Supporting Statement

Supporting Statement A

Evaluation of Frontier Community Health Care Network Coordination Grant

OMB Control No. 0915-XXXX

Terms of Clearance: None

A. Justification

1. Circumstances Making the Collection of Information Necessary

The Health Resources and Services Administration’s (HRSA), Office of Rural Health Policy (ORHP) requests Office of Management and Budget ( OMB) approval for the evaluation of Montana’s Frontier Community Health Care Network Coordination Grant (FCHCNC). In FY 2011, ORHP released a Frontier Community Health Care Network Coordination Grant to support a network that focuses on clinical service coordination by a care coordinator. The program will be coordinated by clinically trained Care Transitions Coordinators (CTC) working with Community Health Workers (CHW) in 11 participating network communities. By developing intervention with clients, the CTCs and CHWs will work to improve care transitions and client outcomes by reducing or eliminating avoidable hospitalizations and re hospitalizations, ER visits and nursing home placements. This three year grant program which began September 30, 2011 and will conclude September 29, 2014, was awarded to the Montana Department of Public Health and Human Services (MT DPHHS).

In FY 2012, ORHP funded an evaluation of the Frontier Community Health Care Network Coordination (FCHCNC) Grant. This evaluation will consist of reviewing the implementation and effectiveness of the FCHCNC Grant for the 11 participating network communities. The evaluation design will allow us to determine the following objectives:

• Identify the strengths and challenges that grantees and key partners are using to implement the FCHCNC grant

• Assess the effectiveness of the grantees implementation of the FCHCNC Grant

• Determine client satisfaction

• Assess whether the intervention is meeting FCHCNC Grant goals

• Assess health care utilization and cost savings associated with FCHCNC Grant participation

The evaluation will collect data from key stakeholders, grantee sites and clients using the following methods:

1. In person and telephonic interviews

2. Grantee data collection forms

3. Client satisfaction survey

ORHP is seeking approval from the OMB for the four methods of data collection. A brief description of the data collection activities for which OMB approval is being sought is included below:

In Person and Telephonic Key Informant Interviews: (Attachments A-F) Interviews will be conducted with hospital administrators, providers, the care transitions coordinator, community health workers and clients participating in the program. The interview guides consist of open ended questions designed to gather information on successes and challenges associated with the program design and implementation. Additionally the interviews seek to gather information about the CHW training, client enrollment, intervention design for clients and satisfaction with the program.

Grantee Data Collection: (Attachment G) The data collected from each grantee site will provide details on program and client activity on a quarterly basis. The data will include the number of clients with whom the CHWs are involved, the intervention goals and objectives for each participant, resources used as part of the interventions, and the time required to achieve the intervention goals. To provide insight on the effectiveness of the grantees’ recruitment, grantee data collection will also provide information on CHWs’ efforts to enroll clients and the successes and challenges experienced with various recruitment methods.

Client Satisfaction Survey (Attachment H) The data collected as part of the client satisfaction survey will include data on types of health services used during their intervention and overall satisfaction with the FCHCNC Grant program.

2. Purpose and Use of Information Collection

The evaluation is designed to contribute to the comprehensive understanding of the planning, implementation and effectiveness of the Montana’s Frontier Community Health Care Network Coordination Grant pilot project. In order to determine the impact of the FCHCNC Grant pilot program, the evaluation will focus on identifying the results of the established evaluation questions provided in Exhibit 1.

Exhibit 1: Key Evaluation Questions

1. What is the grantee’s ability to design, create and implement a functioning patient-centered medical home case management model in frontier areas?

• What community, patient, and population characteristics are associated with the program’s utilization?

• Was the training manual utilized by the program effective in training the community health workers? Is the program being implemented as intended? Why or why not?

• What technology and resources are needed to effectively implement the model?

• What are the lessons learned and barriers identified by the grantee in designing, creating and implementing this model?

• Is this model sustainable after the termination of federal funding?

• Is this model replicable in other frontier communities?

• What are the recruitment and retention issues?

• What were the original issues and concerns that motivated ORHP to pilot this demonstration? 

2. Is the proposed model effective in improving care for the target population?

• Are patients in the target population provided better quality care compared to alternatives?

• Are patients in the target population satisfied with the services as compared to alternatives?

• How has provider satisfaction changed since the program was implemented?

• Has the program reduced avoidable hospitalizations?

3. How has the program facilitated independent living for Medicare beneficiaries?

• Has there been a decrease in the level of acuity of care provided to Medicare beneficiaries?

• Has the availability and use of home health services increased?

• Has the availability and use of home monitoring increased?

4. How has the program increased access to essential health services?

• Has this model allowed for greater integration of primary, tertiary and post-acute care services?

• Has the program benefited the providers who serve the target population?

• Has the program impacted the communities where it has been implemented?

5. How has the program improved care transitions between distant tertiary care providers and local care providers in frontier areas?

• Did the proposed model improve care transitions for the target population?

6. Was the proposed model cost effective?

• What was the impact on the proposed model on costs to Medicare?

• What was the impact of the proposed model on cost to other payers?

• What was the impact of the proposed model on cost to the patients of participating in the program?

In Person and Telephonic Key Informant Interviews: The data collection will focus on provider satisfaction, client and family satisfaction and the design, creation, and implementation of the FCHCNC Grant. Qualitative data will be analyzed and incorporated into the reports. In addition to the site visit interviews, the qualitative analysis will also include telephone interviews with other FCHCNC Grant stakeholders.

Grantee Data Collection: The data collected from each grantee site will provide details on program and client activity on a quarterly basis. The data will include the number of clients with whom the CHWs are involved, the interventions being used by the CHWs, the goals of the interventions, resources used as part of the interventions, and the time to achievement of the intervention goals. To provide insight on the effectiveness of the grantees’ recruitment, grantee data collection will also provide information on CHWs’ efforts to enroll clients and the successes and challenges encountered with various recruitment methods.

Client Satisfaction Survey: The data collected as part of the client satisfaction survey will include client utilization of health services during their intervention and overall satisfaction with the FCHCNC program.

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The data being collected as part of this evaluation is new and unique. If the data listed above are not collected, then the evaluation will not be able to be completed.

2. Use of Improved Information Technology and Burden Reduction

Given the unique challenges of implementing a program in remote and frontier locations, the evaluation was designed to accommodate the large distances between health facilities and client’s homes and the potential physical limitations of the clients enrolled in the program.

In Person and Telephonic Key Informant Interviews: The key informant interviews will take place during the two annual site visits. The interviewees’ responses will be recorded. Because the interview is conducted in-person and the responses will be recorded, there is no paper record to fill out and no ability to transfer the responses electronically, outside of the recording. The final telephone interviews will be recorded as well so there is no paper collection of responses nor is there an ability to transfer responses electronically. (0% will be submitted electronically)

Grantee Data Collection Telephonic and Electronic Submission: Due to the geographically dispersed area of the grant sites and the lack of secure computer access by the CHWs, the grantee data will be collected over the phone with the aid of the Care Transition Coordinator (CTC) and submitted electronically. (100% of quarterly data will be submitted electronically.)

Client Satisfaction Survey: The client satisfaction survey will mailed to the clients who have recently completed the program. A reminder mailer will be sent out once to individuals who have not completed the survey. This method of collection was deemed the easiest way to get the information from the client, given the lack of computer and internet access in this population. The survey will then be mailed back to the Montana Care Transition Coordinator in a pre-addressed stamped envelope and then forwarded to Altarum. (0% of data will be available electronically)

2. Efforts to Identify Duplication and Use of Similar Information

The data requested for this evaluation are unique to the Frontier Community Health Care Network Coordination Grant pilot program and are not available elsewhere.

2. Impact on Small Businesses or Other Small Entities

No small businesses will be involved in this study.

2. Consequences of Collecting the Information Less Frequently

In Person and Telephonic Interviews: The site visit interviews will be conducted annually to obtain an update on program progress. Each interviewee (hospital administrators, grantees, care transition coordinator, clients and community health worker) will be interviewed once during each year of the evaluation for a total of three interviews either in person or via telephone. Collecting this information less frequently may allow key challenges and successes of the pilot program implementation to be missed, possibly impacting the near term and long term success of the program.

Grantee Data Collection: The grantees (community health workers) will report data monthly starting as soon as OMB approval is granted and continue through the fall of 2014 when the Montana FCHCNC Grant terminates. The CHWs will report the data to the Care Transition Coordinator monthly. The Care Transition Coordinator will submit the combined reports quarterly to the Altarum team. Quarterly data collection is the least frequent data collection allowed per the evaluation deliverables outlined in the evaluation contract. Less frequent data collection may result in data integrity concerns including loss of data from recall issues and missing information due to lack of consistent reporting.

Client Satisfaction Survey: The client satisfaction survey will be collected one time only at the end of the client’s participation in the program.

If the data collection efforts listed above occur less frequently than described, then the evaluation will be extremely limited, if not impossible to complete. Given that the evaluation is of a pilot project, all data collected is new and unique. Without the information, no valuable information on the program’s outcomes and effectiveness can be determined. Additionally, the deliverables outlined in the Evaluation of the Frontier Community Health Care Network Coordination Grant contract [HHSH250200646013I/HHSH25034007T] will not be met.

There are no legal obstacles to reduce the burden.

2. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

There are no special circumstances. This request fully complies with the regulation.

2. Comments in Response to the Federal Register Notice/Outside Consultation

Section 8A:

• A 60-day Federal Register Notice was published in the Federal Register on September 5, 2013, vol. 78, No. 172; pp. 54662-63 (See attachment FRN-Info Collection-Frontier Care Coordination-09-05-13). There were no public comments.

Section 8B:

The evaluation team consulted with the MHA Care Transition Coordinator, Heidi Blossom, (Contact information: (406) 442-1911 Ext. 125; Heidi@mtha.org; MHA 1720 Ninth Avenue Helena, MT 59601) to discuss the grantee data collection instrument and to discuss the best ways to collect the information from the CHWs. Additionally, Ms. Blossom provided some feedback on the best process to collect the client satisfaction survey. The consultation occurred during July, August and September of 2013.

2. Explanation of any Payment/Gift to Respondents

There are no payments or gifts provided to any of the respondents in this evaluation.

2. Assurance of Confidentiality Provided to Respondents

For the in person and telephonic interviews, NORC Institutional Review Board (IRB) submitted the interview protocols for review. The research activities were found to be exempt. (Attachments A-F) As part of the protocols each individual is provided informed consent and agrees to participate in the interview.

The grantee data collection instrument and client satisfaction survey underwent IRB review from Chesapeake Institutional Review Board. Both instruments received IRB approval. The IRB waived the requirement for obtaining consent for both the grantee data collection form and the client satisfaction survey. (Attachments G-H)

The grantee data collection does require the client’s Medicare identification number to be collected. The purpose of that information is to aid in cost analysis of the program. The CTC has access to the client information and will transfer the data quarterly using a secure website.

2. Justification for Sensitive Questions

Current health condition of the beneficiaries will be collected. The nature of the program is to help those individuals with chronic health conditions. The health information of those participating in the program will not be tied to individual names.

The client satisfaction survey asks about race and ethnicity. The client satisfaction survey collects general demographic information from those that participated in the program. The question is voluntary and should not create undue burden on the participant to answer.

2. Estimates of Annualized Hour and Cost Burden

12A. Estimated Annualized Burden Hours

In Exhibit 2, estimates of the collection burden on participants from each category of respondent are provided. The client satisfaction survey will take approximately 10 minutes. The interviews for the hospital administrators, the providers, the Director of Grants and Program Development at the Association of Montana Health Care providers and Director of Montana Office of Rural Health and the participants are estimated to take .5 of an hours. The interviews of the community health workers and the care transition coordinator are estimated to take approximately one hour based on the contractor’s experience with similar interviews. The completion of the grantee data collection is estimated to take CHWs four burden hours per quarter. This includes .75 burden hours to report data monthly to the care transition coordinator. Draft interview protocols, grantee data collection form and client satisfaction survey can be found in Attachments A-H.

The following table identifies the annualized burden estimate:

Exhibit 2: Estimated Burden Hours

Type of Respondent	Form Name	Number of Respondents	Number of Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours
Client	Client Satisfaction Survey	85	1	10/60	14.2
Hospital Administrator	Hospital Administrator Interview Protocol	22	1	30/60	11
Provider	Primary care Provider Interview Protocol	22	1	30/60	11
Community Health Workers	Community Health Worker Interview Protocol	11	1	60/60	11
Nurse	Care Transitions Coordinator Interview Protocol	1	1	60/60	1
Director of Grants and Program Development at the Association of Montana Health Care providers; Director of Montana Office of Rural Health	Grantee Interview Protocol	2	1	30/60	1
Client	Client Interview/ Focus Group Protocol	22	1	30/60	11
Community Health Workers	Grantee Data Collection Form	11	4	240/60	176
	Total	176			236.2

12B.

In Exhibit 3, we present the estimated burden cost for the data collection effort. The total estimated annualized cost to the respondents is $4,439.30. This cost estimate was calculated based on the total respondent hour burdens noted in Exhibit 2. The wage rate is the median wage rate for management operations, healthcare practitioners and technical occupations, and health care support occupations according to the US Department of Labor Bureau of Labor Statistics. Data for the clients participating in the project were estimated using the Social Security Administration’s Annual Statistics Supplement 2013 Percentage of distribution of monthly benefit for retired workers, by state and other area and monthly benefit.

Exhibit 3: Estimated Annualized Burden Costs¹

Type of Respondent	Total Burden Hours	Hourly Wage Rate	Total Respondent Costs
Providers	11	$90.002	$990.00
Client	25.2	$2.973	$74.84
Hospital Administrator	11	$36.374	$400.07
Community Health Workers	187	$15.565	$2,909.72
Nurse	1	$28.296	$28.29
Director of Grants and Program Development Association of Montana Health Care providers; Director of Montana Office of Rural Health	1	36.377	$36.37
Total			4,439.30

¹Data is based on the Montana May 2013 State Occupational Employment and Wage Estimates , United States, US Department of Labor, Bureau of Labor Statistics. (http://www.bls.gov/oes/2013/may/oes291069.htm)

²Based on median hourly wages for Healthcare Practitioners and Technical Occupations- Physicians and Surgeons “May 2013 National Occupational and Wage Estimates” United States, US Department of Labor, Bureau of Labor Statistics. Montana specific link for physicians and surgeon rate: (http://www.bls.gov/oes/2013/may/oes_mt.htm#29-0000) General rate link for physicians and surgeons, all other: (http://www.bls.gov/oes/2013/may/oes291069.htm)³ Based on Social Security Administration’s Annual Statistical Supplement 2013.US Social Security Administration, Office of Retirement and Disability Policy. Supplemental Security Income State Data Table 7B3: Number of recipients of federally administered payments and average monthly payment by state or other area, December 2012. Median monthly wage in Montana is 476.71. Assuming 160 hours’ work’ a month gets us to an average of 2.97. (http://www.ssa.gov/policy/docs/statcomps/supplement/2013/7b.html#table7.b3)

3. Based on median hourly wages for Management Operations - Medical and Health Services Managers, “May 2013 National Occupational and Wage Estimates” United States, US Department of Labor, Bureau of Labor Statistics. Montana specific data (http://www.bls.gov/oes/2013/may/oes_mt.htm#11-0000 ) General rate link for Medical and Health Services Managers(http://www.bls.gov/oes/2013/may/oes119111.htm

4. Based on median hourly wages for Healthcare Support Occupations- Healthcare Support Workers, “May 2013 National Occupational and Wage Estimates” United State, US Department of Labor, Bureau of Labor Statistics. Montana specific link found here: (http://www.bls.gov/oes/2013/may/oes319099.htm) General rate link (http://www.bls.gov/oes/2013/may/oes319099.htm)

5. Based on median hourly wages for Healthcare Practitioners and Technical Occupations-Registered Nurse, “May 2013 National Occupational and Wage Estimates” United States, US Department of Labor, Bureau of Labor Statistics. Montana specific link: (http://www.bls.gov/oes/2013/may/oes_mt.htm#29-0000) General rate link for Registered nurses: (http://www.bls.gov/oes/2013/may/oes291141.htm)

6. Based on median hourly wages for Management Operations - Medical and Health Services Managers, “May 2013 National Occupational and Wage Estimates” United States, US Department of Labor, Bureau of Labor Statistics. Montana specific data (http://www.bls.gov/oes/2013/may/oes_mt.htm#11-0000 ) General rate link for Medical and Health Services Managers http://www.bls.gov/oes/2013/may/oes119111.htm

2. Estimates of other Total Annual Cost Burden to Respondents or Recordkeepers/Capital Costs

There are no capital or startup costs associated with data collection.

2. Annualized Cost to Federal Government

The total value of the contract between HRSA and the contractor is $882,329.54 over the course of three years (9/30/2012-9/29/2015). Task 3 of the contract is the Evaluation and Analysis which includes the deployment and analysis of the client satisfaction survey ,the grantee data collection and analysis,and health care utilization and cost analysis. The total cost for task 3 is $224,130.43. The annualized cost of task 3 therefore is $74,710.14.

Task 4 of the contract is the in person and telephonic interviews (site visits) and analysis of the interviews. The total cost of task 4 is $229,244.63. Therefore the annualized cost of task 4 is $75,414.88. The total annualized cost of the evaluation and analysis of the client satisfaction surveys, the grantee data collection and site visit interviews therefore equals $150,125.02. In addition, the estimation of the annualized costs for the Federal employees involved in the oversight and analysis of information collection is $14,628.

The total annualized cost for the assessment therefore is $164,753.02 ( Evaluation costs of $150,125.02 plus the Federal employee costs of $14,628.00).

Evaluation Component	Annualized Cost	Total Cost (3 years)
Evaluation of Frontier Community Health Care Network Coordination Grant Contract	N/A	$882,329.54
Task 3 Evaluation and Analysis	$74,710.14	$224,130.43
Task 4 Site Visits	$75,414.88	$226,244.63
Total Task 3 and 4 Evaluation Costs	$150,125.02	$450, 374.06
Cost of Federal employees involvement	$14,628.00	$43,884.00
Total annualized cost	$164,753.02	$494,259.06

2. Explanation for Program Changes or Adjustments

This is a new data collection

2. Plans for Tabulation, Publication, and Project Time Schedule

Data for the evaluation will be collected during the final two years of the Montana FCHCNC Grant. Information will be collected over a 29 month period following OMB approval. Initial analysis will begin after the data is collected from the grantees, the client satisfaction survey, and the key informant interviews and will continue throughout the project period to produce interim quarterly reports. Additionally, there will be a final evaluation and final policy briefing report upon completion of the evaluation. Exhibit 4 provides a schedule of data collection, analysis and reporting following OMB approval. The remainder of this section describes the analytic techniques that will be employed.

Exhibit 4: Timetable for Data Collection, Analysis and Publication

Activity	Estimated Start Date	Estimated End Date
Key information interviews	Within 12 months of OMB approval	Within 24 months of OMB approval
Grantee Data Collection	Within 3 months following OMB approval	Within 24 months of OMB approval
Client Satisfaction Survey	Within 1 month following OMB approval	Within 24 months of OMB approval
CMS Health Services and Cost data	Within 1 month following OMB approval	Within 24 months of OMB approval
DEVELOPMENT OF REPORTS
Development of Quarterly Report	Within 3 months following OMB approval	Within 33 months of OMB approval
Development of Annual Cost Report	Within 6 months following OMB approval	Within 12 months of OMB approval
Development of Final Evaluation Report	20 month following OMB approval	Within 33 months of OMB approval
Development of Final policy brief	20 month following OMB approval	Within 33 months of OMB approval

Data analysis for the in person and telephonic interviews will be descriptive.

2. Reason(s) Display of OMB Expiration Date is Inappropriate

All data collection materials will display the OMB expiration date.

2. Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification

Attachments for Supporting Statement

1. Beneficiary Interview Guide

2. Care Transition Coordinator Interview Guide

3. Community Health Worker Interview Guide

4. Grantee Interview Guide

5. Hospital Administrator Interview Guide

6. Primary Care Interview Guide

7. Grantee Data Collection Form

8. Client Satisfaction Survey

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