Appendix C – Recruitment and Consent Materials

Appendix C:
Draft Recruitment and
Consent Materials

Appendix C: Draft Recruitment and Consent - OMB Package Supporting Statements Page C-1

AHRQ logo

LETTER FROM AHRQ TO MEMBER ORGANIZATIONS AND
RESEARCH NETWORKS
DATE
Dear [ORGANIZATION NAME],
The Agency for Healthcare Research and Quality (AHRQ) has developed a measure of care
coordination for adults in primary care settings. The goal of the measure is to provide practices with a
patient and family assessment of the quality of care coordination received in primary care. This
assessment, the Care Coordination Quality Measure (CCQM), is designed foremost as a research tool to
support the evidence base on the important role care coordination plays in advancing quality healthcare
outcomes.
AHRQ, with the assistance of our contractor, the American Institutes for Research (AIR), is conducting
a pilot study of the survey. We are writing to request your assistance in this important project. As a
national [PROFESSIONAL ASSOCIATION/RESEARCH NETWORK], your access to a diverse set
of practices throughout the country would allow our team to test the measure with practices that serve
a diverse patient population with varying care coordination needs, in a range of geographic locations
and practice settings.
If this opportunity is of interest, your [ORGANIZATION/NETWORK] would play an important
supporting role as we identify and recruit 30 primary care practices to provide patient samples for the
pilot test. For the pilot, we are seeking primary care practices that vary in:
• Geographic location (including a mix of urban and rural practices)
• Practice size (as defined by the number of primary care clinicians, inclusive of physicians,
advance practice nurses, and physician assistants)
• Specialty: general practice, internal medicine, family medicine, OB/GYN, and primary care
practices that are part of multi-specialty systems
• Number of practice sites: single- and multi-site primary care practices
• Patient-Centered Medical Home status.
We are seeking both wholly physician-owned practices and primary care units that are part of an
integrated health system. Practices would need to provide a list of patients with specific characteristics
for our team to contact. Our goal is to have 150 completed surveys for each practice (practice sample
size of 375 patients with an anticipated 40% response rate). For practices with fewer than 375 patients,
we will seek to sample the full patient census. The sample may need to be further stratified to provide
sufficient variety among adult patients with respect to their health care needs including: routine care
needs, acute/episodic care needs, and complex care needs.
Support from your [ORGANIZATION/NETWORK] would be extremely valuable to this project as
AHRQ moves forward with the measure’s testing and dissemination. If your network is interested, we
will provide additional information including recruitment materials to be sent to your members.
Your assistance in this work to develop a psychometrically sound, comprehensive, and useful measure
of care coordination in primary care settings from the perspective of patients and families would be
greatly appreciated. AHRQ has contracted with the American Institutes for Research (AIR) to assist in

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AHRQ logo
the development and dissemination of the CCQM. To that end we request that you reply to the AIR
project director for the CCQM, Susan Heil, regarding your interest or with any questions or comments.
Please contact:
Susan K. R. Heil, PhD
Project Director
AHRQ Care Coordination Measure Development Contract
at (301)592-2227 or sheil@air.org.
Sincerely,
[Jan Genevro and/or David Meyers signature block(s)]

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AHRQ logo

ORGANIZATION/NETWORK logo

LETTER FROM MEMBER ORGANIZATIONS AND RESEARCH
NETWORKS TO PRACTICES
DATE
Dear [PRACTICE NAME],
The Agency for Healthcare Research and Quality (AHRQ) has developed a measure of care
coordination for adults in primary care settings, the Care Coordination Quality Measure (CCQM). The
goal of the measure is to provide practices with a patient and family assessment of the quality of care
coordination received in primary care. It is designed foremost as a research tool to support the evidence
base on the important role care coordination plays in advancing quality healthcare outcomes.
The AHRQ contractor for this effort, the American Institutes for Research (AIR), is preparing to test the
measure in primary care practices throughout the country. To assist with this effort, [ORGANIZATION
NAME] is working with AIR to identify practices that may be interested in participating in the pilot test.
AIR plans to include 30 practices throughout the country that vary in practice size and specialty
including general practice, family practice, internal medicine, OB/GYN, and primary care practices
that are part of multi-specialty systems. We are seeking both wholly physician-owned practices and
primary care units that are part of an integrated health system.
Responsibilities of Participating Practices
Practices that choose to participate will be assisted by AIR in identifying an eligible sample of their
patients to receive the survey. The survey will be mailed by the AIR team to selected patients for
completion on their own time. Practices will be asked to coordinate with AIR to fulfill the terms of its
IRB-approved partial waiver of HIPAA authorization to draw and share a list of eligible patients with
the research team. Technical assistance and other support will be offered to practices for this
coordination. Each practice will also be asked to fill out a questionnaire about its practice
characteristics and processes of care. AIR will provide a tailored report in appreciation of your time.
Accompanying this letter is a copy of AIR’s IRB approval and HIPAA waiver forms for your review.
Reasons to Participate
Your assistance in this field test will help to develop a psychometrically sound, comprehensive, and
useful measure of care coordination in primary care settings from the perspective of patients and families.
AIR offers an informative, tailored report summarizing the findings from the survey about how care
coordination is perceived by the patients in your practice. The report will include performance
benchmarks based on all participating practices, as well as a subset of practices with characteristics most
similar to yours. This report will help put your practice on the cutting edge of measurement and the
growing movements in accountability, value-based purchasing, quality improvement, research, and
patient-centered care.
AIR would appreciate a response to this invitation at your earliest convenience. Please respond by email
to cpugliese@air.org and include contact information (email address and telephone number) for the
individual in your practice who will serve as AIR’s point of contact for this data collection. If you decide
to participate, we will send you additional information and recruitment materials. If you have any

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ORGANIZATION/NETWORK logo

questions please do not hesitate to contact AIR’s project director, Dr. Susan Heil at (301) 592-2227 or
sheil@air.org.
Sincerely,
ORGANIZATION/NETWORK signature block

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AHRQ logo

PCP logo

SURVEY COVER LETTER FOR PARTICIPANTS AND
REMINDER LETTER
Initial Letter (mailed with first survey) – Care Coordination Survey
DATE
FIRST AND LAST NAME
LINE ONE OF ADDRESS
LINE TWO OF ADDRESS (IF ANY)
CITY, STATE ZIP
Dear {Mr./Ms.} [LAST NAME]:
We would like your help. American Institutes for Research and [PRACTICE NAME] are working together
to better understand how people feel about their health care and how it is coordinated. We have enclosed a
survey that asks about the care you got from [PRACTICE NAME]. By answering the questions in the
survey, you will give this doctor’s office information they can use to better meet the needs of their patients.
You have been chosen at random from a list of patients receiving care from your doctor’s office to be a part
of this scientific sample. You have not been chosen for any reason other than you received care at this
office. To get accurate results, we need to get answers from you and the other people we ask to take part in
this survey. We hope you will take the time to answer these questions.
What you have to say is private. Your answers will be part of a pool of information from others like you.
What you write will be used only by this study. [PRACTICE NAME] will not know your individual
answers, and they will not know if you answer the survey or not. Your survey will not be returned to your
doctor(s). It will be returned to survey researchers at an independent research firm. Your answers will be
combined with the answers we get from others and reported as a group. You may choose to fill out this
survey or not. Your decision will not affect any care you may get from this doctor’s office now or in
the future.
We hope you will take this chance to tell us about the coordination of the care you received from this
doctor’s office. Please review the information on the included “Participant Informed Consent” sheet and
return the completed survey in the enclosed postage-paid envelope by MONTH/DAY/YEAR. If you prefer
not to participate, please return the blank survey in the enclosed envelope so that we may remove you from
the mailing list.
If you have any questions, please call [CONTACT NAME] at (XXX) [XXX-XXXX]. Thank you in
advance for your help!
Sincerely,

Susan Heil, Ph.D.
Project Director
American Institutes for Research

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Second Reminder (mailed with second copy of survey) Care Coordination Survey
DATE
FIRST AND LAST NAME
LINE ONE OF ADDRESS
LINE TWO OF ADDRESS (IF ANY)
CITY, STATE ZIP
Dear {Mr./Ms.} [LAST NAME]:
We recently mailed you letter asking about the care you got from [PRACTICE NAME].
We have enclosed another copy of the survey along with a description of “Participant Informed Consent”
describing the study and your rights as a participant. If you feel this survey does not apply to you, or that
it was sent to you by mistake, please call [CONTACT NAME] at (XXX) [XXX-XXXX].
What you have to say is private. Your answers will be part of a pool of information from others like you.
What you write will be used only by this study. [PRACTICE NAME] will not know your individual
answers, and they will not know if you answer the survey or not. Your survey will not be returned to
your doctor(s). It will be returned to survey researchers at an independent research firm. Your answers
will be combined with the answers we get from others and reported as a group. You may choose to fill
out this survey or not. Your decision will not affect any care you may get from this doctor’s office
now or in the future.
You have been chosen at random from a list of patients receiving care from your doctor’s office to be a
part of this scientific sample. You have not been chosen for any reason other than you received care at
this office. To get accurate results, it is important that you return this survey. We hope you will take the
time to fill out the survey and send the completed survey back by MONTH/DAY/YEAR.
We hope you will take this chance to tell us about the coordination of the care you received from this
doctor’s office. Your answers can help this doctor’s office better meet the needs of its patients.
Thank you in advance for your help!
Sincerely,

Susan Heil, Ph.D.,
Project Director
American Institutes for Research

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AHRQ logo

PCP logo

Care Coordination Experiences: Pilot Test

PARTICIPANT INFORMED CONSENT
(included with survey cover letter)
What is this survey about?
We are interested learning about patients’ experiences of the health care services that they receive.
Attached is a survey that will ask you to answer a series of questions about your experiences with your
doctor’s office. The survey should take you about 25 minutes to complete.
Who is doing this survey?
This survey is being conducted by the American Institutes for Research (AIR), a not-for-profit social
science research organization headquartered in Washington, DC. This survey is funded by the Agency for
Healthcare Research and Quality (AHRQ), a government agency.
Do I have to complete a survey?
No. It is your choice whether to participate or not. Your primary care provider will not know if you
complete a survey or not.
What are the risks and benefits?
There are no anticipated or known risks for you for completing this survey. There are no direct benefits to
you for completing this survey. However, the answers you provide will help researchers, health care
providers, and policymakers better understand how doctors can best meet the needs of their patients.
How will you protect my privacy?
Your responses will only be reported as a group. Your individual responses will never be viewed by your
doctor or insurance/health plan and your name will not be connected with your completed survey.
More Information
If you have questions about this study, you can contact the Project Director, Susan Heil, Ph.D. at
sheil@air.org, (301) 592-2227, or AIR, 10720 Columbia Pike, Ste. 500 Silver Spring, MD 20901. If you
have concerns or questions about your rights as a participant, you can contact AIR’s Institutional Review
Board (which is responsible for the protection of study participants) at IRB@air.org, toll free at 1-800634-0797 or c/o AIR, 1000 Thomas Jefferson Street NW, Washington, DC 20007.
Agreeing to Complete the Survey
Completing this survey and sending it back to us means that you are giving your “informed consent” to
participate in this effort. This means that you:
• have read and understood the information on this form,
• have information about where you should direct any questions you may have, and
• are willing to participate under the conditions we have described.

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