Form 0920-0943 RCC/ADSC Screener and Appointment Setting Call Script

Attachment H

Screener and Appointment Setting Script

Form Approved

OMB No. 0902-0943

Exp. Date xx/xx/20xx

NOTICE – Public reporting burden for the contact verification is estimated to average 15 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 – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note). This law requires the federal government to protect federal computer networks by using computer security programs to identify cybersecurity risks like hacking, internet attacks, and other security weaknesses. If information sent through government networks triggers a cyber threat indicator, the information may be intercepted and reviewed for cyber threats by computer network experts working for, or on behalf, of the government.

INTERVIEWER WILL CALL RCC/ADSC AND ASK TO SPEAK DIRECTLY TO ADMINISTRATOR/DIRECTOR. IF ADMINISTRATOR/DIRECTOR IS NOT AVAILABLE OR IF ROUTED TO THEIR VOICEMAIL, THE INTERVIEWER WILL OFFER TO CALL BACK.

1. Hello, may I please speak to [NAME OF DIRECTOR]. HAVE YOU REACHED THE ADMINISTRATOR/DIRECTOR?

YES  GO TO 2

NO  GO TO 1a

1a. IF ADMINISTRATOR/DIRECTOR IS NOT AVAILABLE ASK FOR THE BEST TIME TO CALL BACK TO REACH THE ADMINISTRATOR/DIRECTOR. NOTE BEST TIME TO CALL.

1b. IF LEAVING A VOICEMAIL:

Hello, my name is _______________ and I’m calling from RTI International on behalf of CDC’s National Center for Health Statistics in regards to the National Study of Long-Term Care Providers study. This national study of adult day services centers/residential care communities will collect information about the characteristics of these centers/communities and their participants/residents. Your center/community was randomly selected to participate and will represent other centers/communities like yours. It is important that we obtain data from all sampled communities in order to achieve accurate and complete statistics representative of all adult day services centers/residential care communities.

I have tried unsuccessfully to reach you by telephone. Can you please call me toll free at [INSERT NUMBER] so that I can answer any questions you may have and see if you are eligible to participate?

For more information about this study, please visit www.cdc.gov/nchs/nsltcp.htm

Thanks you,

RECRUITER FIRST AND LAST NAME

RECRUITER TOLL FREE NUMBER

2. My name is _____ and I’m calling on behalf of the National Study of Long-Term Care Providers, a project being conducted by CDC’s National Center for Health Statistics.

Did you receive and read the advance packet we sent you? IF NECESSARY: It appears it was delivered by UPS on [date] and signed for by [name].

YES  GO TO 2a

NO  GO TO 2b

2a. IF READ ADVANCE PACKET, READ:

Do you have any questions about the materials you received?

NO  GO TO 3 SCREENING ITEMS on page 3.

YES  ANSWER QUESTIONS AS APPROPRIATE THEN CONTINUE TO 3 SCREENING ITEMS

on page 3.

2b. IF NOT READ ADVANCE PACKET:

Shall I describe the study to you, or would you prefer that I call you back after you have reviewed the materials, which I can provide a web link for you to see them online?

DESCRIBE SURVEY  GO TO 2c

VERBALLY GIVE WEB LINK TO MATERIALS & CALL BACK  GO TO 2d

2c. READ THIS TEXT FROM THE ADVANCE PACKET:

NSLTCP tracks trends in five major long-term care services sectors— adult day services centers, assisted living and similar residential care communities, home health agencies, nursing homes, and hospices. NSLTCP collects information about the characteristics of residential care providers/adult day services centers, the services they offer, their staffing profile, and the demographics, functional status, and health of the residents/participants they serve. By participating you will help to improve the value of national estimates to help inform long-term care providers, planners, researchers, and policymakers. We sent you an NCHS data brief as an example.

[IF RCC: These national organizations support NSLTCP: the Center for Excellence in Assisted Living (CEAL), American Seniors Housing Association (ASHA), Argentum, LeadingAge, and the National Center for Assisted Living/American Health Care Association (NCAL/AHCA). We sent you a letter of support from these organizations.]

[IF ADSC: We sent you a letter of support from these organizations. The National Adult Day Services Association (NADSA), LeadingAge, and the National Association of States United for Aging and Disabilities (NASUAD) are in support of NSLTCP.]

Participating in this study will involve completing a provider questionnaire by web or mail, and with the help of a telephone interviewer, selecting two residents/participants using random sampling procedures, and completing a questionnaire for each of them. We ask for approximately one hour of your time to participate. Your participation in this survey is voluntary, but will assist greatly in helping to further our nation’s understanding and planning for the long-term care needs of older adults and people with disabilities. Refusal to participate will involve no loss of benefits and participation can be discontinued at any time. We sent you a letter of approval from the Research Ethics Review Board at the National Center for Health Statistics.

Data collection is authorized under Section 306 of the Public Health Service Act (42 U.S.C. 242k). NCHS is required to keep your survey data confidential in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act (CIPSEA, Title 5 of PL 107-347). Data collected will be used for statistical purposes only. In addition, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 & 151 note). We sent you an NCHS confidentiality brochure that provides more information.

Do you have any questions about the information I just provided you?

NO  GO TO 3 SCREENING ITEMS on page 3.

YES  ANSWER QUESTIONS AS APPROPRIATE THEN CONTINUE TO 3 SCREENING ITEMS

on page 3.

2d. Is this a good time of day to call back or is there a better time to reach you?

PREFERRED DATE: _________ TIME: ________ AM/PM

Thank you very much for your time. I will call you back. END CALL

3. SCREENING ITEMS

I would like to confirm that your [residential care community/adult day services center] is eligible to participate. The questions I have right now should take just a few minutes.

Q1a

IF ADSC OR CASE NOT FLAGGED AS COLOCATED/MULTILEVEL ASK Q1a, ELSE GO TO Q1b

Is this center/residential care community associated with another center/residential care community or is it part of a facility or campus that offers multiple levels of care? (SAY IF NECESSARY: For example, is this center/residential care community part of a continuing care retirement community? Or, does it offer independent living, skilled nursing, or other levels of care other than adult day/residential care?)

Yes, No If Q1a=NO go to Q1, Else go to Q1c

Q1b

IF CASE FLAGGED AS COLOCATED/MULTILEVEL ASK Q1b

ELSE IF Q1a=YES go to Q1c

ELSE GO TO Q1

Our records show that this facility is associated with another residential care community or is part of a facility or campus that offers multiple levels of care.

Is this correct?

Yes, No IF Q1b=YES go to Q1c, Else go to Q1

Q1c

Please answer the following questions only for the adult day/residential care portion operating at [FILL FACILITY NAME, FACILILTY ADDRESS] (under license number [FILL LICENSE NUMBER] OR under ID [FILL FACILITY ID] OR with [FILL NUMBER OF PARTICIPANTS/BEDS] participants/beds.

IF RCC:

Q1. Is this residential care community currently licensed, registered, certified, or otherwise regulated by the State?

Yes, No IF NO, GO TO 4 on page 5.

Q2. At this residential care community, what is the number of licensed, registered, or certified residential care beds? Include both occupied and unoccupied beds. If this residential care community is licensed, registered, or certified by apartment or unit, please count the number of single-resident apartments or units as one bed each, two-bedroom apartments or units as two beds each, and so forth.

_____ Number of beds IF FEWER THAN 4 BEDS, GO TO 4 ON PAGE 5.

Q3. Does this residential care community only serve adults with…

a. an intellectual or developmental disability? YES NO

b. severe mental illness, such as schizophrenia and psychosis? Do not include Alzheimer’s

disease or other dementias. YES NO

IF “YES” TO EITHER 3a or 3b, GO TO 4 ON PAGE 5.

Q4. Does this residential care community offer at least two meals a day to residents?

Yes, No IF NO, GO TO 4 ON PAGE 5.

Q5. What is the total number of residents currently living at this residential care community? Please include residents for whom a bed is being held while in the hospital. If you have respite care residents, please include them. If none, enter “0.”

_____ Number of residents IF ZERO GO TO 4 ON PAGE 5.

Q6. Does this residential care community provide or arrange for any of the following types of staff to be on site 24 hours a day, 7 days a week to meet any resident needs that may arise? On site means the staff are located in the same building, in an attached building or next door, or on the same campus.

a. Personal care aide or staff caregiver Yes On an as-needed basis No

b. Registered nurse (RN), licensed practical nurse (LPN), or licensed vocational nurse (LVN) Yes On an as-needed basis No

c. Director, assistant director, administrator, or operator if they provide personal care or nursing services to residents Yes On an as-needed basis No

IF NO TO 6a, 6b, AND 6c, GO TO 4 ON PAGE 5.

Q7. Does this residential care community offer…

a. help with activities of daily living (ADLs), such as help with bathing, either directly or arranged through an outside vendor? Yes No

b. assistance with medications, such as the administration of medications, give reminders, or provide central storage of medications? Yes No

IF NO TO 7a AND 7b, GO TO 4 ON PAGE 5.

GO TO 5 on page 5.

IF ADSC:

Q1. Is this adult day services center …

1. a. licensed or certified by your State specifically to provide adult day services, or accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF)? YES NO

2. b. authorized or otherwise set up to participate in Medicaid (Medicaid state plan, Medicaid waiver, or Medicaid managed care) or part of a Program of All-Inclusive Care for the Elderly (PACE)? YES NO

IF NO TO BOTH 1a and 1b, GO TO 4 ON PAGE 5.

Q2. 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 ZERO, GO TO 4 ON PAGE 5.

Q3. 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 ZERO, GO TO 4 ON PAGE 5.

GO TO 5 ON PAGE 5.

4. I’m sorry, your [residential care community/adult day services center] does not meet our study eligibility criteria.

5. Based on your responses, your [residential care community/adult day services center] is eligible to participate in our study. The study has two parts: a questionnaire about your [residential care community/center] and a telephone interview to sample and collect information from you on two of your [residents/participants].

   1. You can complete the questionnaire about your residential care community/center online. It takes on average 30 minutes to complete, and we would need an email address to email you the login information. Could you provide me an email address, and I can email you the necessary information to complete that web questionnaire? [SEND EMAIL WHILE YOU HAVE RESPONDENT ON THE PHONE AND CONFIRM RECEIPT]

   2. IF NO: We also have the option to mail you a paper version of the questionnaire about your [residential care community/center] and you can mail it back in a postage-paid envelope that we will include in the questionnaire packet. I can have the questionnaire mailed to you. VERIFY CONTACT INFORMATION AND PHYSICAL STREET ADDRESS.

   3. IF RESPONDENT REFUSES PROVIDER QUESTIONNAIRE: Thank you very much for your time. END CALL

6. I would like to set up an appointment for the second part of the study where you will select two [residents/participants] using random sampling procedures with the help of a telephone interviewer, and complete questionnaires for these two [residents/participants] over the telephone. This telephone interview will take about 30 minutes. We will conduct this telephone interview after receiving your provider questionnaire. ATTEMPT TO SCHEDULE AN APPOINTMENT FOR [If WEB: 4-10, IF MAIL: 8-10] WEEKS OUT. SUGGEST A DATE AND TIME OR IDENTIFY A TIME THAT WORKS BEST FOR THE R. RECORD DATE AND TIME.

ONCE THE APPOINTMENT DATE/TIME IS DETERMINED: I would like to send you an appointment reminder by email. What is the best email address to use? IF PROVIDED EARLIER, VERIFY EMAIL. RECORD EMAIL ADDRESS IN THE CASE TRACKING SPREADSHEET.

IF R DOESN’T WANT TO RECEIVE REMINDER VIA EMAIL: I can send you an appointment reminder by mail. What is the best address to use? IF PROVIDED EARLIER, VERIFY ADDRESS. ADDRESS CANNOT BE P.O. BOX. RECORD ADDRESS IN THE CASE TRACKING SPREADSHEET.

Thank you for your time today. We look forward to talking to you again on DATE/TIME OF APPOINTMENT. If you have any questions as you complete the provider [web/mail] questionnaire or before the appointment for the interview to sample and collect information on two of your [residents/participants], or if you need to reschedule, please call [TOLL-FREE NUMBER].

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