Evaluation of the Home Health Pay for Performance Demonstration: Survey instrument

Forms and Documents

Document Name	Status
Form CMS-10270 Evaluation of the Home Health Pay for Performance Demonstration (CMS-10270) Form and Instruction	New
p4p_survey_final_061709.pdf Supplementary Document	2009-06-18
P4P_Eval - Part A_Attachment_2_ OMB Conf Call Resp w Appendices 052209.doc Supplementary Document	2009-06-18
P4P_Eval - Part A_Attachment_1_HHA Survey Directions 052009.doc Supplementary Document	2009-06-18
Summary of Differences 060309.doc Supplementary Document	2009-06-18
Summary of Changes to Instrument and Documentation 060909.doc Supplementary Document	2009-06-18
Changes to P4P Evaluation Web.doc Supplementary Document	2009-06-18
P4P_Eval - Part B_final_060909.doc Supporting Statement B	2009-06-18
P4P_Eval - Part A_final_052909.doc Supporting Statement A	2009-06-18

IC Document Collections

IC ID	Document Title	Status
186977	Evaluation of the Home Health Pay for Performance Demonstration (CMS-10270) Form and Instruction	New

ICR Details

OMB Control No: 0938-1064	ICR Reference No: 200810-0938-011
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Evaluation of the Home Health Pay for Performance Demonstration: Survey instrument
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/22/2009
	Date Received in OIRA: 10/21/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2012	36 Months From Approved
Responses	570	0	0
Time Burden (Hours)	285	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Home Health Pay for Performance Demonstration is part of a movement by the Centers for Medicare & Medicaid Services toward performance-based purchasing for a variety of provider types. The current phase of the Home Health Pay for Performance Demonstration (HHP4PD) relies on the voluntary participation by home health agencies within several states, with random assignment of participating agencies to treatment or control groups within each state, where the control group will not be eligible for incentive payments. These two groups form the primary comparison for determining if the HHP4PD was effective in creating improved, targeted outcomes for patients served by home health agencies.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 36329	06/26/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 53026	09/12/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Evaluation of the Home Health Pay for Performance Demonstration (CMS-10270)	CMS-10270	Home Health Agencies Survey

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	570	0	0	570	0	0
Annual Time Burden (Hours)	285	0	0	285	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Burden increase reflects the resources required to collect information from demonstration participants. See item 12 on p. 4 Part A.

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Annual Cost to Federal Government: $4,508

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/21/2008

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