Name and Title of Person Completing Questionnaire:______

Provider Survey

Your opinion and input are very important to us. All of your answers will be kept confidential and results will only be presented in aggregate and tabulated form.

AGENCY PROFILE SECTION

Agency Name:______

Name and Title of Person Completing Questionnaire:______

Phone Number:______

Industry Type: (i.e. home health, etc):______

Briefly describe the types of services your agency provides and the population you serve:

______

Service Area: Please indicate the communities/areas that your agency serves. (Check all that apply.)

Central Region / East Region / North Central Region / South Region
College Grove
Downtown
East San Diego
Encanto
Golden Hills/Southeast
Hillcrest/Mission Hills
Normal Heights/Kensington
North Park
Paradise Hills
Pier Area
South East/Logan Heights / Alpine
Boulevard
Campo
Descanso
Dulzura
El Cajon
Guatay
Jacumba
Jamul
Lakeside
La Mesa
Lemon Grove
Mt. Laguna
Pine Valley
Potrero
Santee
Spring Valley
Tecate / Clairemont
Grantville/Del Cerro
La Jolla
Linda Vista
Miramar
Mira Mesa
Morena/Old Town/Bay Park
Mission Valley
Navajo/San Carlos
North City West
Ocean Beach
Pacific/Mission Beach
Point Loma
Serra Mesa/Mission Village
Sorrento Valley
Tierrasanta / Bonita
Chula Vista
Coronado
Imperial Beach
National City
North Island Naval Air Station
Nestor
San Ysidro

North Region

Anza/Imperial
Bonsall
Borrego
Cardiff
Carlsbad
Del Mar
Encinitas/Leucadia / Escondido
Fallbrook
Julian
Oceanside
Camp Pendleton
Pala
Palomar / Pauma Valley
Poway
Rainbow
Ramona
Ranchita
Rancho Bernardo
Rancho Penasquitos / Rancho Santa Fe
San Marcos
San Onofre/San Clemente
Santa Isabel
Solana Beach / Temecula
Valley Center
Vista
Warner Springs/Agua Caliente

What types of long term care services does your agency provide? (Check all that apply)

Financial Management / Skilled Nursing Facilities (Institutional)
Home Help/Personal Care Services / Home Health/Nursing
Adult Day Health Care / Respite, Family Support
Home Delivered Meals / Hospice
Transportation / Durable Medical Equipment
Care/Case Management Services / Nutrition Services
Counseling/Education Advocacy / In-home Supportive Services
Independent Living Services / Home Modification
Alzheimer’s Day Care Resources / Housing and Residential Services
Medical Care (primary & specialty) / Mental Health Services
 / Other (Please Specify): ______

Which of the following types of long term care services do your clients have difficulty accessing?

(Check all that apply)

What are the root causes for these gaps or difficulty in obtaining services?

______

What problems do you have in trying to obtain long term care services for the clients you serve?

______

If you had the opportunity to design an integrated long-term care delivery system to meet the needs of the elderly and disabled in San Diego County, what services would you be sure to include in the system?

a. ______

b.______

c.______

Based upon your experience caring for the aged and disabled population, what additional long term care services need to be added to meet the needs of the elderly and disabled in San Diego County?

a.______

b.______

c.______

What do you think are the top three strengths of the existing long-term care delivery system?

a.______

b.______

c.______

What are your recommendations for improving access to and the availability of needed long-term care services in San Diego County?

______

For each of the following types of long term care services, please indicate the degree to which you believe an adequate service network exists to meet the needs of the elderly and disabled Medi-Cal population in San Diego County.

Financial Management Services
More than adequate
Adequate
Somewhat adequate
Not adequate / Skilled Nursing Facilities (Institutional)
More than adequate
Adequate
Somewhat adequate
Not adequate / Hospice
More than adequate
Adequate
Somewhat adequate
Not adequate
Home Help/Personal Care Services
More than adequate
Adequate
Somewhat adequate
Not adequate / Home Health/Nursing
More than adequate
Adequate
Somewhat adequate
Not adequate / Durable Medical Equipment
More than adequate
Adequate
Somewhat adequate
Not adequate
Adult Day Health Care
More than adequate
Adequate
Somewhat adequate
Not adequate / Respite, Family Support
More than adequate
Adequate
Somewhat adequate
Not adequate / Nutrition Services
More than adequate
Adequate
Somewhat adequate
Not adequate
Home Delivered Meals
More than adequate
Adequate
Somewhat adequate
Not adequate / In-home Supportive Services
More than adequate
Adequate
Somewhat adequate
Not adequate / Independent Living Services
More than adequate
Adequate
Somewhat adequate
Not adequate
Transportation
More than adequate
Adequate
Somewhat adequate
Not adequate / Home Modification
More than adequate
Adequate
Somewhat adequate
Not adequate / Alzheimer’s Day Care Resources
More than adequate
Adequate
Somewhat adequate
Not adequate
Care/Case Management Services
More than adequate
Adequate
Somewhat adequate
Not adequate / Housing and Residential Services
More than adequate
Adequate
Somewhat adequate
Not adequate / Medical Care (primary & specialty)
More than adequate
Adequate
Somewhat adequate
Not adequate
Counseling/Education Advocacy
More than adequate
Adequate
Somewhat adequate
Not adequate / Mental Health Services
More than adequate
Adequate
Somewhat adequate
Not adequate

Please provide us with any other comments that may be helpful.

______

Please list any surveys or needs assessment information that you are aware of that may be helpful in assessing the adequacy of the long term care provider network in San Diego County.

______