This instrument was developed for the National Board and Care Survey project. This project was conducted by the Bureau of the Census under contract for the Department of Health and Human Services (HHS) Office of Disability, Aging and Long-Term Care Policy. For additional information about this subject, you can 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, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Robert Clark.
| NOTE: This is a recreation of this form. See the PDF version for a scanned version of the actual form. |
QUESTIONNAIRE 4
LOCAL AGENCY
FIFTY STATE SURVEY OF AGENCIES INVOLVED
IN THE REGULATION OF BOARD AND CARE HOMES
| STATE: _________________________ AGENCY: _________________________ CONTACT: _________________________ POSITION: _________________________ | DATE: _________________________ INTERVIEWER: _________________________ |
| START TIME: _________________________ |
PART I: CASE MANAGEMENT
1. How many elderly board and care residents does your agency serve?
Enter number: _____ If unknown code "9's."
2. What percentage of elderly board and care residents receive CASE MANAGEMENT services from your agency?
Enter percentage: _____
3. Does any other agency have case management responsibilities for elderly board and care residents?
Agency name: _________________________ Abbreviate, if possible.
4. What is the average case load for case managers in your agency?
Enter number: _____ If unknown code "9's."
5. How are case management services for elderly board and care residents funded? _________________________
6. How many elderly board and care residents are actually receiving case management services?
Enter number: _____ If unknown code "9's."
7. How often are the following activities included in case management activities for elderly board and care residents?
A. Making determination of need for board and care services _____ Always _____ Frequency _____ Seldom _____ Never _____ Don't Know A = Always
F = Frequently
S = Seldom
N = Never
D = Don't KnowB. Checking on financial eligibility _____ Always _____ Frequency _____ Seldom _____ Never _____ Don't Know C. Referring resident to homes _____ Always _____ Frequency _____ Seldom _____ Never _____ Don't Know D. Arranging for resident placement _____ Always _____ Frequency _____ Seldom _____ Never _____ Don't Know E. Briefing provider on resident needs _____ Always _____ Frequency _____ Seldom _____ Never _____ Don't Know F. Arranging for outside ancillary services for the resident _____ Always _____ Frequency _____ Seldom _____ Never _____ Don't Know G. Monitoring resident adjustment _____ Always _____ Frequency _____ Seldom _____ Never _____ Don't Know H. Monitoring for change in resident status resulting in the need for placement in a different facility or for added services _____ Always _____ Frequency _____ Seldom _____ Never _____ Don't Know I. Monitoring for quality of care/life _____ Always _____ Frequency _____ Seldom _____ Never _____ Don't Know J. Monitoring for resident satisfaction _____ Always _____ Frequency _____ Seldom _____ Never _____ Don't Know K. Other case management activities: _____ Always _____ Frequency _____ Seldom _____ Never _____ Don't Know L. _________________________ M. _________________________
8. What three aspects of case management discussed above, does your agency devote most of its time to?
a. _________________________ b. _________________________ c. _________________________
9. Does your agency develop written specific plans - for example, Individual Social Plans (ISPs) or Individual Health Plans (IHPs) - for board and care residents?
_____Yes Y = Yes
N = No
D = Don't Know_____No (IF ANSWER IS "NO" SKIP TO QUESTION 13.) _____Don't Know
10. What percentage of the elderly residents you serve have these plans?
_____% If unknown enter "9's."
11. How often are these plans updated? _________________________ Specify in yearly intervals.
12. Does agency staff have separate or mixed responsibilities for assessment, placement, and monitoring of clients?
_____ Separate S = Separate
M = Mixed
D = Don't Know_____ Mixed _____ Don't Know
13. Does your agency visit elderly case management clients in the board and care homes?
_____Yes Y = Yes
N = No
D = Don't Know_____No (IF ANSWER IS "NO" SKIP TO QUESTION 18.) _____Don't Know
14. On the average, how often are these visits made? _________________________ Specify in monthly intervals.
15. What is the purpose of these visits? _________________________
16. What is done if a client is dissatisfied? _________________________
17. What is done if the quality of care or environment seems inferior?
18. Are comments or opinions about the quality of care in the home sought from the residents and/or their families?
_____Yes Y = Yes
N = No
D = Don't Know_____No _____Don't Know
19. Are comments or opinions about the quality of care in a board and care home sought from other people, such as the ombudsman?
_____Yes Y = Yes
N = No
D = Don't Know_____No _____Don't Know
20. What is done if the client seems misplaced in terms of his/her needs and the services the home provides? _________________________
21. Are you authorized to refer elderly residents in board and care home for other home or community-based services?
_____Yes Y = Yes
N = No
D = Don't Know_____No (IF ANSWER IS NO, SKIP TO QUESTION 26.) _____Don't Know
22. What are the links between your agency and community-based service agencies and AoA agencies? _________________________
23. Which home and community-based services are authorized for elderly board and care residents? How many residents actually received this service last year? Who generally pays for the service? (LIST EACH AUTHORIZED SERVICE SEPARATELY.)
SERVICE NUMBER WHO
RECEIVEDWHO FUNDS a. _________________________ _________________________ _________________________ b. _________________________ _________________________ _________________________ c. _________________________ _________________________ _________________________ d. _________________________ _________________________ _________________________ e. _________________________ _________________________ _________________________ f. _________________________ _________________________ _________________________ g. _________________________ _________________________ _________________________ h. _________________________ _________________________ _________________________
24. Does your agency have a system for tracking elderly board and care residents who are in need of other home and community-based services?
_____ Yes Describe _________________________ _____ No _____ Don't Know
25. In your opinion, are most of the board and care residents receiving needed community based services?
_____ Yes _____ No Why not? _________________________ _____ Don't Know
26. In your opinion, what are the major strengths or benefits of your program for elderly clients who reside in board and care homes? (LIST EACH STRENGTH/BENEFIT SEPARATELY.)
a. _________________________ b. _________________________ c. _________________________ d. _________________________ e. _________________________ f. _________________________
27. What are the greatest problems your agency faces in serving elderly clients who reside in board and care homes? (LIST EACH PROBLEM SEPARATELY.)
a. _________________________ b. _________________________ c. _________________________ d. _________________________ e. _________________________
PART II: REFERRAL
28. When selecting a board and care facility for a client, which of the following are considered?
_____ a. Availability If checked, code "Y;" if not checked, code "N." _____ b. Appropriateness of services provided by the home _____ c. Condition of client _____ d. Cost _____ e. Client freedom and maximum independence _____ f. Client protection _____ g. Other (SPECIFY) _________________________
29. Which three factors are the most important when selecting a facility?
a. _________________________ b. _________________________ c. _________________________
30. To what extent, are clients, or their families or guaridans, involved in selecting the facility into which they will be placed? (CHECK ONE.)
_____ Very involved, client (or family) have total choice = V _____ Some involvement of client or family = S _____ Minimal or pro forma involvement = M _____ No involvement = N _____ Don't know = D
31. In your opinion, should clients and their families have more, the same, or less involvement in selecting a placement facility?
_____ More M = More
S = Same
L = Less_____ Same _____ Less
32. What criteria are used to select homes for inclusion on your referral list? (LIST CRITERIA SEPARATELY.)
A. _________________________ B. _________________________ C. _________________________ D. _________________________ E. _________________________ F. _________________________
33. Do you do any on-site visits to home before referring clients?
_____Yes Y = Yes
N = No
D = Don't Know_____No _____Don't Know
34. Do you do periodic on-site visits to the homes to determine whether you want to continue referring clients to them?
_____Yes Y = Yes
N = No
D = Don't Know_____No _____Don't Know
35. Are persons who are receiving state supplemental SSI payments for board and care required to reside in facilities which are licensed?
_____Yes Y = Yes
N = No
D = Don't Know_____No Why not?_________________________ _____Don't Know Any other requirements? _________________________
36. Do you refer or place clients in homes which are not on your referral list?
_____No Y = Yes
N = No
D = Don't Know_____Yes Why?_________________________ _____Don't Know
37. Do you refer or place clients in unlicensed homes?
_____No Y = Yes
N = No
D = Don't Know_____Yes Why?_________________________
(IF ANSWER IS YES, SKIP TO QUESTION 40.)_____Don't Know
38. How does your agency insure that referrals are made only to licensed homes? _________________________
39. Are there penalties for referring clients to unlicensed homes?
_____No _____Yes (LIST SEPARATELY AND GIVE NUMBER OF TIMES INVOKED IN LAST YEAR.) PENALTY TIMES A. _________________________ _________________________ B. _________________________ _________________________ C. _________________________ _________________________ D. _________________________ _________________________ E. _________________________ _________________________ _____Don't Know
40. Are the following used/considered in matching clients with board and care facility?
A. Client assessment instrument? Yes _____ No _____ Y = Yes
N = No
D = Don't KnowB. Instrument to match client and facility? Yes _____ No _____ C. Conputerized linkage? Yes _____ No _____ D. Professional judgment? Yes _____ No _____ E. Special resource directory? Yes _____ No _____ F. Client's (or client's family) preference? Yes _____ No _____ G. Provider preference? Yes _____ No _____ H. Geographic location - proximity? Yes _____ No _____ I. Availability of beds? Yes _____ No _____ J. Licensure status of facility? Yes _____ No _____ K. Other (SPECIFY) _________________________ Yes _____ No _____
41. Do your agency's placement and referral practices differ by whether a client will pay privately or with SSI?
_____No Y = Yes
N = No
D = Don't Know_____Yes Why?_________________________ _____Don't Know
42. Are clients whose care will be paid for by SSI/SSP? (CHOOSE ONE.)
_____ More difficult = M _____ About the same as self-pay clients = S _____ Less difficult to place than self-pay clients = L
43. Are there any types of clients that are difficult to place because board and care homes are reluctant to accept them?
_____No Y = Yes
N = No
D = Don't Know_____Yes Why?_________________________ _____Don't Know
44. In your opinion, what kinds of problems does your agency encounter in placing clients in appropriate board and care facilities? (LIST EACH PROBLEM SEPARATELY.)
a. _________________________ b. _________________________ c. _________________________ d. _________________________ e. _________________________
PART III: COMMUNITY SERVICES AVAILABLE TO B&C RESIDENTS
45. Are the following services available to ALL residents in need of the service, to a LIMITED NUMBER of residents in need of the service, or to NONE of the residents in need of the service? (CIRCLE THE APPROPRIATE RESPONSE AND THEN SPECIFY AGENCIES PROVIDING THE SERVICES, OR THE FUNDING FOR THE SERVICES.)
AVAILABLE TO: A. Mental health services
Agency: _________________________ALL LIMITED NONE B. Home health services
Agency: _________________________ALL LIMITED NONE C. Dental service
Agency: _________________________ALL LIMITED NONE D. Optical vision services
Agency: _________________________ALL LIMITED NONE E. Other routine medical services
Agency: _________________________ALL LIMITED NONE F. Voc rehab services
Agency: _________________________ALL LIMITED NONE G. Adult day care
Agency: _________________________ALL LIMITED NONE H. Senior center program
Agency: _________________________ALL LIMITED NONE I. Social and recreational programs outside of the home
Agency: _________________________ALL LIMITED NONE J. Outreach services (e.g., friendly visiting)
Agency: _________________________ALL LIMITED NONE K. Protective and legal services
Agency: _________________________ALL LIMITED NONE L. Protective and legal services
Agency: _________________________ALL LIMITED NONE M. Personal/family counseling
Agency: _________________________ALL LIMITED NONE N. Other social or medical services
(SPECIFY) _________________________
Agency: _________________________ALL LIMITED NONE
46. Are residents of board and care facilities eligible for the services that are funded through the Area Agencies on Aging?
_____ Yes Which services? (LIST SEPARATELY) 1. _________________________ 2. _________________________ 3. _________________________ _____No Why not?_________________________
47. Are you satisfied with the current state and local division of responsibility for board and care within your state?
_____No Y = Yes
N = No
D = Don't Know_____Yes Why not?_________________________ _____Don't Know