Research Triangle Institute
PDF Version (15 PDF pages)
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: _____________________________________________________________________
Interview Name: ________________________________________________ Interviewer ID#__________
Date of Inteview: Month_____/Day_____/Year_____
Start Time: _____:_____am/pm End Time: _____:_____am/pm
| Paperwork Reduction Act 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 average 10 minutes per response, including time for reviewing instruction, searching existing data sources, gathering and maintaining the necessary data, and completing and reviewing the collection of information. Send comments regarding the burden estimate of 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, as to speak with the resident. If the resident is deceased, 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 and use the Discharged Resident Proxy Interview Form. Read introduction/consent 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 you in-person while you were a resident at _____. This is a follow-up interview for all residents in the study who subsequently left any of the several hundred facilities in the study.
As you may remember, this study is being conducted for the U.S. Department of Health and Human Services to learn more about the role that assisted living and residential care facilities can play in meeting the needs of older persons. Determining ther experiences of residents who have left such facilities will help the government understand the role such facilities play in providing long-term care for other persons.
The follow-up study is being conducted for the government by Research Triangle Institute (RTI). RTI is a nonprofit university-affiliated research organization in North Carolina.
As before, your participation is voluntary. 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. The information you provide will not be reported in any way that identified you or the facility. This interview will take about 10 minutes. It asks about your experience and views, including why you left the facility.
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 for older persons.
1. On what date did you leave? Month_____/Day_____/Year_____
2. Which of the following best describes the place where you are currently staying?
01 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) ________________________
3. Did you go anyplace else between leaving _____ [FACILITY] and where you currently are staying?
01 YES
02 NO (SKIP TO Q. 5)
4. Which of the following best describes the place (or places) you 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) _________________________
5. Which of the following best describes the decision to leave the facility? Would you say the decision was:
01 Mainly mine or my family’s decision
02 Mainly the facility’s decision
03 Mutual
04 DK
6. All in all, how much control did you have over the decision to leave _____ [FACILITY]?
01 Complete or almost complete control
02 Some control
03 Little or no control
7. Please tell me which of the following statements describe the reasons you 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 my 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 Is there any other reason not mentioned here? (SPECIFY) _________________________
8. Which of the following statements best describes your feeling about the timing of your departure from _____ [FACILITY]?
01 Wish I had left sooner
02 Wish I had been able to stay there longer
03 Left at just the right time
9. When you moved into _____ [FACILITY], did you expect that you 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 you entered _____ [FACILITY], did someone discuss with you the conditions under which you would be asked to leave or when the facility would NO longer be able to meet your care needs?
01 YES
02 NO (SKIP TO Q. 12)
-4 DK (SKIP TO Q. 12)
11. Which of the following 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. 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 need for personal assistance or health care? _____Score
-4 DK
13. 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
14. Think back to when you 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 resident wanted, but the responses should reflect preferences.)
| YES | NO | |
|---|---|---|
| Having a private bedroom | 01 | 02 |
| Having a private bathroom | 01 | 02 |
| Being able 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 you 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 needs change | 01 | 02 |
| The availability of a nursing home on the same campus | 01 | 02 |
| The activities that were available | 01 | 02 |
| Location | 01 | 02 |
| Price | 01 | 02 |
| NONE OF THE ABOVE | 77 |
15. Did your opinion of what was most important to you change over time, as you lived in the facility?
01 YES
02 NO (SKIP TO Q. 17)
16. Which of the following became MORE important to you as you lived at _____ [FACILITY]? (CIRCLE ALL THAT APPLY) (If the facility did not offer something but the resident wanted it or needed it, the response for that item should be a “YES.”)
| YES | NO | |
|---|---|---|
| Having a private bedroom | 01 | 02 |
| Having a private bathroom | 01 | 02 |
| Being able 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 you 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 needs change | 01 | 02 |
| The availability of a nursing home on the same campus | 01 | 02 |
| The activities that were available | 01 | 02 |
| Location | 01 | 02 |
| Price | 01 | 02 |
| NONE OF THE ABOVE | 77 |
17. 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
18. 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
19. 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
20. Overall, which of the following statements best describes your 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
21. Would you recommend this facility to a friend who had the same type of needs and interests you 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 |
|---|---|