_____am/pm
| Public Reporting Burden Statement A federal 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. Public reporting burden for this collection of information is estimated to an average of 12 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the necessary data, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information to the OS Reports Clearance Officer, ASMB/Budget/PIOM, Room 503H HHH Bldg., 200 Independence Avenue, SW, Washington, DC 20201. |
| INTERVIEWER INSTRUCTIONS: Unless you know that the resident is deceased, ask to speak with the resident and use the Discharged Resident Interview. If the resident is deceased or too physically ill or cognitively impaired to respond, ask to speak with a family member who has the most information about the resident’s experience in the assisted living facility/residential care home. Read introduction below before you begin with the questions. |
INTRODUCTION
You are being asked to participate in a national study of assisted living and residential care for the frail elderly. About six months ago, we interviewed one of your family members, _________________________ [RESIDENT]. This is a follow-up interview about all residents in the study who have left the facility or who are deceased.
This study is being conducted for the U.S. Department of Health and Human Services. This agency is sponsoring the study to learn more about the role that assisted living and residential care facilities can play in meeting the needs of the elderly. Determining the experiences of residents who have left such facilities or who died while a resident there will be very helpful in understanding the role such facilities play in providing long-term care to elders. Research Triangle Institute (RTI) is conducting the study on behalf of the government. RTI is a nonprofit university-affiliated research organization in North Carolina.
Your participation is voluntary, and you may refuse to answer any question we ask. In addition, all your responses are confidential and will not be disclosed except as required by law. Your responses will also not be reported in any way that identifies you or your family member. This interview will take about 12 minutes. It asks about the experience of your family member in the facility and your views of the care HE/SHE received.
We hope you will agree to participate, since your views and experiences are important in helping us learn more about how to provide good care to elders.
1. What is/was your relationship to _____ [RESIDENT]? Are you his/her…
01 Spouse
02 Child
03 Child-in-law
04 Sibling
05 Grandchild
06 Niece/nephew
07 Other (SPECIFY) ________________________
| 2. Reason for not conducting the interview with resident? (IF POSSIBLE, CODE WITHOUT ASKING BASED ON INFORMATION PROVIDED BY TELEPHONE SURVEY LOCATORS)
|
2a. On what date did _____ [RESIDENT] die/pass on? Month_____/Day_____/Year_____
2b. Did _____ [RESIDENT] die/pass on at _____ [FACILITY]?
01 Yes (SKIP TO Q.2e)
02 No
2c. On what date did _____ [RESIDENT] leave _____ [FACILITY]? Month_____/Day_____/Year_____
2d. Which of the following describes where _____ [RESIDENT] went between leaving ____ [FACILITY] and when he/she died? (CIRCLE ALL THAT APPLY)
01 Hospital (acute care hospital)
02 Nursing home
03 Rehabilitation facility or subacute care unit
04 Another residential care or assisted living facility
05 Own home or apartment
06 Home or apartment of a relative
07 Some other place (SPECIFY)
2e. Did he/she receive hospice care while living at _____ [FACILITY]?
01 Yes (SKIP TO Q.9)
02 No (SKIP TO Q.9)
3. On what date did _____ [RESIDENT] leave _____ [FACILITY]? Month_____/Day_____/Year_____
4. Which of the following best describes the place where _____ [RESIDENT] is currently staying?
01 Hospital (Acute care hospital)
02 Nursing home
03 Rehabilitation facility or subacute care unit
04 Another residential care or assisted living facility
05 Own home or apartment
06 Home or apartment of a relative
07 Some other place (SPECIFY) _________________________
5. Did _____ [RESIDENT] go anyplace else between leaving _____ [FACILITY] and where he/she is currently staying?
01 YES
02 NO (SKIP TO Q.7)
6. Which of the following best describes the place (or places) he/she went between leaving _____ [FACILITY] and where you are currently staying? (CIRCLE ALL THAT APPLY)
01 Hospital (acute care hospital)
02 Nursing home
03 Rehabilitation facility or subacute care unit
04 Another residential care or assisted living facility
05 Own home or apartment
06 Home or apartment of a relative
07 Some other place (SPECIFY) _________________________
7. Which of the following best describes the decision to leave the facility? Would you say the decision was:
01 Mainly relative or our family’s decision
02 Mainly the facility’s decision
03 Mutual
04 DK
8. Please tell me which of the following statements describe the reasons your relative left _____ [FACILITY]: (CIRCLE ALL THAT APPLY)
01 Required hospital care
02 Needed nursing home care
03 Required more care than the facility could provide
04 Preferred location closer to family or friends
05 Exhausted his/her resources and had to leave because of money
06 Dissatisfied with the quality of care
07 Dissatisfied with the price or charges
08 Dissatisfied with some other aspect of the Facility
09 It was the facility’s request for unknown reason
10 Relative died/passed on
11 Is there any other reason not mentioned here? (SPECIFY) _________________________
9. When _____ [RESIDENT] moved into _____ [FACILITY], did you expect that he/she would be able to remain in that facility as long as you wanted to? Sometimes this is called being able to “age in place.”
01 YES
02 NO
10. When your relative entered _____ [FACILITY], did someone discuss with you the conditions under which he/she would be asked to leave or when the facility would no longer be able to meet his/her care needs?
01 YES
02 NO (SKIP TO Q. 12)
-4 DK (SKIP TO Q. 12)
11. Which of the following statements best describes the facility’s policies about discharge?
01 Very unclear - what the facility promised and what it actually did were very different
02 Unclear - you didn’t know what to expect because the terms were very vague
03 Adequate - you had a general idea of what to expect
04 Very Clear - facility policies were clear, and the facility lived up to what it promised
12. Which of the following statements best describes your feeling about the length of your relative’s stay in _____ [FACILITY]?
01 Wish he/she had left sooner, for example to go to a nursing home
02 Wish he/she had been able to stay there longer
03 Left at just the right time
13. Use any number on a scale from zero to ten, with zero being the worst and 10 being the best. How would you rate the facility’s performance in terms of meeting your relative’s need for personal assistance or health care? _____Score
-4 DK
14. Did you help your relative select _____ [FACILITY]?
01 YES
02 NO (SKIP TO Q.18)
15. Think back to when your relative moved in to _____ [FACILITY]. Which of the following were important to you? (CIRCLE ALL THAT APPLY) (The facility selected may not have had all the things the family member or resident wanted, but the responses should reflect preferences.)
| YES | NO | |
|---|---|---|
| Private bedroom | 01 | 02 |
| Private bathroom | 01 | 02 |
| Ability to bring your own furniture to the facility | 01 | 02 |
| Having access to a place to store and cook food | 01 | 02 |
| The attractiveness and amenities of outside areas | 01 | 02 |
| The attractiveness and amenities of the indoor public spaces | 01 | 02 |
| The availability of monitoring, for example if your relative fell or needed help with medications | 01 | 02 |
| The quality of the direct care staff (knowledge, training, attitudes, staffing level) | 01 | 02 |
| Whether the facility had a Registered Nurse on staff | 01 | 02 |
| The ability of the facility to provide more or different services if your relative’s needs changed | 01 | 02 |
| The availability of a nursing home on the same campus | 01 | 02 |
| The activities that were available | 01 | 02 |
| Location | 01 | 02 |
| Total Cost (Price plus extra charges) | 01 | 02 |
| All were equally important | 77 |
16. Did your opinion of what was most important change over time, as your relative lived in the facility?
01 YES
02 NO (SKIP TO Q. 18)
17. Which of the following became MORE important to you over time? (CIRCLE ALL THAT APPLY)
| YES | NO | |
|---|---|---|
| Private bedroom | 01 | 02 |
| Private bathroom | 01 | 02 |
| Ability to bring your own furniture to the facility | 01 | 02 |
| Having access to a place to store and cook food | 01 | 02 |
| The attractiveness and amenities of outside areas | 01 | 02 |
| The attractiveness and amenities of the indoor public spaces | 01 | 02 |
| The availability of monitoring, for example if your relative fell or needed help with medications | 01 | 02 |
| The quality of the direct care staff (knowledge, training, attitudes, staffing level) | 01 | 02 |
| Whether the facility had a Registered Nurse on staff | 01 | 02 |
| The ability of the facility to provide more or different services if your relative’s needs changed | 01 | 02 |
| The availability of a nursing home on the same campus | 01 | 02 |
| The activities that were available | 01 | 02 |
| Location | 01 | 02 |
| Total Cost (Price plus extra charges) | 01 | 02 |
| NONE OF THE ABOVE, All were equally important | 77 |
18. In the two months before your relative left the facility/dies, how often were you able to go to _____ [FACILITY] and visit?
01 Daily
02 Several times a week (3 or more times) but not daily
03 1-2 times a week
04 2-3 times a month
05 Once a month or less
19. Did you have any knowledge about the charges at _____ [FACILITY]?
01 YES
02 NO (SKIP TO Q.22)
20. Did you find that charges at _____ [FACILITY] increased at a faster rate than you expected or that there were additional, unexpected charges, over and above the monthly rate?
01 YES
02 NO
21. Use any number on a scale from 0 to 10, with 0 being the worst and 10 being the best. How would you rate the facility’s performance in terms of meeting your expectations about how much it would cost on a monthly basis? _____ Score
-4 DK
22. Which of the following were better than you expected at _____ [FACILITY]? (CIRCLE ALL THAT APPLY)
01 The accommodations
02 The price
03 The activities
04 The transportation that was offered
05 The staff (quality and number)
06 The availability of services or assistance you needed
07 None of the above
23. Which of the following were worse than you expected at _____ [FACILITY]? (CIRCLE ALL THAT APPLY)
01 The accommodations
02 The price
03 The activities
04 The transportation that was offered
05 The staff (quality and number)
06 The availability of services or assistance you needed
07 None of the above
24. Overall, which of the following statements best describes your feelings about your relative’s experience at _____ [FACILITY]? Would you say it was …
01 Better than you expected
02 Worse than you expected
03 About the same as you expected
25. Would you recommend this facility to a friend who had the same type of needs and interests that your relative had?
01 YES
02 NO
END
Thank you for your assistance in helping us understand the role of assisted living and other residential care settings in providing care to older persons.
PROBLEM SHEET
| Item | Comments |
|---|---|