Form CMS-10270 Home Health Agencies Survey

Supporting Statement For Paperwork Reduction Act Submission – Part A

“Evaluation of Home Health Pay for Performance Demonstration”

Appendix: Treatment and Control Survey Questionnaire Instruments

"HHA Treatment" Survey

Home Health Pay for Performance Demonstration Evaluation Survey

The purpose of this survey is to gather information from home health agencies that were selected to be Treatment agencies in the Medicare Home Health Pay for Performance Demonstration. These questions focus on information about the implementation of the demonstration, and any changes in agency policy or practices that may have occurred in response to the demonstration.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

1. Enter the Name of Agency: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

1a. [OPTIONAL] Email address of Agency or Person completing survey:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2. Enter Agency's Medicare Provider Number: _ _ _ _ _ _

3. Title of person completing form: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(Name of Agency = 50 characters; [OPTIONAL] Email address = 50 characters; Provider Number = 6 characters; Title = pull-down menu based on titles in Item #4)

4. Which of the following changes in personnel have been made at your agency since the beginning of the demonstration (January 1, 2008)? Indicate change for each--if any.

(Radio button w/ "No Change" as default)

Job Category	Decreased Staffing	No Change	Increased Staffing
Senior management (CEO, DON, etc.)			
Quality improvement or performance improvement coordinator			
Clinical supervisory positions			
Registered nurse			
Registered nurse (with specialty license, e.g., wound, psychiatric)			
Licensed practical nurse			
Respiratory therapist			
Physical therapist			
Occupational therapist			
Medical social worker			
Home health aide			
Administrative/support			
Other (specify ___25 characters_______)			

5. Have you added any new positions/functions specifically because of your participation in the demonstration? If so, please indicate if
   1) the position and function did not exist and was not added,
   2) the position and/or function already exists,
   3) a new function added to an existing position, or
   4) a new position and function was created since January 1, 2008?
   Check all that apply.

(Radio button w/ "Not Added" as default)

Job Function	Not Added (1)	Already Exists (2)	New Function (3)	New Position (4)
Quality improvement or performance improvement coordination				
Documentation quality assurance or OASIS accuracy				
Staff education				
Outcome analysis				
Utilization review				
Some combination of "a - e" functions				
Other (specify_____________)				

6. Between January 2008 and August 2008 have you participated in a quality improvement program with your Medicare Quality Improvement Organization?
Yes  No 

(Radio button w/ "No" as default; If "Yes" is checked, then at least one QIO outcome measure must be listed; Based on call w/ CFMC, three is max number of outcome measures; 50 characters each available to describe each outcome measure)

6a. If you participated in a Quality Improvement Organization program, what outcome measures are you targeting? (List all that apply)

7. Were you participating in a quality improvement program with your Medicare Quality Improvement Organization before enrolling in the Pay for Performance Demonstration, i.e., before January 2008?
Yes  No 

(Radio button w/ "No" as default; If "Yes" is checked, then at least one QIO outcome measure must be listed; Based on call w/ CFMC, three is max number of outcome measures; 50 characters each available to describe each outcome measure)

7a. If you were participating in a Quality Improvement Organization program, what outcome measures were you targeting in the year prior to the demonstration?
(List all that apply)

8. What policy changes has your agency implemented since the beginning of the demonstration (January 1, 2008)? Policies related to…(Check all that apply)

(Check box; no pre-fill)

 a. Changes in care practices (e.g., “front-loading” visits)

 b. Implementation of care pathways/standardized care plans

 c. Decrease in time between referral and admission visit

 d. Communication with patient (quantity and/or quality)

 e. Communication with physician (quantity and/or quality)

 f. Disease management programs

 g. Telehealth programs

 h. Falls prevention programs

 i. Patient infection control programs

 j. New clinical specialties programs (specify): __________________

 k. Change in on-call staff for non-business hours

 l. Expanded business hours

 m. Changes in productivity requirements for staff

 n. Changes in staff hiring requirements

 o. Other (specify): __________________

9. What activities directed toward care providers and intended to increase quality of care has your agency implemented since the beginning of the demonstration (January 1, 2008)? (Check all that apply)

(Check box; no pre-fill)

 a. New staff education programs and/or changes in requirements for number of educational hours

 b. Performance improvement programs

 c. Mentoring programs

 d. Additional clinical team meetings

 e. Additional record review activities

 f. New staff competencies

 g. Changes in staff evaluation criteria

 h. Employee incentives for performance improvement

 i. Changes in staff management practices of nursing or therapy staff (e.g., increased oversight, etc.)

 j. Changes in home health aide supervisory practices

 k. Additional clinical resources for field staff (e.g., consultation; new specialty care staff; Web access to best practices, etc.)

 l. Other (specify): _____________________

10. What technological innovations designed to improve the quality of patient care has your agency implemented since the beginning of the demonstration (January 1, 2008)? (Check all that apply)

(Check box; no pre-fill)

 a. Telemonitoring equipment

 b. Electronic medical records

 c. Electronic information exchange with referral sources (e.g., hospital)

 d. Electronic information exchange with physicians

 e. Secure electronic messaging systems for agency care team members

 f. New infusion devices

 g. New respiratory equipment (e.g., ventilators, etc.)

 h. Physiologic monitoring equipment (e.g., blood glucose monitors, prothrombin monitors, etc.)

 i. Inflatable mattresses or similar equipment to reduce incidence of pressure ulcers

 j. Special dressings or therapies for wound care

 k. Medication reminder systems

 l. Medication dispensing systems

 m. Implementation of medication checking/reconciliation software

 n. Personal emergency response systems

 o. Electronic access to policies, procedures, best practices, etc.

 p. Other (specify): _____________________

11. What care practice changes designed to improve the specific clinical outcomes has your agency implemented since the beginning of the demonstration (January 1, 2008)? (Check all that apply)

(Check box; no pre-fill)

 a. Changes in visit patterns (e.g., front-loading; increased number visits for specific diagnoses)

 b. Introduction of telemonitoring

 c. Changes in visit mix (e.g., increased use of PT, etc.)

 d. Introduction of disease management programs

 e. Introduction and/or increased use of clinical pathways

 f. Changes in patient teaching plans

 g. Increased communication with MD

 h. Inclusion on POC of specific parameters for when to call physician (e.g., call MD for BS > 150)

 i. Increased care team communication (e.g., team meetings, etc.)

 j. Implementation of screening assessments (e.g., falls risk)

 k. Implementation of falls prevention programs

 l. Enhanced wound care protocols

 m. Increased efforts to improve vaccination rates (e.g., flu and pneumococcus)

 n. Use of medication reminder or dispensing systems

 o. Other (specify): _____________________

12. If your agency is part of a home health agency chain, identify any corporate initiatives that have been implemented since the beginning of the demonstration (January 1, 2008). (Indicate change for each--if any)

(Radio button w/ "No Change" pre-filled)

 NA, Not Part of Chain

Corporate Initiative Focus	No Change	Modified Existing Program	Implemented New Program
Reducing potentially avoidable hospitalizations			
Reducing potentially avoidable emergency care			
Improving rehabilitation outcomes			
Pressure ulcer treatment			
Use of technology to support patient care			
Staff training			
Participation in QIO quality initiatives			
Performance incentive program (monetary)			
Enhanced corporate communications			
Other (specify):__________________			

13. Identify any local/regional changes that have occurred since January 1, 2008 that may have created an impact on your agency. (Indicate impact for each--if any)

(Radio button w/ "No Impact" pre-filled)

		Type of Impact
	Type of Local/Regional Change	No Impact	Negative	Both + / -	Positive
a.	# of community hospitals (or hospital beds)				
b.	# of skilled nursing facilities (or SNF beds)				
c.	# of urgent/emergency care facilities				
d.	# of home health agencies				
e.	Availability of nurses locally				
f.	Availability of physical therapists locally				
g.	Availability of occupational therapists locally				
h.	Availability of home health aides locally				
i.	Increase in population locally				
j.	Natural disaster, e.g., flood, fire, etc.				
k.	State health care policy (e.g., Medicaid funding)				
l.	Informal local health care practice patterns				
m.	Change in available community resources (e.g., Assisted living facilities, adult day care, transportation programs, meal programs, respite care providers, etc.)				

14. What is your best estimate of the effects of activities related to the pay for performance demonstration on the cost of providing care to your patients?

(Radio button w/ "Less than 1% change" pre-filled)

Decrease by > 10%	Decrease by 5 – 10%	Decrease by 1 – 5%	Less than 1% change	Increase by 1 – 5%	Increase by 5 – 10%	Increase by > 10%
						

15. How much of an impact on your patients do you think your quality improvement activities have had on the outcomes targeted in the demonstration?

(Radio button w/ "No Impact" pre-filled)

		Probable impact of QI on outcomes
	Outcome Measure	No Impact	Modest Improvement	Substantial Improvement
a.	Incidence of Acute Care Hospitalization			
b.	Incidence of Any Emergent Care			
c.	Improvement in Bathing			
d.	Improvement in Ambulation/Locomotion			
e.	Improvement in Transferring			
f.	Improvement in Status of Surgical Wounds			
g.	Improvement in Management of Oral Medications			

16. What effect do you think the demonstration will have on the following?

(Radio button w/ "No Impact" pre-filled)

	Very Negative	Slightly Negative	No Impact	Slightly Positive	Very Positive
My agency’s patient outcomes					
Quality of care at my agency					
Quality of care statewide					
Access to care for Medicare beneficiaries					
Cost of providing home health care					
Financial solvency of my agency					
Financial solvency of home health agencies statewide					
Profitability of my agency					
Profitability of home health agencies statewide					

17. Rate each of the following groups/individuals as demonstrating Low/No, Moderate, or High levels of Commitment, Readiness, or Willingness to Sustain the P4P demonstration? Please check either "Low", "Mod" or "High" for each of these three constructs for each of the positions/groups indicated. Leave row blank if "not applicable" or "position does not exist".

(Check box with no pre-filled values)

	Commitment			Readiness			Willingness to Sustain
	Low	Mod	High	Low	Mod	High	Low	Mod	High
a. Administrator/Owner/CEO									
b. Senior Clinical (Physician, DON)									
c. Clinical Managers/Supervisors									
d. Field RNs									
e. Field PTs									
f. Field OTs									
g. Field Social Workers									
h. Field Home Health Aides									
i. Admin. Staff (incl. QI/PI Coord.)									

18. Please rate the feedback on your agency’s performance provided to you by the demonstration implementation contractor.

(Radio button w/ "N/A" pre-filled)

	Disagree Strongly	Disagree Somewhat	Agree Somewhat	Agree Strongly	N/A
The reports are accurate and complete					
The information is presented in a manner that is easy to understand.					
The information is delivered to our agency in a timely manner.					
The information is useful to my agency for quality improvement purposes.					

19. Please use the space below to provide any other comments on the demonstration and any suggestions you have for the implementation of home health pay for performance. (optional)

(There will be a 250-word limit on this box with automatic word count)

Thank you very much for providing your feedback. Please review your answers prior to pressing the "Send" button.

"HHA Control" Survey

Home Health Pay for Performance Demonstration Evaluation Survey

The purpose of this survey is to gather information from home health agencies that were selected to be Control agencies in the Medicare Home Health Pay for Performance Demonstration. These questions focus on information about the implementation of the demonstration, and any changes in agency policy or practices that may have occurred in response to the demonstration.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

6. Enter the Name of Agency: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

1a. [OPTIONAL] Email address of Agency or Person completing survey:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

7. Enter Agency's Medicare Provider Number: _ _ _ _ _ _

8. Title of person completing form: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(Name of Agency = 50 characters; [OPTIONAL] Email address = 50 characters; Provider Number = 6 characters; Title = pull-down menu based on titles in Item #4 from Treatment survey)

4. Between January 2008 and August 2008 have you participated in a quality improvement program with your Medicare Quality Improvement Organization?
Yes  No 

(Radio button w/ "No" as default; If "Yes" is checked, then at least one QIO outcome measure must be listed; Based on call w/ CFMC, three is max number of outcome measures; 50 characters each available to describe each outcome measure)

4a. If you participated in a Quality Improvement Organization program, what outcome measures are you targeting? (List all that apply)

5. What policy changes has your agency implemented since the beginning of the demonstration (January 1, 2008)? Policies related to…(Check all that apply)

(Check box; no pre-fill)

 a. Changes in care practices (e.g., “front-loading” visits)

 b. Implementation of care pathways/standardized care plans

 c. Decrease in time between referral and admission visit

 d. Communication with patient (quantity and/or quality)

 e. Communication with physician (quantity and/or quality)

 f. Disease management programs

 g. Telehealth programs

 h. Falls prevention programs

 i. Patient infection control programs

 j. New clinical specialties programs (specify): __________________

 k. Change in on-call staff for non-business hours

 l. Expanded business hours

 m. Changes in productivity requirements for staff

 n. Changes in staff hiring requirements

 o. Other (specify): __________________

6. What activities directed toward care providers and intended to increase quality of care has your agency implemented since the beginning of the demonstration (January 1, 2008)? (Check all that apply)

(Check box; no pre-fill)

 a. New staff education programs and/or changes in requirements for number of educational hours

 b. Performance improvement programs

 c. Mentoring programs

 d. Additional clinical team meetings

 e. Additional record review activities

 f. New staff competencies

 g. Changes in staff evaluation criteria

 h. Employee incentives for performance improvement

 i. Changes in staff management practices of nursing or therapy staff (e.g., increased oversight, etc.)

 j. Changes in home health aide supervisory practices

 k. Additional clinical resources for field staff (e.g., consultation; new specialty care staff; Web access to best practices, etc.)

 l. Other (specify): _____________________

7. What technological innovations designed to improve the quality of patient care has your agency implemented since the beginning of the demonstration (January 1, 2008)? (Check all that apply)

(Check box; no pre-fill)

 a. Telemonitoring equipment

 b. Electronic medical records

 c. Electronic information exchange with referral sources (e.g., hospital)

 d. Electronic information exchange with physicians

 e. Secure electronic messaging systems for agency care team members

 f. New infusion devices

 g. New respiratory equipment (e.g., ventilators, etc.)

 h. Physiologic monitoring equipment (e.g., blood glucose monitors, prothrombin monitors, etc.)

 i. Inflatable mattresses or similar equipment to reduce incidence of pressure ulcers

 j. Special dressings or therapies for wound care

 k. Medication reminder systems

 l. Medication dispensing systems

 m. Implementation of medication checking/reconciliation software

 n. Personal emergency response systems

 o. Electronic access to policies, procedures, best practices, etc.

 p. Other (specify): _____________________

8. What care practice changes designed to improve the specific clinical outcomes has your agency implemented since the beginning of the demonstration (January 1, 2008)? (Check all that apply)

(Check box; no pre-fill)

 a. Changes in visit patterns (e.g., front-loading; increased number visits for specific diagnoses)

 b. Introduction of telemonitoring

 c. Changes in visit mix (e.g., increased use of PT, etc.)

 d. Introduction of disease management programs

 e. Introduction and/or increased use of clinical pathways

 f. Changes in patient teaching plans

 g. Increased communication with MD

 h. Inclusion on POC of specific parameters for when to call physician (e.g., call MD for BS > 150)

 i. Increased care team communication (e.g., team meetings, etc.)

 j. Implementation of screening assessments (e.g., falls risk)

 k. Implementation of falls prevention programs

 l. Enhanced wound care protocols

 m. Increased efforts to improve vaccination rates (e.g., flu and pneumococcus)

 n. Use of medication reminder or dispensing systems

 o. Other (specify): _____________________

9. Identify any local/regional changes that have occurred since January 1, 2008 that may have created an impact on your agency. (Indicate impact for each--if any)

(Radio button w/ "No Impact" pre-filled)

		Type of Impact
	Type of Local/Regional Change	No Impact	Negative	Both + / -	Positive
a.	# of community hospitals (or hospital beds)				
b.	# of skilled nursing facilities (or SNF beds)				
c.	# of urgent/emergency care facilities				
d.	# of home health agencies				
e.	Availability of nurses locally				
f.	Availability of physical therapists locally				
g.	Availability of occupational therapists locally				
h.	Availability of home health aides locally				
i.	Increase in population locally				
j.	Natural disaster, e.g., flood, fire, etc.				
k.	State health care policy (e.g., Medicaid funding)				
l.	Informal local health care practice patterns				
m.	Change in available community resources (e.g., Assisted living facilities, adult day care, transportation programs, meal programs, respite care providers, etc.)				

10. How much of an impact on your patients do you think your quality improvement activities have had on the outcomes targeted in the demonstration?

(Radio button w/ "No Impact" pre-filled)

		Probable impact of QI on outcomes
	Outcome Measure	No Impact	Modest Improvement	Substantial Improvement
a.	Incidence of Acute Care Hospitalization			
b.	Incidence of Any Emergent Care			
c.	Improvement in Bathing			
d.	Improvement in Ambulation/Locomotion			
e.	Improvement in Transferring			
f.	Improvement in Status of Surgical Wounds			
g.	Improvement in Management of Oral Medications			

11. What effect do you think the demonstration will have on the following?

(Radio button w/ "No Impact" pre-filled)

	Very Negative	Slightly Negative	No Impact	Slightly Positive	Very Positive
My agency’s patient outcomes					
Quality of care at my agency					
Quality of care statewide					
Access to care for Medicare beneficiaries					
Cost of providing home health care					
Financial solvency of my agency					
Financial solvency of home health agencies statewide					
Profitability of my agency					
Profitability of home health agencies statewide					

12. Please use the space below to provide any other comments on the demonstration and any suggestions you have for the implementation of home health pay for performance. (optional)

(There will be a 250-word limit on this box with automatic word count)

Thank you very much for providing your feedback. Please review your answers prior to pressing the "Send" button.

P4P Eval Survey (Treatment) Annotated 6/26/2008 Page 15 of 15