PIM Generic Clearance Request

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 2900-0770)

TITLE OF INFORMATION COLLECTION: PACT Intensive Management National Evaluation: Patient Experience Interviews

PURPOSE: In 2014, the VHA Office of Primary Care Services (PCS) funded 5 VA sites across the country to implement an intensive management program for patients at highest risk of hospitalization or death. PCS also funded a National Evaluation Center to evaluate the effectiveness of these programs. Patient experience is one of the primary outcomes of interest for the evaluation. We propose to conduct brief telephone interviews with 50-100 patients across the 5 PACT Intensive Management (PIM) programs to collect information on satisfaction with PIM and care received for their chronic illnesses. The information obtained from the interviews will be used to improve care for patients at highest risk of hospitalization or death at the 5 PIM sites, and may be helpful for improving care received by this population of patients across the VA from their PACTs. These interviews will be conducted once, beginning in late Summer 2015.

DESCRIPTION OF RESPONDENTS: VHA patients with a Care Assessment Need (CAN) score of 90 or above and with at least one inpatient admission or ER visit in the past 6 months, who are enrolled in a PIM program at one of 5 national sites: Atlanta VAMC, Cleveland VAMC, Milwaukee VAMC, San Francisco VAMC, Salisbury VAMC. To be eligible, patients must be in good enough health to participate in a 20-30 minute phone interview, and must not have serious cognitive impairment.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [X] Other: _Telephone interviews___

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

4. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name:______Lisa Rubenstein___ ___________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [X] Yes [ ] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [X] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No NA

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X] No

BURDEN HOURS (sample calculation in grey)

Category of Respondent	No. of Respondents	Participation Time ( × minutes =)	Burden (÷ 60 =)
Individuals & Households	50	30	.5 hours
VA Form:	0	0	0
Totals	50 brief telephone interviews	1500 minutes	25 hours

FEDERAL COST: The estimated annual cost to the Federal government is _$0_

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [X] Yes [ ] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

The National Evaluation Center creates lists for each of the 5 PIM sites of patients at their facility with Care Assessment Need (CAN) score of 90 or above and with at least one inpatient admission or ER visit in the past 6 months. The PIM teams review the charts of these patients, determine their care needs based on their chronic conditions, and contact patients who they believe would benefit from the PIM program. We will use the lists created by the NEC to select patients for the telephone interviews, and stratify patients by number of encounters with the PIM team. We will exclude patients with less than 3 encounters with the PIM team, as they may not have had sufficient experience with the program to provide information about the care they received. Then we will stratify patients with more than 3 encounters into two groups: 1) 4-9 encounters, and 2) 10 or more encounters. In order to screen out patients who would not be physically/mentally capable of completing the interview, we will show the patient lists to the PIM teams at each site and ask them to note which patients would be ineligible for the following reasons: 1) physical health too poor to complete a 20-30 minute phone interview, and/or 2) severe cognitive impairment. After removing the ineligible patients from the list, we will assign random numbers to patients within these two strata, order them according to the random number within strata, then contact them beginning with the first patient in the strata.

We will mail an invitation to participate in the interview to the home address listed in the patients’ records, and follow-up with a telephone call to recruit them a few days later. We anticipate we will need to contact approximately 100 patients (10 per site) in order to obtain 50 completed interviews (5 per site). The letter will provide the contact information of the investigator so that patients may indicate their willingness to participate or can contact the investigator to opt out of the interview. Beginning approximately one week after the invitiation letter is mailed, we will begin calling patients to complete the interview, continuing until we have fulfilled a quota of 5 patients per strata for each site.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[X] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [X] Yes [ ] No

Please make sure that all instruments, instructions, and scripts are submitted with the request.

Attachments:

1. PIM patient interview guide

2. Q&A addendum for patient interviews

3. Interview Invitation letter

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Submit all instruments, instructions, and scripts are submitted with the request.

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