Studying the Implementation of a Chronic Care Toolkit and Practice Coaching In Practices Serving Vulnerable Populations

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #10 Consumer Assessment of Healthcare Providers and Systems- Primary Care Adult (CAHPS)	Form and Instruction	New	Available
Form Form #9 Patient Assessment of Chronic Illness Care (PACIC)	Form and Instruction	New	Available
Form Form #8 Primary Care Staff Satisfaction Survey (PCSSS)	Form and Instruction	New	Available
Form Form #7 Change Process Capability Questionnaire (CPCQ)	Form and Instruction	New	Available
Form Form #6 Assessment of Chronic Illness Care (ACIC)	Form and Instruction	New	Available
Form Form #5 Physician Practice Connections-Readiness Survey (PPC-RS)	Form and Instruction	New	Available
Form Form #4 Primary Care Practice Profile (PCPP)	Form and Instruction	New	Available
Form Form #3 Key informant interviews with staff	Form and Instruction	New	Available
Form Form #2 Key informant interviews with providers	Form and Instruction	New	Available
Form Form #1 Key informant interviews with practice coaches	Form and Instruction	New	Available
OMB response Chronic Care Toolkit August 26th 2010.doc	Supplementary Document	Uploaded 2010-08-30	Available
omb crosswalk Aug 26 2010.doc	Supplementary Document	Uploaded 2010-08-30	Available
Supporting Statement Part B -- Implementing Practice Coaching and the Chronic Care Model 1-8-2010.doc	Supporting Statement B	Uploaded 2010-04-05	Available
Attachment A -- Healthcare Research and Quality Act of 1999.pdf	Supplementary Document	Uploaded 2010-04-05	Available
Attachment L - Chart Audit Abstraction Form.doc	Supplementary Document	Uploaded 2010-04-05	Available
Attachment M -- Federal Register Notice.pdf	Supplementary Document	Uploaded 2010-04-05	Available
Supporting Statement Part A -- Implementing Practice Coaching and the Chronic Care Model 1-8-2010.doc	Supporting Statement A	Uploaded 2010-04-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
192657	Consumer Assessment of Healthcare Providers and Systems- Primary Care Adult (CAHPS)	Form and Instruction	New	Consumer Assessment of Healthcare Providers and Systems- Primary Care Adult (CAHPS)
192656	Patient Assessment of Chronic Illness Care (PACIC)	Form and Instruction	New	Patient Assessment of Chronic Illness Care (PACIC)
192655	Primary Care Staff Satisfaction Survey (PCSSS)	Form and Instruction	New	Primary Care Staff Satisfaction Survey (PCSSS)
192654	Change Process Capability Questionnaire (CPCQ)	Form and Instruction	New	Change Process Capability Questionnaire (CPCQ)
192653	Assessment of Chronic Illness Care (ACIC)	Form and Instruction	New	Assessment of Chronic Illness Care (ACIC)
192652	Physician Practice Connections-Readiness Survey (PPC-RS)	Form and Instruction	New	Physician Practice Connections-Readiness Survey (PPC-RS)
192651	Primary Care Practice Profile (PCPP)	Form and Instruction	New	Primary Care Practice Profile (PCPP)
192650	Key informant interviews with staff	Form and Instruction	New	Key informant interviews with staff
192649	Key informant interviews with providers	Form and Instruction	New	Key informant interviews with providers
192648	Key informant interviews with practice coaches	Form and Instruction	New	Key informant interviews with practice coaches

ICR Details

OMB Control No: 0935-0166	ICR Reference No: 201004-0935-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Studying the Implementation of a Chronic Care Toolkit and Practice Coaching In Practices Serving Vulnerable Populations
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: 09/21/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/21/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2013	24 Months From Approved
Responses	3,924	0	0
Time Burden (Hours)	1,984	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: An important part of AHRQ's mission is to disseminate information and tools that can support improvement in quality and safety in the U.S. health care community. This proposed information collection supports that part of AHRQ's mission by further refining the practice coaching delivered in conjunction with a previously developed toolkit, Implementing Integrating Chronic Care and Business Strategies in the Safety Net: A Toolkit for Primary Care Practices and Clinics. AHRQ requests that the Office of Management and Budget approve, under the Paperwork Reduction Act of 1995, AHRQ's intention to collect information needed to determine whether practice coaching is effective in facilitating adoption of the Chronic Care Model (CCM) for improving treatment and management of chronic medical conditions by primary care physicians, especially those who care for underserved populations. This project is being conducted pursuant to AHRQ's statutory authority to conduct and support research on health care and on systems for the delivery of such care, including activities with respect to quality measurement and improvement and with respect to clinical practice, including primary care and practice-oriented research. 42 U.S.C. 299a(a)(2) and (4). This project will be conducted by AHRQ through a contract with the University of Minnesota.

---

Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 5081	02/01/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 16129	03/31/2010
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Assessment of Chronic Illness Care (ACIC)	Form #6	Assessment of Chronic Illness Care (ACIC)
Change Process Capability Questionnaire (CPCQ)	Form #7	Change Process Capability Questionnaire (CPCQ)
Consumer Assessment of Healthcare Providers and Systems- Primary Care Adult (CAHPS)	Form #10	Consumer Assessment of Healthcare Providers and Systems- Primary Care Adult (CAHPS)
Key informant interviews with practice coaches	Form #1	Key informant interviews with practice coaches
Key informant interviews with providers	Form #2	Key informant interviews with providers
Key informant interviews with staff	Form #3	Key informant interviews with staff
Patient Assessment of Chronic Illness Care (PACIC)	Form #9	Patient Assessment of Chronic Illness Care (PACIC)
Physician Practice Connections-Readiness Survey (PPC-RS)	Form #5	Physician Practice Connections-Readiness Survey (PPC-RS)
Primary Care Practice Profile (PCPP)	Form #4	Primary Care Practice Profile (PCPP)
Primary Care Staff Satisfaction Survey (PCSSS)	Form #8	Primary Care Staff Satisfaction Survey (PCSSS)

---

ICR Summary of Burden

table that charts list 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	3,924	0	0	3,924	0	0
Annual Time Burden (Hours)	1,984	0	0	1,984	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: This ICR is for a new data collection.

---

Annual Cost to Federal Government: $300,000

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]? No

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

---

Common Form ICR:  No

---

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: 04/21/2010

---