HomeHealthCAHPS_OMB_PartA revised 7-8-10

The Home Health Care CAHPS Survey
Part A
Justification and Supporting Statement

TABLE OF CONTENTS
Section

Page

A. Justification ..........................................................................................................................1
A.1

Circumstances Making the Collection of Information Necessary ............................ 1

A.2

Purpose and Use of Information ............................................................................... 6

A.3

Use of Improved Information Technology ............................................................... 6

A.4

Efforts to Identify Duplication ................................................................................. 7

A.5

Involvement of Small Entities .................................................................................. 7
A.5.1
A.5.2

National Implementation ..........................................................................7
Mode Experiment......................................................................................8

A.6

Consequences If Information is Collected Less Frequently ..................................... 8

A.7

Special Circumstances .............................................................................................. 9

A.8

Federal Register Notice and Outside Consultations ................................................. 9
A.8.1
A.8.2

A.9

Federal Register Notice.............................................................................9
Outside Consultations ...............................................................................9

Payments/Gifts to Respondents .............................................................................. 11

A.10 Assurance of Confidentiality .................................................................................. 11
A.11 Questions of a Sensitive Nature ............................................................................. 13
A.12 Estimates of Annualized Burden Hours and Costs ................................................ 13
A.13 Estimates of Annualized Respondent Capital and Maintenance Costs .................. 17
A.14 Estimates of Annualized Cost to the Government ................................................. 17
A.15 Changes in Hour Burden ........................................................................................ 18
A.16 Time Schedule, Publication, and Analysis Plans ................................................... 18
A.16.1

A.16.2

National Implementation of Home Health Care CAHPS .......................18
A.16.1a National Implementation Analysis .........................................18
A.16.1b Individual-Level Estimation and Adjustment ........................21
Home Health Care CAHPS Mode Experiment .......................................21
A.16.2a Mode Experiment Analysis ....................................................22
A.16.2b Data Elements for the Mode Analysis ....................................23

A.17 Exemption for Display of Expiration Date............................................................. 25

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EXHIBITS
Number

Page

1. Estimated annualized burden hours: National Implementation of The Home
Health Care CAHPS Survey ..............................................................................................14
2. Estimated annualized cost burden: National Implementation ...........................................14
3. Estimated annualized burden hours: Mode Experiment ....................................................14
4. Estimated annualized cost burden: Mode Experiment.......................................................15
5. List of Potential Variables for Data Analysis ....................................................................24

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A.

JUSTIFICATION

A.1

Circumstances Making the Collection of Information Necessary

Home health care is an important and rapidly growing segment of the U.S. health care
system. National health expenditure data show that spending for home health care was more than
$47 billion in 2005―an 11.1% increase over the previous year. Public spending for home health
services, which accounts for three quarters of such spending, rose 12.4% in 2005. Spending for
home health care is expected to continue to increase. The Centers for Medicare & Medicaid
Services (CMS) has projected that by 2010, spending for home health care will top $70 billion
annually and is expected to be more than $110 billion annually by 2016. (These figures come
from http://www.cms.hhs.gov/NationalHealthExpendData/. Last viewed August 27, 2007.)
Home health care is a key benefit covered under Medicare Part A. The benefit includes
coverage of part-time, medically necessary skilled care (nursing, physical therapy, occupational
therapy, and speech-language therapy) that is ordered by a physician. If patients are eligible for
skilled services, they can also receive part-time assistance with personal care needs by a home
health aide. Patients are required to be ―homebound‖ as a condition of eligibility for Medicare
home health benefits. Home health care services are delivered at home to patients who are
recovering from care in hospitals or nursing homes; patients who are disabled; the frail elderly;
and chronically or terminally ill persons in need of medical, nursing, or therapeutic treatment and
assistance with the essential activities of daily living. There are approximately 9,000 Medicarecertified home health agencies throughout the United States. In 2006, more than 3 million
beneficiaries were served, and 103,931,188 visits made. As baby boomers age, the need for
patient-centered, cost-effective care will be a priority to CMS―78 million baby boomers are
about to begin turning 65 (http://www.cms.hhs.gov/HomeHealthQualityInits/).
For some patients, home health care can be an alternative to more costly institutional
health care. Monitoring and improving the quality of home health care, as with all Medicare
services, is an important policy issue. Monitoring and ensuring home health care, in particular,
can be a challenge because care is provided in patients’ residences and therefore lacks some of
the oversight feasible in institutional settings. In 2001, Secretary Thompson of the Department of
Health and Human Services (DHHS) announced the Quality Initiative to ensure the quality of
health care for all Americans through accountability and public disclosure. The goals of the
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initiative are to empower consumers with quality-of-care information so they can make more
informed decisions about their health care and to stimulate and support providers and clinicians
to improve the quality of health care. The Quality Initiative was launched nationally in
November 2002 for nursing homes and was expanded to home health agencies (the Home Health
Quality Initiative) in 2003. A major gap in the information currently available regarding the
quality of home health care is the lack of information from the patient perspective.
As part of the DHHS Transparency Initiative on Quality Reporting, CMS plans to
implement a process to measure and publicly report patients’ experiences with home health care
they receive from Medicare-certified home health agencies through the data collection effort
described in this request: the Consumer Assessment of Healthcare Providers and Systems
(CAHPS®) Home Health Care Survey. The Home Health Care CAHPS Survey, which was
developed and tested by the Agency for Healthcare Research and Quality (AHRQ) and is part of
the family of CAHPS surveys, is a standardized survey for home health patients to assess their
home health care providers and the quality of the home health care they receive. Prior to the
Home Health Care CAHPS survey, there was no national standard for collecting data about
home health care patients’ experience with their home health care.
In the first half of 2008, AHRQ conducted a field test of the Home Health Care CAHPS
Survey to determine its length and contents and to test the reliability and validity of the survey
items. After reviewing field test results with a technical expert panel consisting of home health
industry experts, patient advocates, and researchers, the Home Health Care CAHPS Survey was
finalized as a 34-item survey instrument. (See Appendix A for a copy of the Home Health Care
CAHPS Survey questionnaire.) The survey contains questions about the patient’s interactions
with the home health agency, interactions with the agency’s providers, provider care and
communications, and patient characteristics. Patients will also be asked to provide an overall
rating of the home health care they receive. CMS submitted the final Home Health Care CAHPS
Survey to the National Quality Forum (NQF) for endorsement. The survey was endorsed March
31, 2009. The NQF endorsement represents the consensus opinion of many healthcare providers,
consumer groups, professional organizations, purchasers, federal agencies, and research and
quality organizations. As a result of the endorsement process, a few minor changes were made to
the survey. The words ―over the counter‖ were added to Questions 4 and 5. In Question 14, the

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word ―important‖ was removed since a respondent may have difficulty determining which side
effects are important. Questions regarding age and gender were removed from the survey since
they are available from home health administrative data. The revised survey is 34 questions long.
Questions 1-25 on the instrument are the core survey items, and questions 26-36 are the
―About You‖ questions. Five measures from this survey will be used for public reporting – 3
composite measures and 2 global ratings. The 3 composites cover ―Care of Patients,‖
―Communication between Providers and Patients‖ and ―Specific Care Issues.‖ The global items
include the overall rating of agency care, and would you recommend this agency to friends and
family.
Initially, confirmatory factor analysis (CFA) based on structural equation modeling
(SEM) was conducted to see whether the field test data were consistent with the hypothesized
composite structure. The CFA of the field test questionnaire revealed that the observed data did
not fit this model. Following the poor CFA results, exploratory analyses were conducted to
identify the structure underlying the observed responses. Analyses were conducted upon a
random sample of 50% of the single-imputation data set. This enabled us to evaluate the
generalizability of the final model in the other 50% of the data, as well as the data sets comprised
of each of the other four imputations. An exploratory factor analysis (EFA) was conducted on the
correlation matrix using the principle factor method with squared multiple correlations as initial
communality estimates and oblique rotation (promax) with Kaiser normalization. The number of
factors was determined by the eigenvalues, and the interpretability of the rotated factor pattern
matrix.
The internal consistency reliability (alpha) (a measure of how well the items in a
composite hang together) was .75 for Care of Patients, .73 for Communication between
Providers and Patients and .84 for Specific Care Issues. The scaling success (a measure that
summarizes the discriminant validity of the composites, that is, the degree to which each item
correlates more highly with its own scale than it does with competing scales) is 88% for Care of
Patients, 90% for Communication between Providers and Patients and 100% for Specific Care
Issues.

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The Care of Patients composite is produced by combining responses to four questions
that ask:
―In the last 2 months of care, how often did home health providers from the agency
seem informed and up-to-date about all the care or treatment you got at home?‖
―In the last 2 months of care, how often did home health providers from this agency
treat you as gently as possible?‖
―In the last 2 months of care, how often did home health providers from this agency
treat you with courtesy and respect?‖
―In the last 2 months of care, did you have any problems with the care you got
through this agency?‖
The Communication between Providers and Patients composite is produced by
combining responses to six questions that ask:
―When you first started getting home health care from this agency, did someone from
the agency tell you what care and services you would get? ―
―In the last 2 months of care, how often did home health providers from this agency
keep you informed about when they would arrive at your home?‖
―In the last 2 months of care, how often did home health providers from this agency
explain things in a way that was easy to understand? ―
―In the last 2 months of care, how often did home health providers from this agency
listen carefully to you?‖
―In the last 2 months of care, when you contacted this agency’s office did you get the
help or advice you needed?‖
―When you contacted this agency’s office, how long did it take for you to get the help
or advice you needed?‖ {It is converted into a measure of whether the patient got help
on the same day – yes/no}
The Specific Care Issues composite is produced by combining responses to seven
questions that ask:
―When you first started getting home health care from this agency, did someone from
the agency talk with you about how to set up your home so you can move around
safely?‖
―When you started getting home health care from this agency, did someone from the
agency ask to see all the prescription and over-the-counter medicines you were
taking?‖

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―When you started getting home health care from this agency, did someone from the
agency ask to see all the prescription and over-the-counter medicines you were
taking?‖
―In the last 2 months of care, did you and a home health provider from this agency
talk about pain?‖
―In the last 2 months of care, did home health providers from this agency talk with
you about the purpose for taking your new or changed prescription medicines?‖
―In the last 2 months of care, did home health providers from the agency talk with
you about when to take these medicines?‖
―In the last 2 months of care, did home health providers from this agency talk with
you about the side effects of these medicines?‖
CMS has begun planning for a national implementation of the Home Health Care
CAHPS survey, which will be conducted by multiple independent survey vendors working under
contract with home health agencies. In 2008, CMS, with assistance from its contractor RTI
International, is developing standardized data collection and data submission tools and
procedures for survey vendors when implementing Home Health Care CAHPS on behalf of their
home health agency clients. As part of this Home Health Care CAHPS coordination and
implementation strategy, RTI will conduct a mode experiment to test three modes of data
collection that will be used on the Home Health Care CAHPS Survey: mail, telephone, and
mixed mode (mail with telephone follow-up of nonrespondents). A sample of home health
agencies will be asked to participate in the mode experiment, which will be conducted in
spring/summer 2009.
Recruitment and training of survey vendors that apply to become approved Home Health
Care CAHPS vendors will begin in spring 2009. Home health agencies can voluntarily conduct
the Home Health Care CAHPS Survey using an approved Home Health Care CAHPS survey
vendor starting in summer 2009 and submit the data to CMS for public reporting. Data collection
for the national survey of the Home Health Care CAHPS Survey will be conducted on an
ongoing basis. Comparative results from the national Home Health Care CAHPS Survey will be
publicly reported on Home Health Compare, located on the Medicare.gov website, and will be
updated on a quarterly basis.

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A.2

Purpose and Use of Information

The national implementation of the Home Health Care CAHPS Survey is designed to
collect ongoing data from samples of home health care patients who receive skilled services from
Medicare-certified home health agencies. The data collected from the national implementation of
the Home Health Care CAHPS Survey will be used for the following purposes:
to produce comparable data on the patients’ perspectives of the care they receive from
home health agencies,
to create incentives for agencies to improve the quality of care they provide through
public reporting of survey results, and
to enhance public accountability in health care by increasing the transparency of the
quality of care provided in return for the public investment.
Sampling and data collection will be conducted on a monthly basis. Survey results will be
analyzed and reported on a quarterly basis, with publicly reported results based on one year’s
worth of data.
As part of this information collection request for the national implementation of Home
Health Care CAHPS, CMS is also requesting approval to conduct a randomized mode
experiment with a sample of home health agencies. The mode experiment will compare the
responses to the survey across the three proposed modes to determine whether adjustments are
needed to ensure that the data collection mode does not influence the survey results. In addition,
data from the mode experiment will be used to determine which, if any, patient characteristics
may affect the patients’ rating of the care they receive and, if so, develop an adjustment model of
those data based on those factors. CMS is working with its contractor to recruit approximately
100 home health agencies to participate in the mode experiment. The mode experiment will
involve up to 23,000 home health care patients.
A.3

Use of Improved Information Technology

The national implementation is designed to allow independent survey vendors to
administer the Home Health Care CAHPS Survey using mail-only, telephone-only, or mixed
(mail with telephone follow-up) modes of survey administration. Experience with previous
CAHPS surveys, including the field test of the Home Health Care CAHPS instrument, shows
that mail, telephone, and mail with telephone follow-up data collection modes work well for

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respondents, vendors, and health care organizations. Any additional forms of information
technology, such as web surveys, would not be feasible with this population, many of whom are
expected to be ill, elderly, and lack access to the Internet.
A.4

Efforts to Identify Duplication

Some home health agencies already carry out their own patient experience of care
surveys. These diverse surveys do not allow for comparisons across home health care agencies.
Making comparative performance information available to the public can help consumers make
more informed choices when selecting a home health care agency and can create incentives for
home health care agencies to improve the care they provide. Vendors/home health care agencies
will have the option to add their own questions to the Home Health Care CAHPS core
questionnaire. If a home health agency/vendor plans to add their own questions, they need to add
them after the core questions (questions 1 - 25). The ―About You‖ section can be placed after the
core items or following the home health agency-specific items. If a home health agency/vendor
decides to add their own questions, they should pay attention to the length of the questionnaire.
The longer the questionnaire, the greater the burden is on respondents.
A.5

Involvement of Small Entities

A.5.1 National Implementation

All Medicare-certified home health agencies (HHAs) can voluntarily sponsor a Home
Health Care CAHPS Survey, including the many small home health care agencies. However, if
they choose to participate in the CMS national implementation, agencies must contract with a
survey vendor that has been approved by CMS. These approved survey vendors may include
small survey firms. Survey respondents will be adult home health care patients who receive
skilled home health care regardless of payer (i.e., including Medicare, Medicaid, and private
payers). Each month, each HHA sponsoring a Home Health Care CAHPS Survey must prepare
and submit to its survey vendor a file containing patient data on patients served the preceding
month that will be used by the survey vendor to select the sample and field the survey. This file
(essentially the sampling frame) for most home health agencies can be generated from existing
databases with minimal effort. For some small HHAs, preparation of a monthly sample frame

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may require more time. However, data elements needed on the sample frame will be kept at a
minimum to reduce the burden on all home health agencies.
The survey instrument and procedures for completing the instrument are designed to
minimize burden on all respondents. No significant burden is expected for small agencies beyond
providing their contracted vendor with a monthly file of patients served.
A.5.2 Mode Experiment

For the mode experiment, a sample of home health agencies that represent a broad range
of agency sizes, including some small agencies, will be selected and asked to voluntarily
participate in the mode experiment to ensure representation of patients across various types of
home health agencies. Each month during a 3-month data collection period, participating HHAs
will be asked to provide patient information that will be used for sample selection and fielding
the mode experiment. Most participating home health agencies will be able to provide the sample
frame with minimum effort. However, data elements needed on the sample frame will be kept at
a minimum to reduce the burden on all agencies.
As in the national implementation, the survey instrument and procedures for completing
it are designed to minimize burden on all respondents. No significant burden is expected for
small agencies beyond providing RTI with a monthly file of patients served.
A.6

Consequences If Information is Collected Less Frequently

So that home health patients can assess the home health care they receive as soon as
possible after a home health care visit, CMS will require that participating home health agencies
provide a sample frame consisting of patients who received at least one home health visit during
the sample month to their survey vendor on a monthly basis. Vendors will, in turn, be required to
initiate the data collection from patients within 3 weeks after the sample month closes.
Respondent burden is increased and the recall factor becomes a problem if patients are asked to
recall their care experiences after longer lapses of time. Monthly sampling and continuous data
collection (surveying the sample within 3 weeks after the sample window closes) will reduce the
amount of time between when patients receive home health care and when they are surveyed.
Respondent recall, especially with home health patients, will be enhanced, thus improving the

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quality of survey data and results. For this reason, CMS does not believe that a less frequent data
collection period will result in the most accurate and complete data for public reporting and
quality monitoring purposes. While data collection will be completed by vendors on a monthly
basis, data will be submitted on a quarterly basis.
A.7

Special Circumstances

Some home health patients have chronic conditions which require long-term home health
care. To reduce respondent burden, CMS proposes that home health care patients not be eligible
for the survey more than once during a 6-month period.
A.8

Federal Register Notice and Outside Consultations

A.8.1 Federal Register Notice

Appendix B includes the text of the notice of this implementation in the Federal Register
published for 60-day comment on January 9, 2009. Twenty three comments were received. The
Home Health Care CAHPS Survey was initially discussed in the May 4, 2007, Federal Register
(72 Fed.Reg. 25356, 25452). A copy of that notice is included as Appendix C.
A.8.2 Outside Consultations

AHRQ was responsible for the development and testing of the Home Health Care
CAHPS Survey. As the lead agency, AHRQ worked with three grantee organizations to develop
and test the survey instrument: the American Institutes for Research, the Yale/Harvard team, and
RAND. An additional contractor, Westat, also participated in a supporting role. During the
survey instrument development phase, AHRQ also consulted with a range of outside
organizations and individuals representing state and federal government agencies and non-profit
and private sector organizations. AHRQ convened technical expert panels on February 8, 2007,
and July 15, 2008. Panel members for the instrument development included representatives from
the following organizations:
AARP (American Association of Retired Persons)
Abt Associates Inc.
American Academy of Home Health Care Physicians
American Association for Homecare

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American Association of Homes and Services for the Aging
American Hospital Association
American Occupational Therapy Association
American Physical Therapy Association
American Speech-Language-Hearing Association
Maryland Health Care Commission
National Association for Home Care & Hospice
National Center for Health Statistics, Centers for Disease Control and Prevention
(CDC)
National Quality Forum
Paraprofessional Healthcare Institute
Professional Healthcare Resources, Inc.
Quality Insights of Pennsylvania
Quality Partners of Rhode Island
Veterans Health Administration
Visiting Nurse Associations of America (VNAA)
For the national implementation, CMS has worked with RTI International, a contractor
operating in the role of implementation coordinator. RTI is responsible for developing the
protocols required to ensure standardized administration of the Home Health Care CAHPS
Survey, recruiting survey vendors, working with CMS to train multiple independent survey
vendors, providing oversight of the approved vendors, and receiving and processing Home
Health Care CAHPS Survey data collected and submitted by survey vendors. RTI will also be
responsible for analyzing data from the mode experiment to determine the mode adjustment and
the patient-mix adjustment model. During the national implementation, RTI will adjust the data
for mode of survey administration, patient mix and nonresponse and provide comparative results
for public reporting.
In addition, RTI has convened a technical expert panel composed of representatives from
the home health industry, consumer advocacy organizations, the government, and research
organizations. Members of the committee have provided guidance to RTI on the development of
the design for the mode experiment and plans for the national implementation. RTI, CMS, and
members of the technical expert panel met on February 21, April 15, and June 19, 2008.
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The technical expert panel members who provided input and guidance to RTI for the
national implementation represent the following organizations:
AARP (American Association of Retired Persons)
American Association of Homes and Services for the Aged
Center for Medicare Advocacy, Inc.
Consumer Coalition for Quality Health Care
Health Services Advisory Group
Independent Consultant, formerly of AHRQ
National Association for Home Health Care and Hospice
RAND
Service Employees International Union
Visiting Nurse Service of New York
A.9

Payments/Gifts to Respondents

No payments or gifts will be provided to respondents.
A.10

Assurance of Confidentiality

Individuals and organizations will be assured of the confidentiality of their replies under
Section 934(c) of the Public Health Service Act, 42 USC 299c-3(c). They will be told the
purposes for which the information is collected and that, in accordance with this statute, any
identifiable information about them will not be used or disclosed for any other purpose.
Individuals and organizations contacted will be further assured of the confidentiality of
their replies under 42 U.S.C. 1306, 20 CFR 401 and 4225 U.S.C.552a (Privacy Act of 1974), and
OMB Circular No.A-130. In instances where respondent identity is needed, the information
collection will fully comply with all respects of the Privacy Act.
For the mode experiment, RTI will include an assurance of confidentiality of the data in
the mail survey cover letters and in the interview introductory script that will be used in
interviews with sampled patients included in the phone-only data collection mode and in the
telephone follow-up with sample patients in the mixed-mode sample (the mail survey cover

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letters and the telephone interview introductory script are included in Appendices D and E,
respectively).
RTI understands the privacy and confidentiality concerns regarding access to Home
Health Care CAHPS Survey data. All RTI staff members who will have access to patient
information will be required to sign and abide by the terms of a nondisclosure agreement, where
they agree to protect the identity of patients included in the mode experiment and the data they
provide. RTI has redundant security protocols to protect data and computer systems. Servers are
maintained in climate-controlled environments, with restricted access. A firewall stands between
the internal systems and the Internet, requiring authentication of all users requesting access. User
identification and passwords are unique and changed on a regular basis. Full backups are
conducted on a weekly basis, with incremental backups performed nightly. Copies of backup
materials are stored offsite in a secure location in case of system failure.
RTI received a Defense Security Service rating of ―Superior‖ for the physical security of
its research center. As data are collected and assembled into databases for analysis and
interpretation, RTI incorporates a number of database security safeguards to protect data from
accidental or intentional access and disclosure threats. RTI’s data collection and storage security
measures include the following:
Maintenance of all servers in RTI’s environmentally controlled Computer Center,
where computers are located in a center constructed of masonry with an automatically
locking steel door that is locked at all times; fire protection is provided by a halon
system with all servers having an Uninterruptible Power Supply.
User ID and password authentication to access all systems. Where appropriate,
systems are configured to support the use of Digital Security Certificates for
additional user authentication.
Encrypted transmission of data.
Use of Transport Layer Security, the successor technology to Secure Socket Layer for
encryption of data across the Internet.
Connection to the Internet by an Internet firewall via a high-speed T2 (6.2 MBs) line.
In the event of a failure, a T1 (1.544 MBs) backup will automatically provide
uninterrupted Internet connectivity. Subscription to virus-protection services from
McAfee VirusScan with automated update of virus signature files on all computers.
Redundant servers with automatic switchover to ensure 24/7 availability.
Daily incremental backups of all data files, with full backups created weekly.

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Offsite storage of data backups.
For the national implementation, survey vendors will submit only de-identified survey
data to RTI for analysis.
Survey vendors approved to conduct a Home Health Care CAHPS survey for HHAs
participating in the national implementation will be required to have systems and methods in
place to protect the identity of sampled patients and the confidential nature of the data that they
provide. CMS and its contractor (RTI) will review each approved Home Health Care CAHPS
Survey vendor’s data security systems during periodic site visits during the national
implementation.
A.11

Questions of a Sensitive Nature

There are no questions of a sensitive nature in this survey.
A.12

Estimates of Annualized Burden Hours and Costs

The estimated annual hour burden is as follows:
The length of the survey estimate of .20 hours (12 minutes) is based on the written length
of the survey and AHRQ’s experience conducting the field test with a sample of home health
patients. It is also based on RTI’s experience conducting other surveys of similar length and
complexity.
Estimated annualized burden hours and costs for the national implementation of the
Home Health Care CAHPS Survey are shown in Exhibits 1 and 2. These estimates assume that
9,000 home health agencies (the universe of Medicare-certified agencies) will sponsor a Home
Health Care CAHPS Survey and that 300 patients sampled from each agency will complete the
survey. Not all agencies will participate in national implementation so we have estimated the
maximum burden possible.
The Bureau of Labor Statistics reported the average hourly wage for civilian workers in
the United States was $19.29 in June 2006. An estimate of $20 per hours allows for inflation and
represents a conservative estimate of the wages of respondents.

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Estimated annualized burden hours and costs for the Home Health Care CAHPS mode
experiment are shown in Exhibits 3 and 4.
EXHIBIT 1. ESTIMATED ANNUALIZED BURDEN HOURS: NATIONAL IMPLEMENTATION OF THE
HOME HEALTH CARE CAHPS SURVEY

Form name
Home Health Care CAHPS
Survey (mail only, telephone
only and mail with telephone
follow-up data collection modes)
Total

Number of
respondents

Number of
responses
per
respondent

Hours per
response

Total
burden
hours

2,700,000
2,700,000

1
1

.20
.20

540,000
540,000

EXHIBIT 2. ESTIMATED ANNUALIZED COST BURDEN: NATIONAL IMPLEMENTATION

Form name
Home Health Care CAHPS
Survey (mail only, telephone
only and mail with telephone
follow-up data collection modes)
Total

Number of
respondents

Total
burden
hours

Average
hourly wage
rate*

Total
cost
burden

2,700,000
2,700,000

540,000
540,000

$20.00
$20.00

$10,800,000
$10,800,000

*Based on average wages, ―National Compensation Survey: Occupational Wages in the United States, June 2006,‖
U.S. Department of Labor, Bureau of Labor Statistics (http://www.bls.gov/ncs/home.htm; last viewed August 27,
2007).

EXHIBIT 3. ESTIMATED ANNUALIZED BURDEN HOURS: MODE EXPERIMENT

Form name
Home Health Care CAHPS
Survey (mail only, telephone
only and mail with telephone
follow-up data collection modes)
Total

Number of
respondents

Number of
responses
per
respondent

Hours per
response

Total
burden
hours

6,000
6,000

1
1

.20
.20

1,200
1,200

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EXHIBIT 4. ESTIMATED ANNUALIZED COST BURDEN: MODE EXPERIMENT

Form name
Home Health Care CAHPS
Survey (mail only, telephone only
and mail with telephone followup data collection modes)
Total

Number of
respondents

Total
burden
hours

Average
hourly wage
rate*

Total cost
burden

6,000
6,000

1,200
1,200

$20.00
$20.00

$24,000
$24,000

*Based on average wages, ―National Compensation Survey: Occupational Wages in the United States, June 2006,‖
U.S. Department of Labor, Bureau of Labor Statistics (http://www.bls.gov/ncs/home.htm; last viewed August 27,
2007).

We have prepared a revised package to reflect the following additional burden in the
HHCAHPS. In the 2011 Home Health Prospective Payment System Rule, Section 484.250,
Patient Assessment Data, will require an HHA to submit to CMS, HHCAHPS data in order for
CMS to administer the payment rate methodologies described in §§ 484.215, 484.230, and
484.235. The burden associated with this is the time and effort put forth by the HHA to submit
the HHCAHPS patient files to their approved HHCAHPS survey vendor. Section 484.255(i)
requires the submission of quality measures as specified by the Secretary. As part of this
requirement, each HHA sponsoring a Home Health Care CAHPS (HHCAHPS) Survey must
prepare and submit to its survey vendor a file containing patient data on patients served the
preceding month that will be used by the survey vendor to select the sample and field the survey.
This file (essentially the sampling frame) for most home health agencies can be generated from
existing databases with minimal effort. For some small HHAs, preparation of a monthly sample
frame may require more time. However, data elements needed on the sample frame will be kept
at a minimum to reduce the burden on all HHAs. The burden associated with this requirement is
the time and effort put forth by the HHA to prepare and submit the file containing patient data on
patients. The survey instrument and procedures for completing the instrument are designed to
minimize burden on all respondents. No significant burden is anticipated for small agencies
beyond providing their contracted vendor with a monthly file of patients served. For very small
HHAs serving less than 60 eligible patients in an annual period, these agencies have been
informed to file an exemption form on the website (www.homehealthcahps.org).

15

We have determined that the provision of the monthly file will take 16.0 hours for each
HHA. Therefore, if every eligible HHA (9,890) conducted HHCAHPS, the burden would be
9,890 times 16 hours, equaling a total of 158,240 hours. The reasons for the additional burden to
the HHAs are because the HHAs must do the following: (1) Contract with an approved
HHCAHPS survey vendor to administer the HHCAHPS survey and to submit the HHCAHPS
survey data to the Data Center on the HHAs’ behalf; (2) Register for credentials to access the
private secure links on the HHCAHPS website, www.homehealthcahps.org; (3) When
registering for credentials to access the private links on the HHCAHPS website, the system will
automatically generate a customized Consent Form for the HHAs. Each HHA must print this
Consent Form and mail the completed signed and notarized Consent Form to the HHCAHPS
Coordination Team; (4) Authorize an HHCAHPS survey vendor to collect and submit the
HHCAHPS survey data to the Data Center; (5) Stay informed about HHCAHPS by checking
www.homehealthcahps.org at least twice a week; (6) Prepare a monthly patient information file
containing information that the survey vendor needs for sampling and fielding the survey; and
(7) Submit the monthly patient information file to the survey vendor by the date specified or
agreed to by your contracted survey vendor.
CMS believes that the 16 hours of labor that the HHA will need to do annually can be
conducted by a Medical Records Reviewer. The U.S. Bureau of Labor Statistics has determined
that the hourly wage of a Medical Records Reviewer is $24.94. Therefore, the annual cost of the
wage labor would be 16 hours times $24.94 equals $399.04 per HHA. The total cost for all
HHAs would therefore be 9,890 HHAs times $399.04 equals $3,946,505.60.

16

EXHIBIT 5. ESTIMATED COST BURDEN TO THE HHAS

Form name
Home Health Agencies Medical
Records Reviewer on Staff
Total

A.13

Number of
respondents

Total
burden
hours

Average
Cost to
Contract

Total cost
burden

1
9,890

16
158,240

$24.94
$24.94

$399.04
3,946,505.60

Estimates of Annualized Respondent Capital and Maintenance Costs

Capital and maintenance costs include the purchase of equipment, computers or computer
software or services, or storage facilities for records, as a result of complying with this data
collection. We have determined that there is an annual-time cost to the HHAs to secure the
services of approved HHCAHPS survey vendors to conduct the HHCAHPS on their behalf. In
Exhibit 6, we have summarized the estimated cost burden to the HHAS. If all 9,890 HHAs
participate in the HHCAHPS, at the estimated cost of $4,000 for contract costs, then the total
cost is estimated to be $39,560,000.
EXHIBIT 6. ESTIMATED COST BURDEN TO THE HHAS

Form name
Home Health Agencies
contracting with approved
HHCAHPS Survey Vendors
Total

A.14

Number of
respondents

Total
burden
hours

Average
Cost to
Contract

Total cost
burden

1
9,890

16
158,240

$4,000
$4,000

$4,000
$39,560,000

Estimates of Annualized Cost to the Government

The total cost for the survey costs is $1,665,634 for labor hours, materials and supplies,
overhead, and general and administrative costs and fees. The cost for CMS staff to oversee the
project is $100,000, including benefits, for a total 1-year project cost of $1,765,634. The
contracted service costs include approximately $942,869 for development of systems, protocols,
and materials to manage the national implementation, and $1,665,634 for training, technical
assistance, oversight of vendors participating in the first year of data collection and data analysis.

17

A.15

Changes in Hour Burden

This is a revised collection of information. The change is the additional burden of
158,240 hours for the 9,890 HHAs of contracting with approved HHAHPS survey vendors to
conduct the HHCAHPS on their behalf.
A.16

Time Schedule, Publication, and Analysis Plans

A.16.1 National Implementation of Home Health Care CAHPS

Data collection for the national implementation of Home Health Care CAHPS survey is
scheduled to begin in summer 2009 by vendors sponsored by home health agencies that wish to
voluntarily participate in the survey. Sampling and data collection will be conducted on an
ongoing basis by survey vendors working under contract with the sponsoring home health
agencies. CMS will begin publishing results from the national implementation of Home Health
Care CAHPS survey on Home Health Compare located on the Medicare.gov website when
HHAs have four quarters of data available for reporting. Survey vendors will submit data to
CMS’ Home Health Care CAHPS Data Center (maintained and operated by RTI) on a monthly
or quarterly basis; however, results that will be posted will reflect one year’s worth of data. In
each quarter, RTI will adjust the data for mode of survey administration, patient mix, and nonresponse, if necessary. The results posted on Medicare.gov will reflect data collected in the four
most recent quarters (with data from the earliest quarter replaced by the current quarter).
A.16.1a

National Implementation Analysis

Analysis for the national implementation will focus on making appropriate adjustments
for mode and/or patient mix, as needed depending on the outcomes of the mode experiment. The
data collected each month during the national implementation phase will be transmitted to RTI.
Four quarters of data will be aggregated and analyzed for these adjustment purposes. Each
quarter, the oldest data will be dropped and the newest quarter added. For each item to be
reported, a mean or percentage of patients choosing a particular response will be computed. The
following describes how the results of the model that will be developed as part of the mode
experiment, which is described in Section A.16.2, will be applied in adjusting the raw observed
national survey data to remove the influences of factors not related to the care provided (and,

18

hence, need to be adjusted prior to public reporting of comparative results from individual home
health agencies).
A model, estimated using a linear or linear probability approach, can be conceptualized
as having the predictive form for a specific HHAi, as shown in Equations 1a and 1b below.
Equation 1a
Mean responsei = a*patient characteristicsi + b*modei + c*HHAi
or
Equation 1b
% with response of interesti = a*patient characteristicsi + b*modei + c*HHAi
Although the model will be estimated on individuals, it will be applied at the HHA level,
where a*patient characteristicsi represents the list of estimated coefficients multiplied by the
percentage of patients in HHAi with each of the characteristics or the mean of each characteristic;
b*modei is the list of coefficients for each mode multiplied by the percentage of patients with
that mode; and c*HHAi is list of coefficients multiplied by the percentage of patients in that
HHA (i.e., agency fixed effects).
In the national implementation, a home health agency can choose to use one of three data
collection modes—mail, telephone, or mixed mode (i.e., mail with telephone follow-up). During
any one quarter, one mode will have a value of 100% and the others 0%. It is possible that
modeling will indicate that, in the case of the mixed mode, the actual response mode should be
indicated. In this case, such an HHA could have a percentage in each mode.
To transform the estimation equation to an adjustment equation, all the HHA fixedeffects terms will be dropped. For each HHA, Equation 1b, for example, becomes

19

Equation 2
Adjustment for % with response of interesti = – a*patient characteristicsi –
b*modei
The estimated coefficients in the a and b lists may be positive or negative in the
estimation; positive coefficients become negative adjustments and negative coefficients become
positive adjustments.
While the mode coefficients will be determined by the mode experiment, the value of the
coefficients for the patient characteristics will be determined quarterly using all of the data
collected for the particular reporting period. The regression equation for the adjustment model
will have the mode coefficients fixed and the patient-mix coefficients estimated.
In the next step, the adjustment in Equation 2 will be normalized so that it is relative to a
patient whose characteristics are at the means of those characteristics in the national
implementation using one year of data. When the equations are estimated, each patient
characteristic factor with a 1/0 value has a coefficient magnitude representing an impact of
having the characteristic (variable = 1) compared to a reference group indicated by a variable
that has been intentionally omitted from the equation during estimation. The omitted group is
one of convenience for interpretation. In normalization, the adjustments are converted so that
they are relative to the mean of the patient characteristics of the sample. To do this, the
percentages (or means) for each characteristic for the entire Home Health Care CAHPS Survey
are subtracted from the percentages or means for each of the patient characteristics specific to
each HHA; the normalized patient characteristic in Equation 3 is the difference: HHA mean (or
percentage) of the characteristic minus the national mean (or percentage) of the characteristic.
Equation 3
Normalized Adjustment for % with response of interesti = – a*normalized patient
characteristicsi – b* modei

20

Since Equation 3 is an adjustment and not a final value for the percentage with the
response of interest, one more step is needed to arrive at the adjusted response, as shown in
Equation 4.
Equation 4
Adjusted % with response = raw % with response – a*normalized patient
characteristicsi – b* modei
The form of the adjustment is similar when the dependent variable is treated as a
continuous variable from 1 to 10 or from 1 to 4.
A.16.1b

Individual-Level Estimation and Adjustment

The formulations for the equations above assume that linear models are being used in the
model estimation phase. If the linear approximation is not deemed satisfactory, nonlinear
probability models such as logit will be needed.
A.16.2 Home Health Care CAHPS Mode Experiment

Home health agencies that participate in the national implementation of Home Health
Care CAHPS survey can choose to use a mail-only, phone-only, or mixed (mail with telephone
follow-up of nonrespondents) data collection mode. The intent of the mode experiment is to
develop a method to make the results from each sponsoring home health agency that participates
in the national implementation comparable based on any differences caused by the data
collection mode used. In addition, the mode experiment will be used to estimate patient
characteristics that are beyond the agencies’ control and that affect patient responses to the
survey. Home health agencies may treat different kinds of patients; that is, some may have more
long-term Medicaid, short-term private-pay, and aged and disabled post-acute patients than
others. Some may have more rehabilitative patients and some more medically ill patients.
Patients may rate the care that they receive from their home health agency providers differently
based on these patient characteristics and others such as age, education, and overall health status.
The statistical analysis that will be conducted on data from the mode experiment will be used to
determine which factors in and of themselves affect survey responses. Factors such as these have

21

been shown to be significant in other surveys and in CAHPS surveys, in particular. The
regression methods proposed, discussed in detail below, have been applied in other surveys.
CMS will use the results of the mode experiment to adjust the data collected in the
national implementation of Home Health Care CAHPS based on factors that are not directly
related to the home health agencies’ performance. Data collection for the mode experiment is
scheduled to begin May 2009; however, this start date is contingent upon receiving OMB
clearance by April 30, 2009. During the national implementation, the data will be gathered and
the reported responses adjusted for the mode of survey administration and patient characteristics.
The reports appearing in the Home Health Compare system will have been purged, to the extent
possible, of influences not related to the character of the care being given by the HHAs.
There are no plans for publication of the results from the mode experiment. The results
will be made publicly available on http://www.homehealthcahps.org.
A.16.2a

Mode Experiment Analysis

Based on data collected for the mode experiment, RTI will conduct analysis to predict
CAHPS responses and ratings as a function of the mode used to administer the survey and,
additionally, will estimate the potential effects of patient characteristics outside the control of the
HHA.
The regression models and variable formulations will be empirically driven. Each
regression model in the mode experiment analysis will estimate a dependent variable, which will
be either one of the responses or a composite of responses. The responses to the survey items of
greatest interest usually have ordinal responses. Answer structures are typically yes/no,
never/sometimes/usually/always, or a global rating (0, 2,…10). There is no constant linear or
ratio relationship inherent in these responses. Two is not necessarily twice as good as 1, and 4 is
not twice as good as 2. Such responses may be rigorously modeled using logit methods
concerning the probability of selection. However, if the data approximate normality and are not
strongly clustered at the extreme ends of the distributions, linear regression with numeric values
1–4 or 0–10 can be used successfully.
Generally, the linear forms of the estimation models will be

22

Dependent variable = sum of (coefficients*patient characteristic indicators) + sum of
(coefficients*mode indicators) + sum of (coefficients*home health agency indicators).
When there are categorical patient characteristics, such as age groups, one group is
omitted from the set of categories included in the model. That group is a reference category to
which the effect of related categories is scaled. The home health agency variables will capture
the home health agency–specific effects in order to isolate the effects of mode and other
characteristics.
Each item under consideration for reporting will be tested for inclusion in the appropriate
adjustment formula. The outcome of the process will be to determine the mode coefficients to be
used as adjusters in the implementation phase and the patient characteristic variables that will be
used as adjusters in that phase. The actual coefficients on patient characteristics used in the
implementation adjustments will be re-estimated as part of that analysis.
A.16.2b

Data Elements for the Mode Analysis

We anticipate requesting data for analysis variables from three sources for the mode
experiment analysis: the HHA, the survey itself, and (during the national implementation) the
survey vendor. Exhibit 5 contains a list of potential variables for analysis.

23

EXHIBIT 7. LIST OF POTENTIAL VARIABLES FOR DATA ANALYSIS

Data variables
Date of birth (for experiment)
Gender
Medical Record Number
Payer
Dual Medicare-Medicaid eligibility
Managed care organization
Diagnoses (ICD-9 codes) underlying
cause of care and comorbidities
End-stage renal disease (ESRD) patient
on dialysis
Admission date to HHA
Number of visits – skilled and
aide/personal care
Source of admission
Deficits in activities of daily living
(ADLs)—score from OASIS
Overall health status
Mental health status
Race and ethnicity
Education level
Whether respondent lives alone
Did someone help respondent with survey
Potential other items on survey
Mode of survey administration
Number of prompts to elicit response
Agency identifier
Interview completion date

From HHA
X
X
X
X
X
X

From survey
respondent
-

From survey
vendor in
implementation
only
-

X

-

-

X

-

-

X

-

-

X

-

-

X

-

-

X

-

-

-

X
X
X
X
X
X
X
-

X
X
X
X

The dependent variables to be analyzed include all survey items (or will be derived from
survey items). The independent variables may come from the survey as self-reported
characteristics or may have another source (such as enrollment or other administrative data).
Because the survey will be fielded to patients associated with all payers, there is no single source
of data that can be used for the mode analysis. Home health agencies will need to provide data
from the patient record to their survey vendor (during the national implementation) or to RTI (for

24

agencies participating in the mode experiment). Since we do not know, a priori, which variables
will be most important for this population, we may be requesting, for the mode experiment, more
than we will ultimately use in our implementation analyses. We recognize, however, the
importance of minimizing HHA burden. Discussions with home health agencies conducted by
RTI suggest that the additional administrative data requested are available at agencies, including
small home health agencies, and could be supplied with minimal burden.
A.17

Exemption for Display of Expiration Date

CMS does not seek this exemption.

25