CMS-10451.Supporting Statement Part B & Instruments

Supporting Statement for
Evaluation and
Development of Outcome
Measures for Quality
Assessment in Medicare
Advantage and Special
Needs Plans
Contract Number: HHSM-500-2005-00028I
Task Order Number: HHSM-500-T0004

October 2, 2012 (revised February 8, 2013)
Prepared for Centers for Medicare & Medicaid
Services
Susan Radke, COTR
Lisa Palucci, Alternate COTR
RAND Corporation
1776 Main Street
P.O. Box 2138
Santa Monica, CA 90407-2138

TABLE OF CONTENTS
I. Supporting Statement Part B

1.
2.
3.
4.
5.

Collection of Information Employing Statistical Methods
Respondent Universe and Respondent Selection.................................................1
Data Collection Procedures..................................................................................2
Response Rates and Non-Response .....................................................................3
Tests of Procedures or Methods...........................................................................3
Statistical and Data Collection Consultants .........................................................3

II. Attachments
A.

Collection Materials .......................................................................................................6
1. Transitions of Care.....................................................................................................7
a. Instructions for Plans..............................................................................................7
b. Table of Hospital to Community Discharges for Measurement ............................13
c. Medical Record Abstraction Form .........................................................................14
d. Medical Record Abstraction Form Guidelines ......................................................26
e. Excel Data Template ..............................................................................................30
f. Resource and Time Survey .....................................................................................56
2. Continuity between Mental Health Provider and Primary Care Provider .................57
a. Instructions for Plans..............................................................................................57
b. Table of Patients for Mental Health Continuity Measurement ..............................61
c. Medical Record Abstraction Form .........................................................................62
d. Medical Record Abstraction Form Guidelines ......................................................68
e. Excel Data Template ..............................................................................................75
f. Resource and Time Survey .....................................................................................90
g. Diagnosis Codes.....................................................................................................91
3. Language Centered Care, Cultural Competence, Physical Activity, Healthy
Eating, and Caregiver Strain ......................................................................................94
a. Prenotification Letter to Beneficiaries ...................................................................94
b. CAHPS Survey with Additional Items – English Version ....................................95
c. CAHPS Survey with Additional Items – Spanish Version ....................................112

B. Disclosure Statement .........................................................................................................126
III. Record of Information Clearances ..............................................................................127

Supporting Statement--Part B
Collection of Information Employing Statistical Methods
1.

Respondent Universe and Respondent Selection
(1) For the transitions of care measure, up to six MAO contracts will be recruited by CMS
for participation, with a goal of including one or more plan benefit packages within each
contract to comprise a final sample of: two different size MA plans, two D-SNPs and two
C-SNPs. A sample size of 50 hospital discharges is conservatively selected to give 80%
power to detect a 30% absolute difference in satisfying a particular quality measure
between any two plans, where the overall likelihood of satisfying a particular quality
measure is conservatively assumed to be 50% and the rate of falsely detecting a quality
difference where none actually exists (alpha) is set by convention at 5%. Although a
larger sample size would give more precision in terms of estimating differences in quality
of care between plans, it would also impose a greater burden on plans.
(2) For the measure of continuity between mental health provider and PCP, up to six MAO
contracts will be recruited by CMS for participation, with a goal of including one or more
plan benefit packages within each contract to comprise a final sample of: two different
size MA plans, two D-SNPs and two C-SNPs. A sample size of 50 patients is
conservatively selected to give 80% power to detect a 30% absolute difference in
satisfying a particular quality measure between any two plans, where the overall
likelihood of satisfying a particular quality measure is conservatively assumed to be 50%
and the rate of falsely detecting a quality difference where none actually exists (alpha) is
set by convention at 5%. Although a larger sample size would give more precision in
terms of estimating differences in quality of care between plans, it would also impose a
greater burden on plans.
(3) For measures informed by the amended CAHPS survey items: The sample size per MA
contract for the national implementation of Medicare CAHPS is 800 eligible enrollees.
An eligible enrollee is defined as:
Age 18 or older at the time of the sample draw,
Having six months of continuous enrollment in the plan,
And not residing in an institution.
We have assumed that these eligibility criteria will apply to the field test of the amended
CAHPS survey. We intend to randomly select 230 beneficiaries from each of ten largely
English-speaking MAO contracts for a total field test sample of 2,300 English-speaking
respondents, and 250 beneficiaries from each of ten largely Spanish-speaking MAO
contracts for a total field test sample of 2,500 Spanish-speaking beneficiaries.
Employing the MA & PDP CAHPS survey administration procedures described above
we anticipate an average plan response rate of 41.6%. Thus, this CAHPS field test is
anticipated to yield about 1000 English surveys and about 1000 Spanish surveys.

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2.

Data Collection Procedures
(1) For the transitions of care measure, plans will be prepared to identify a suitable sample,
obtain medical records, and perform chart abstraction. According to specific instructions
(Appendix 1.a), plans will identify a consecutive set of patients transitioning from the
inpatient to the community setting after a hospitalization of at least three days. Hospital
and PCP records for these patients will be abstracted. The abstraction will be completed
by registered nurses, according to an abstraction form (Appendix 1.c) and accompanying
guidance document (Appendix 1.d). The medical record abstraction process includes a reabstraction of 10 patient cases (20%) for inter-rater reliability measurement. These 10
cases will be abstracted by two different nurses. Abstracted data will be entered into an
Excel spreadsheet (Appendix 1.e) by the plans. The number of records obtained and
abstracted and the time required by personnel to complete the data collection will be
recorded by the plans (Appendix 1.f). All data will be returned by plans to CMS for
further analysis by RAND.
(2) For the measure of continuity between mental health provider and PCP, plans will be
prepared to identify a suitable sample, obtain medical records, and perform chart
abstraction. According to specific instructions (Appendix 2.a), plans will identify
consecutive patients with a new mental health provider visit for a mental health problem.
Outpatient mental health provider and PCP records for these patients will be abstracted.
The abstraction will be completed by registered nurses, according to an abstraction form
(Appendix 2.c) and accompanying guidance document (Appendix 2.d). The medical
record abstraction process includes a re-abstraction of 10 patient cases (20%) for interrater reliability measurement. These 10 cases will be abstracted by two different nurses.
Abstracted data will be entered into an Excel spreadsheet (Appendix 2.e) by the plans.
The number of records obtained and abstracted and the time required by personnel to
complete the data collection will be recorded by the plans (Appendix 2.f). All data will be
returned by plans to CMS for further analysis by RAND.
(3) For items to be added to the CAHPS survey, RAND’s Survey Research Group (SRG)
will administer the amended CAHPS according to the protocol used for national
implementation of MA & PDP CAHPS. We anticipate a field period of 12 weeks to
include the following steps:
A pre-notification letter from CMS will be sent to inform beneficiaries of the upcoming
survey (Appendix 3.a);
One week later, an initial survey will be mailed. There are two versions of the survey,
one in English (Appendix 3.b) and one that will be translated to Spanish (Appendix 3.c).
Questions that have been added to the CAHPS for this data collection have been
highlighted in the survey appended to this volume. While content differs slightly between
survey versions (e.g. questions about caregiver strain are found only in the English
version, and questions about language centered care are found only in the Spanish
version), the overall number of questions being asked of English- and Spanish-speaking
groups is similar;
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Three weeks after the initial mailing, a second survey will be mailed to non-responders;
SRG will attempt to obtain a completed survey from remaining non-responders by
telephone interview (five calls will be attempted on different days of the week at different
times).
Data will be entered into an electronic file for analysis.
3.

Response Rates and Non-Response

Each of the measures described in this collection request have undergone pilot testing. Results of
pilot tests informed estimates of response rates for this collection. Findings from pilot tests also
suggested revisions to instruments that are likely to make them more effective in subsequent
collections.
The abstraction process for transitions of care and continuity between mental health provider and
PCP measures includes a re-abstraction for 10 patient cases (20%) for inter-rater reliability
measurement. When the sample is drawn and abstractor lists are assigned, each list will include a
20% sample of records that will be abstracted by two different abstractors. This is intended to
ensure greater accuracy and to enhance the reliability of information gathered through medical
record abstraction.
For items added to the CAHPS survey, we will follow CAHPS protocol. CAHPS protocol
specifies telephone follow-up for non-responders.
4.

Tests of Procedures or Methods

The measures for which information collection is being requested have already undergone pilottesting. The purpose of this data collection is to test implementation and enhance the quality of
these measures for future use by CMS.
5.

Statistical and Data Collection Consultants

The data collection methods and instruments were designed and results will be analyzed by the
RAND Corporation, a CMS contractor, under the leadership of:
Neil Wenger, MD, MPH
RAND Corporation
1776 Main Street
PO Box 2138
Santa Monica, CA 90407-2138
310-393-0411
Data will be collected by plan benefit packages within MAO contracts that will be recruited for
participation by CMS. These contracts and their plans are yet to be determined. Plans are likely

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to contract with vendors to perform much of the efforts required. These vendors are yet to be
determined.

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II. Attachments

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A. Collection Materials

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Appendix 1.a

Transitions of Care: Hospital Discharge to Community

Instructions for Plans
Introduction
The importance of care transitions between clinical care venues, particularly between the
hospital and home or nursing home, has rapidly gained recognition as a key element of quality
of care. If care transitions are not handled properly, they can be a source of medical errors and
adversely affect patient health. Medication management, diagnostic evaluation, treatment
continuation and information such as preferences for aggressiveness of care must successfully
traverse care venues.
This package includes instructions for the medical record data collection focusing on the quality
of transitions of care for Medicare patients who have been hospitalized and are being
discharged to the community. You will find instructions related to the following topics:
Quality measures
Medical record format issues
Identifying the patient sample
Medical record acquisition
Orientation of nurse abstractors
Inter-rater reliability (IRR) process
Submission of data

Quality Measures
The quality measures that serve as the focus of this data collection target the timely and
complete exchange of essential information between the hospital and the primary care provider
(PCP) and/or other post-discharge source of care. They also target the follow-through of
recommended post-discharge appointments, tests, and therapies. The measures include 2
endorsed by the National Quality Forum (NQF) and 5 measures from the Assessing Care of
Vulnerable Elders (ACOVE) measurement set. The measures fall in to 3 areas of hospital
transition continuity: transition record continuity, PCP continuity, and follow-up care continuity.
The specific quality measures include the following:

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[NQF] Transition Record Continuity:
NQF #0647: Transition Record with Specified Elements Received by Discharged Patients
The percentage of patients discharged from an inpatient facility to home or any other site of
self-care or their caregiver(s) who received a transition record at the time of discharge including
at a minimum, all of the specified elements:
Reason for admission
Major procedures/tests and results
Principal diagnosis
Current medication list
Studies pending at discharge
Patient instructions
Advance directive/surrogate or reason why not
24/7 contact information for stay-related emergencies
Contact information for results of pending studies
Plan for FU care (therapy, DME, support)
MD/site designated for FU care
NQF #0648: Timely Transmission of Transition Record
The percentage of patients discharged from an inpatient facility to home or any other site of
care for whom a transition record was transmitted to the facility or primary physician or other
health care professional designated for follow-up care within 24 hours of discharge via FAX,
email, or mutual access to EHR. The transition record includes, at a minimum, all of the
specified elements:
Reason for admission
Major procedures/tests and results
Principal diagnosis
Current medication list
Studies pending at discharge
Patient instructions
Advance directive/surrogate or reason why not
24/7 contact information for stay-related emergencies
Contact information for results of pending studies
Plan for FU care (therapy, DME, support)
MD/site designated for FU care

[ACOVE] PCP Continuity:
ACOVE Continuity #7: PCP Notification
IF a vulnerable elder is treated in an Emergency Department (ED) or admitted to the hospital,
THEN there should be documentation (during the ED visit or within the first 2 days after
admission) of communication with a continuity physician or that there is no continuity physician.

ACOVE Continuity #9: Post-Hospitalization Medications
If a vulnerable elder is discharged from a hospital to home and received a new chronic disease
medication or a change in medication prior to discharge, THEN the outpatient medical record
should document the medication change within 6 weeks of discharge.

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[ACOVE] Follow-up Care Continuity:
ACOVE Continuity #10: Serum Level
IF a vulnerable elder is discharged from a hospital to home with a new medication that requires
a serum medication level to be checked, THEN the medical record should document the
medication level, that the medication was stopped, or that the level was not needed.
ACOVE Continuity #11: Post-Hospitalization Pending Tests
IF a vulnerable elder is discharged from a hospital to home or a nursing home and the transfer
form or discharge summary indicate that a test result is pending, THEN the outpatient or
nursing home medical record should include the test results within 6 weeks of hospital
discharge or indicate that the result was followed-up elsewhere or why the results cannot be
obtained.
ACOVE Continuity #12: Post-Hospitalization Appointments
IF a vulnerable elder is discharged from a hospital to home or a nursing home and the hospital
medical record specified a follow-up appointment for a physician visit or a treatment, THEN the
medical record should document that the visit/treatment took place, that is was postponed, or
not needed.

Medical record format issues
Measuring quality of transitions of care is a complex and challenging process due to multiple
providers of care and multiple settings involved. While continuity measurement may focus on
patient survey (perception of care quality) or organizational self-assessment (organizational
structure and culture), this exercise focuses on quality measured from medical record data.
The focus is the patient discharged from an acute hospitalization back to the community.
Continuity is imperative at this time to ensure that the patient’s potential for return to his/her
pre-hospitalization (or improved) state is facilitated and hospital-related complications are
avoided (or minimized).
While post-hospitalization care may involve multiple providers and care sites, access to all of
those records of care is not readily feasible. For this continuity measurement, only the hospital
record and the PCP record are accessed. While other providers (including physician
specialists) may be involved, good continuity should be reflected in the inclusion of essential
continuity information found in the PCP record of care.
As providers continue to transition to an electronic health record (EHR), the concept of
facilitated information sharing between providers is a goal. While some healthcare systems
have mutual access EHRs (a single patient record to which all within-system providers have
access), more often than not, multiple providers of care utilize variable formats for
documentation that are not easily shared. Provider EHRs may be different versions of the
same basic vendor product or different EHR products altogether. Other providers use
“traditional” paper records or even a combination of paper and electronic documentation.
For this medical record abstraction, the plan will need to access both hospital and PCP records
either through a hard copy or scanned copy of the record or, if an EHR, via remote access.

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Identifying the patient sample
Patients will be identified from the time period between 6 and 9 months prior to date that the
measure is implemented. From the date of implementation of this measure, identify the 3month period between 6 and 9 months prior to this date. Identify consecutive patients during
this period hospitalized for at least three days and discharged from the acute care hospital to
the community setting. For each patient, identify the hospital and the primary care provider
and record these on the log in Appendix 1.b.

Medical record acquisition
Once the sample has been identified, the relevant hospital and PCP records will need to be
acquired or accessed. This may be done by the plan through a directed request for copies to
the providers of interest or by the utilization of a record-access vendor.
The required records are:
Complete hospital record for the admission under study
PCP record covering all care from 9 months prior to the date of the implementation of the
data collection (total of nine months of care). This time frame is required to allow time for
recommended post-discharge care to occur and be documented.
When acquiring copies of records, remember to request complete copies of the record content
for the time frame specified, including the following:
Hospital records:
Entire documentation for the specified hospitalization
If EHR and content is selected for print, be sure to include all of the following:
Emergency department (ED) record, if admitted through the ED
Admitting history and physical exam
MD orders
Progress notes
Specialist consults
Telephone and message contacts with outside providers
Operative and procedure reports
Ancillary care (e.g., physical therapy, respiratory therapy)
Lab tests
X-rays, scans, and any other test results
Nursing admission note
Nursing notes and flow sheets
Vital signs flow sheets
Medication administration record
Discharge planning notes
Discharge summary/transition record sent to outside provider
Discharge care and medication instructions given to the patient
Medication reconciliation records
Outpatient records:
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All documentation of care from all providers during the 9 month study period
Include all of the following:
Health maintenance summary records
Problem lists
Medication summary records
Visit notes (office and home, if applicable)
Consult reports
Hospitalization documentation and summaries
ED visit documentation
Ancillary care (e.g., physical therapy, home care)
Lab tests
X-rays, scans, and any other test results
Nurse care manager documentation
Telephone and message contacts with patient
Telephone and message contacts with other providers
A medical record tracking system should be established to track the status of the acquisition of
the requested records (Appendix 1.b). Hospital and PCP records will need to be matched by
patient ID for abstraction (if hard copies). Hospital and PCP records may be abstracted
sequentially; that is, it is not necessary to have both records on hand during the abstraction.
However, the hospital record needs to be abstracted first. It is anticipated that the abstraction
of both the hospital and PCP records should take, on average, approximately 60 minutes per
patient case.

Orientation of nurse abstractors
The medical record abstraction is designed to be completed by registered nurses. The content
requires clinical judgment and therefore, nurse abstractors are required. Ideally, this
abstraction would be completed by experienced nurse abstractors at the plan who are familiar
with the records of care. If no abstractors are available, the task could be outsourced to a
reputable vendor.
The Medical Record Abstraction Forms and related Guidelines are located in Appendices 1.c
and 1.d of this document. It is suggested that the nurse abstractors review the abstraction form
and guidelines in advance of abstraction and meet as a group with their supervisor to review
the process and answer any outstanding questions.
Each abstractor will be assigned a list of Study IDs to complete. Each abstractor will maintain
the log of Study IDs provided to him/her with the date the case was abstracted, or if not
abstracted, the reason why not.

Medical record abstraction reliability
The medical record abstraction process includes a 20% sample for inter-rater reliability
measurement. When the sample is drawn and abstractor lists are assigned, each list should
include a 20% sample of patient cases that will be abstracted by two different abstractors. The
total number of completed abstraction cases will be 10.
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Submission of data
Abstraction data will be entered by the plan into an Excel template (Appendix 1.e) and
submitted to CMS for analysis by RAND.
Time and effort expended by the plan to conduct the project should be documented in the Time
and Resource Survey form located in Appendix 1.f.

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Appendix 1.d: Abstraction Form Guidelines

Transitions of Care: Hospital Discharge to Community
Medical Record Abstraction Form Guidelines

I. HOSPITAL RECORD:
1. Type of hospital record: Indicate the type of record that applies to the hospital record you
are abstracting. Mutual access integrated EHR refers to a centralized electronic health
record that is utilized by the hospital and is also accessible to other providers, including at a
minimum, the patient’s primary care provider (PCP). If not a mutual access EHR, the
hospital record may be an EHR that is not accessible to other providers, may be a
combination of portions that are electronic and portions that are paper, or it may be a
traditional paper record. Classify an EHR as such even if you are utilizing a printed copy of
its contents for this abstraction.
2. Hospital Admission: Use this date and time as reference when answering Q4 (PCP
Contact).
3. Hospital Discharge: Use this date and time as reference when answering Q11 (Timeliness
of Transmission of Transition Record/Discharge Summary) and Q17 (Transition
Record/Discharge Summary in PCP Record).
4. PCP Contact: Based on the hospital record, indicate if there is documentation that the PCP
was contacted by the hospital staff (or an attempt was made) to alert the PCP of the
patient’s hospitalization within 48 hours of admission. If the PCP admitted the patient or
sent the patient to the emergency room and that visit resulted in the admission, choose
response 1. Choose response 2 only if the patient’s PCP is not known to the hospital staff
or the patient does not have a PCP. Otherwise, indicate the timeliness of the contact or
contact attempt. If no evidence of contact or contact attempt is documented (and response
1 and 2 are not applicable), choose response 9.
5. Discharge Disposition: Indicate the patient’s discharge disposition. If the patient was
NOT discharged to home [e.g., was an acute transfer, sent to a skilled nursing facility (SNF)
or to long-term care (LTC) or to an assisted living facility (ALF), died during the admission,
or left against medical advice (AMA)], stop abstracting.
6. Transition Record to Patient: Indicate if the hospital record contains the transition
record/discharge instructions that were given to the patient or patient’s caregiver at the time
of discharge. This may include more than one document, e.g., discharge instructions and a
separate medication list.
7. Transition Information to Patient: Indicate in column ii) which of the listed types of
information were included in the printed discharge records given to the patient. Some types
of information may be not applicable, as when a patient had no surgery during the
admission [item 7b) i) and ii)] or major tests such as imaging, cardiac catheterization [item
7b) iii) and iv)]. A patient may not need pending results information [item 7 i)] if there are no
pending test results at discharge or follow-up treatment information (item 7 j)] if there is no
order for follow-up treatment such as home care, physical therapy, etc. For items that were
not included in the patient discharge information (response 2 or “No”), indicate, where
applicable, if that information was noted as discussed with the patient (e.g., discharge
medications).
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8. Transition Medications PCP Reconciliation: Medications on Admission: Based on the
hospital record admitting information (e.g., nursing admission assessment, admitting history
and physical), list in column i) all the medications that the patient was taking at the time of
admission. List regular and prn medications, over-the-counter medications, vitamins and
herbal preparations and include the dosage and frequency of administration.
In column ii) and for each listed medication, indicate the disposition for that drug at the time
of hospital discharge. If the medication is to be continued after discharge and the dosage
and frequency remain unchanged, choose response 3. If either dosage or frequency
changed, choose response 1. If the medication was discontinued, choose response 2.
Later in the abstraction (after Q14) when you are reviewing the PCP record, you will come
back to Q8 to complete column iii). At that time and for each listed medication, indicate in
column iii) if at the first PCP visit after discharge, the PCP record accurately listed the
discharge medication. Accurately listed means the medication list at that visit included the
correct drug, dose, and frequency for each continued medication (changed or same) and did
NOT include medications that were discontinued. Choose response 2 (Exp) if the listing is
not accurate, but there is documentation in the PCP record that explains or justifies this
discrepancy [e.g., patient seen in an emergency department (ED) before first PCP visit and
a medication change was made in the ED, or medication discontinued due to adverse
effect].
9. Transition Medications PCP Reconciliation: New Medications: Based on the hospital
record admitting and discharge information (e.g., nursing admission assessment, admitting
history and physical, discharge medication list), list in column i) all NEW medications that
were prescribed during the hospitalization and are to be continued after discharge. List
regular and prn medications, over-the-counter medications, vitamins and herbal
preparations and include the dosage and frequency of administration.
Later in the abstraction [after Q14 and completing Q8 ii)] when you are reviewing the PCP
record, you will come back to Q9 to complete column ii). At that time and for each listed
medication, indicate in column ii) if at the first PCP visit after discharge, the PCP record
accurately listed the NEW discharge medication. Accurately listed means the medication list
at that visit included the correct drug, dose, and frequency for each NEW medication.
Choose response 2 (Exp) if the listing is not accurate, but there is documentation in the PCP
record that explains or justifies this discrepancy [e.g., patient seen in an emergency
department (ED) before first PCP visit and a medication change was made in the ED, or
medication discontinued due to adverse effect]. When you have completed column ii), you
may proceed to complete Q14 based on the PCP record.
10. Allergy/Untoward Medication Reaction: Indicate if during the hospitalization, the patient
experienced an allergic or otherwise untoward reaction to a medication. If so indicate in
Q10a) if this information was included in the transition record/discharge summary that was
sent to the post-discharge follow-up provider.
11. Timeliness of Transmission of Transition Record/Discharge Summary: Indicate if the
transition record was sent to the PCP (and other source of care, if applicable) within 24
hours. If the patient record is a mutual access EHR, choose response 1. Otherwise, look
for evidence in the hospital record that document was emailed or faxed to the PCP within 24
hours of the patient’s discharge. If this information is not contained in the hospital record,
you may possibly deduce whether or not this occurred from the PCP record. For example, if
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the transition record is in the PCP record and it is stamped as received within 24 hours of
discharge, you may choose response 2. Do not do this, however, unless it is definitely clear
from the PCP record documentation that transmission occurred within 24 hours. If the
document is in the PCP record but is stamped as received more than 24 hours after
discharge, it will not be possible to know if the transition record was sent within 24 hours, but
was not acknowledged and filed until after that time period or if the document was sent from
the hospital more than 24 hours after discharge. Therefore, if a document is filed more than
24 hours after discharge and in the absence of any information about the time it was sent
from the hospital, you would choose response 4 (transmitted, but time unknown).
12. Physician of Follow-up: Based on the hospital record, indicate the physician(s) noted as
the source of follow-up care for the patient after discharge.
13. Timing of Recommended Follow-up: Indicate the number of days recommended at
discharge for the timing of the post-discharge appointment or (in the absence of this) of
when to call for an appointment for the PCP and, if applicable, specialist.
14. Post-Hospitalization Appointments and Therapies: Based on information in the hospital
record at the time of discharge, indicate which of the listed types of care the patient was
recommended or ordered to have. Items a) and b) refer to tests that were done during the
admission with results that were still pending at the time of discharge. If this applies to the
abstracted case, specify the test and choose response 1 in column ii). Later when you
review the PCP record, you will record in column iii) whether or not the pending results were
obtained, or if not, if an explanation or justification was documented for the lack of results.
Items c)-k) refer to other types of care that may have been ordered. Similar to items a) and
b), indicate in column ii) if the care was ordered. Later when you review the PCP record,
you will record in column iii) whether or not the ordered care occurred in the prescribed time,
or if not, if an explanation or justification was documented for the lack of care (e.g., order is
for pacemaker consult when TSH is normal; record does not include evidence of pacemaker
consult, but includes several TSH results that are out of the normal range). After completing
column iii) based on the PCP record, you may return to Q19.
II. PCP RECORD
15. Type of PCP record: Indicate the type of record that applies to the PCP record you are
abstracting. Mutual access integrated EHR refers to a centralized electronic health record
that is utilized by the hospital and is also accessible to other providers, including at a
minimum, the patient’s primary care provider (PCP). If not a mutual access EHR, the PCP
record may be an EHR that is not accessible to other providers, may be a combination of
portions that are electronic and portions that are paper, or it may be a traditional paper
record. Classify an EHR as such even if you are utilizing a printed copy of its contents for
this abstraction.
16. Initial Post-Hospitalization Contact(s): Based on the PCP record, indicate which types of
listed post-discharge care the patient experienced within the first six weeks after discharge.
If the care occurred, list the date in column iii). If the date is unknown, indicate in column iv
if the care occurred prior to the first post-discharge PCP visit.
17. Transition Record/Discharge Summary in PCP Record: Indicate if the PCP record
contained the transition record /discharge summary from the studied hospitalization. If the
patient record is a mutual access EHR that is utilized by the PCP, choose response 1. If the
record is mutual access, indicate in Q17b) whether or not the PCP acknowledged receipt of
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the transition record. If the record is NOT mutual access, indicate if there is an
acknowledgement of the transition record within 48 hours of discharge. The
acknowledgment must include a date stamp on the transition record or a note of its receipt
within the 48 hour time window.
18. Content of Transition Record/Discharge Summary: Indicate which of the listed types of
information were included in the transmitted transition record/discharge summary received
by the PCP. Some types of information may be not applicable, as when a patient had no
surgery during the admission [item 7b) i) and ii)] or major tests such as imaging, cardiac
catheterization [item 7b) iii) and iv)]. A patient may not need pending results information
[item 7 i)] if there are no pending test results at discharge or follow-up treatment information
(item 7 j)] if there is no order for follow-up treatment such as home care, physical therapy,
etc. For items that were not included in the discharge information, indicate, where
applicable, if that information was noted in the PCPs notes.
After completing Q18, follow the boxed instructions for completing the PCP portion of
Q8, Q9, and Q14. After completion of these items, return to Q19.
19. Case Manager: Indicate if there is evidence that the patient’s post-discharge care included
involvement with a nurse care manager. This individual may be associated with the PCP
practice, another practice, or another organization. Case manager contact may be in
person or by telephone.
20. Case Manager Activities: Indicate in column ii) which of the listed activities occurred within
the six weeks after discharge. Care types a)-i) refer to activities performed by the case
manager with the patient. Care types j)-t) are contacts the case manager made with the
listed entities while managing or facilitating the patient’s post-discharge care. If a care type
occurred, indicate in column iii) the date it occurred.
21. Patient Death: If the patient died in the three months after discharge, indicate this and the
date of death (if known) or the date the death was acknowledged in the record of care where
it was found.

[29]

[30]

[31]

[32]

[33]

[34]

[35]

[36]

[37]

[38]

[39]

[40]

[41]

[42]

[43]

[44]

[45]

[46]

[47]

[48]

[49]

[50]

[51]

[52]

[53]

[54]

[55]

[56]

Appendix 2.a: Continuity between Mental Health Provider and Primary Care
Provider

Mental Health (MH) Continuity
Instructions for Plans
Introduction
Substantial evidence shows that there is considerable unmet need in mental health care. Unmet
need is present in screening, diagnosis and treatment, but a particular deficit exists in the
integration of mental health treatment with the other aspects of medical care provided to the
patient. This is a particular concern for MA plan and SNP enrollees, for whom mental health
services may be a “carve out” that is separate from medical care. In this case, there is no
consultant relationship between mental health specialists and primary care providers, and there
are real and perceived barriers to transfer of information between mental health and primary
care. The need to be aware of potential drug-drug interactions and disease-drug interactions, as
well as the potential to monitor adherence and condition severity across providers, argues for a
closer relationship between mental health and primary care. Furthermore, information about
mental health conditions may be essential to choice of many medical therapies and their
implementation.
This data collection focuses on medical record documentation from two sources: the primary
care provider (PCP) and the mental health (MH) provider.
This package includes instructions for the medical record data collection focusing on the
continuity of MH care for Medicare beneficiaries who have a PCP and who recently initiated MH
services from a MH provider. You will find instructions related to the following topics:
Quality measures
Medical record format issues
Identifying the patient sample
Medical record acquisition
Orientation of nurse abstractors
Inter-rater reliability (IRR) process
Submission of data

Quality Measures
Despite the essential nature of continuity between mental health care and general medical care
and evidence of deficits in this area, little has been done to measure the quality of care in this
area. The quality measures that are the basis of this data collection stem from two measures
from the Assessing Care of Vulnerable Elders (ACOVE) measurement set. These focus on
[57]

medication, consultant, and emergency/acute care treatment continuity. The specific quality
measures include the following:
(New) Percentage of patients who newly see a mental health professional for a mental health
disorder and also see a primary care physician for whom there is communication between these
clinicians within three months of the first mental health provider visit.
ACOVE Continuity #3: Medication Continuity
IF a vulnerable elder is under the outpatient care of ≥ 2 physicians, and one physician
prescribed a new chronic disease medication or a change in prescribed medication, THEN the
non-prescribing physician should acknowledge the medication change at the next visit.
ACOVE Continuity #7: Communication with PCP
IF a vulnerable elder is treated at an emergency department or admitted to a hospital, THEN
there should be documentation (during the ER visit or within the first 2 days after admission) of
communication with a continuity physician, of an attempt to reach a continuity physician, or that
there is no continuity physician.
In addition to addressing the quality measures noted above, the data collection includes
documentation of details of the nature of communications between providers and any specific
continuity problems identified by the PCP and/or MH provider.

Medical record format issues
The focus of this data collection is the patient who recently initiated MH services from a MH
provider. As providers continue to transition to an electronic health record (EHR), the concept of
facilitated information sharing between providers is a goal. While some healthcare systems
have mutual access EHRs (a single patient record to which all within-system providers have
access), more often than not, multiple providers of care utilize variable formats for
documentation that are not easily shared. Provider EHRs may be different versions of the same
basic vendor product or different EHR products altogether. Other providers use “traditional”
paper records or even a combination of paper and electronic documentation. Usually, even
within systems with wide access to records across the spectrum of care, mental health records
are not usually accessible to primary care physicians and other medical care providers. For this
medical record abstraction, access to both the PCP and MH provider records is necessary
either through a hard copy or scanned copy of the record or, if an EHR, via remote access.

Identifying the patient sample
Administrative data are needed for a two year period: Year 1 is needed to ensure that the
patient was not seen by a mental health professional during the prior year and year 2 is the time
period in which the patient is first seen by a mental health provider and medical records are
reviewed for evidence of communication between the mental health provider and the PCP.
Patients are eligible if they have (1) been enrolled in the plan for two consecutive years, (2)
have an outpatient claim for a visit with a mental health provider for a mental health problem
during the first 9 months of year 2 (the first visit is the “index mental health visit”), (3) have no
mental health provider claims during year 1, and (4) have a claim for a visit with a primary care
[58]

provider during year 2. Diagnosis codes are included in Appendix 2.g. A primary or secondary
diagnosis code should be counted as evidence of a visit. Medical records will be requested for
consecutive eligible patients during this period. Enter each patient including the names of their
mental health provider and primary care provider into the log in Appendix 2.b.

Medical record acquisition
Once the patient sample has been identified, the relevant PCP and MH provider records will
need to be acquired or accessed. This may be done by the plan through a directed request for
copies to the providers of interest or by the utilization of a record-access vendor.
The required records are:
MH provider record for year 2 (this will cover only the portion of year 2 since the index
mental health provider visit).
PCP record for all of year 2.
When acquiring copies of records, remember to request complete copies of the record content
for the time frame specified, including the following:
PCP and MH provider records:
All documentation of care during the specified study period
Include all of the following:
Health maintenance summary records
Problem lists
Medication summary records
Visit notes (office and home, if applicable)
Consult reports
Hospitalization documentation and summaries
ED visit documentation
Ancillary care (e.g., physical therapy, home care)
Lab tests
X-rays, scans, and any other test results
Nurse care manager documentation
Telephone and message contacts with patient
Telephone and message contacts with other providers
A medical record tracking system should be established to track the status of the acquisition of
the requested records. PCP and MH provider records will need to be matched by patient ID for
abstraction (if hard copies). PCP and MH provider records need to be abstracted concurrently;
that is, it is necessary to have both records on hand during the abstraction. It is anticipated that
the abstraction of both the PCP and MH provider records should take, on average, 30 minutes
per patient.

[59]

Orientation of nurse abstractors
The medical record abstraction is designed to be completed by registered nurses. The content
requires clinical judgment and therefore, nurse abstractors are required. Ideally, this abstraction
would be completed by experienced nurse abstractors at the plan who are familiar with the
records of care. If no abstractors are available, the task could be outsourced to a reputable
vendor.
The Medical Record Abstraction Form and related Guidelines are located in Appendices 2.c and
2.d, respectively. It is suggested that the nurse abstractors review the abstraction form and
guidelines prior to abstraction and meet as a group with their supervisor to review the process
and answer any outstanding questions.
Each abstractor will be assigned a list of Study IDs to complete. Each abstractor will maintain
the log of Study IDs provided to him/her with the date the case was abstracted, or if not
abstracted, the reason why not.

Medical record abstraction reliability
The medical record abstraction process includes a 20% sample for inter-rater reliability
measurement. When the sample is drawn and abstractor lists are assigned, each list should
include a 20% sample of patient cases that will be abstracted by two different abstractors. The
total number of completed abstraction cases will be 10.

Submission of data
Abstraction data will be entered by the plan into an Excel template (Appendix 2.e) and
submitted to CMS for analysis by RAND.

Time and effort expended by the plan to conduct the study should be documented in the Time
and Resource Survey form located in Appendix 2.f.

[60]

[61]

[62]

[63]

[64]

[65]

[66]

[67]

Appendix 2.d: Abstraction Form Guidelines

Mental Health (MH) Continuity
Medical Record Abstraction Form Guidelines

1. Initiation of MH Care: Indicate the date when the new MH services began. The
patient may have had prior MH services with this provider. But the focus of this
abstraction is the most recent initiation of care after a period of at least 12 months of
no care for the MH problem with the same provider, or the current episode of care
represents a new MH problem or exacerbation. This date should match the onset of
MH services date specified on your list of study patients for abstraction. If it does
not, check with your supervisor to investigate the available information to identify the
correct date. This represents the start of the study period. The end of the study
period will be identified for you by the person in your organization who drew the
patient sample. The study period for patients in the sample will vary from as little as
3 months to as long as 12 months, depending on the occurrence of the initiating MH
visit.
2. PCP Care: Indicate if the patient had at least 1 PCP visit during the study period. If
not, stop abstracting. If at least 1 PCP visit occurred, indicate in Q2a) the total
number of PCP and MH visits that occurred during the study period.
3. Medical Record(s): Indicate if the source of abstraction is a mutual access EHR or
not. A mutual access EHR is a single, centralized EHR that both the PCP and the
MH provider access and use to document the patient’s care.
4. PCP Awareness of MH Provider: Indicate if at any time during the study period the
PCP documented an awareness that the patient was also under the care of the MH
provider. This awareness could be the fact that the PCP referred the patient to the
MH provider. It could also be a note by the PCP or some other documentation that
makes this awareness clear (e.g., “patient seeing psychiatrist,” “patient states his
depression medications were revised yesterday and he is doing much better now”).
For either response 1 or 2, enter the date the PCP first acknowledged the MH
provider care. In section a) indicate if any provider record documents a patient
refusal to allow the sharing of his/her mental health care with the PCP, and if so, the
date this was first noted.
5. MH Hospitalizations/Emergency Care: Based on the MH provider record, indicate
if any mental health related hospitalizations or emergency department (ED) visits
occurred during the study period. This should include hospitalizations that may have
been initiated for a non-mental health reason, but included a mental health issue
during the hospital stay.
6. PCP Awareness of Hospitalizations/ED Care: Enter the admission and discharge
dates of any MH hospitalizations and/or service dates of any MH ED visits (up to 3)
that were noted in the MH provider’s record.
Based on the PCP record, complete columns iv) and v), where applicable, to indicate
if the PCP record reflected the PCP’s awareness of the MH hospitalization/ ED visit.
If so, indicate the date of the PCP’s first awareness in column v).
[68]

7. Psychotropic Medications: The focus of this question is whether or not medication
continuity occurred between successive MH and PCP visits. In Part A, identify the
first PCP visit that occurred during the study period that was also after the
initiation of the MH care. Depending on when the MH care began, this PCP visit
may or may not be the first one during the study period. But is should be the first
one that occurred once MH care was started. Enter this date in i). Then, identify the
MH visit that occurred just prior to the PCP visit listed in i). Enter this date in ii).
Then, based on the MH provider record, list in iii) all (up to 6) psychotropic
medications that the patient was taking at the end of this MH visit. Enter both the
name of the drug as well as the dose and frequency of the medication.
Psychotropic medications include antidepressants, antipsychotic agents, antianxiety
agents, sedatives, and hypnotics. See the medication list at the end of this
document. If there are >6 medications, list the medications that are taken regularly
before listing prn medications. Then, based on the PCP record and the visit noted in
i), indicate in column iv) if each listed medication was listed in the current medication
list in the PCP record at the beginning of that visit. Use code “2” (Exp) if the
medication is not listed, but there is an explanation or justification noted in the record
for this discrepancy (e.g., “discontinued fluoxetine due to side effects,” “was seen in
ED yesterday and meds discontinued”). If a medication was listed in the current
medication list, indicate in v) if the daily dosing information was accurate. It is not
necessary that the frequency be specified as long as the daily dosage is correct. If
no dosage information is provided, use code “9.”
8. Provider Communication: This item summarizes the evidence from the abstracted
records of any planned or actual communication between the PCP and the MH
providers, as well as contact with other specialists and non-physician health
providers with regard to the patient’s mental health care. Do not include contacts for
issues related to problems that are not mental health related.
In part A, list the dates of all such planned or actual communication by the MH
provider. In column ii), indicate the type of communication and in column iii), note
the target provider. “Other” could include providers such as case managers, social
workers, benefits managers, etc. If the target provider was a physician specialist or
non-physician provider, specify the type in column iv). If there were no
communication plans or attempts of any kind by the MH provider, check the box
provided and skip to Part B of this question.
In part B, list the dates of all such planned or actual communication by the PCP. In
column ii), indicate the type of communication and in column iii), note the target
provider. “Other” could include providers such as case managers, social workers,
benefits managers, etc. If the target provider was a physician specialist or nonphysician provider, specify the type in column iv). If there were no communication
plans or attempts of any kind on the part of the PCP, check the box provided and
skip to Q7.
9. MH Provider: Noted Continuity Problem: Based on the MH provider record,
indicate if at any time during the study period the MH provider documented a
concern related to continuity of care or a failure of continuity of care. This type of
problem could include any issue of risk to the patient that was caused by or
exacerbated by a failure of care coordination. The list of concerns in Part A of Q9a)
[69]

lists several examples of these problems. If a continuity problem is noted that does
not fit any of the listed categories, enter it in line xiv) and specify the problem.
Examples of continuity problems include things like the patient have multiple
prescriptions for the same drug from several providers, duplicative medications, lack
of clarity about which provider he/she should see next, noncompliance of care based
on confusion or lack of resources, etc. These concerns can be about any aspects of
care, not just those that are directly related to mental health care, since continuity
problems can affect all aspects of a patient’s care.
10. PCP Noted Continuity Problem: Based on the PCP record, indicate if at any time
during the study period the PCP documented a concern related to continuity of care
or a failure of continuity of care. This type of problem could include any issue of risk
to the patient that was caused by or exacerbated by a failure of care coordination.
The list of concerns in Part A of Q10a) lists several examples of these problems. If a
continuity problem is noted that does not fit any of the listed categories, enter it in
line xiv) and specify the problem. Examples of continuity problems include things
like the patient have multiple prescriptions for the same drug from several providers,
duplicative medications, lack of clarity about which provider he/she should see next,
noncompliance of care based on confusion or lack of resources, etc. These
concerns can be about any aspects of care, not just those that are directly related to
mental health care, since continuity problems can affect all aspects of a patient’s
care.

[70]

Psychotropic Medication List
Abilify
Alprazolam
Alurate
Ambien
Amitriptyline
Amobarbital
Amoxapine
Amytal
Anafranil
Aplenzin
Aprobarbital
Aquachloral Supprettes
Aricept
Aripiprazole
Asenpine
Atarax
Ativan
Atomoxetine
Aventyl
Bupropion
BuSpar
Buspirone
Butabarbital
Butisol
Celexa
Chloral hydrate
Chlorazepate
Chlordiazepoxide
Chlorpromazine
Citalopram
Clomipramine
Clozapine
Cognex
Compro
Cymbalta
Desipramine
Desvenlafaxine
Dexmedetomidine
Diastat AcuDial
Diazepam
Donepezil
Doral
Doxepin
Duloxetine
Edluar
Effexor
Equanil
Escitalopram
[71]

Eskalith
Estazolam
Eszopicone
Etrafon
Exelon
Fanapt
FazaClo
Fluoxetine
Fluphenazine
Fluvoxamine
Galantamine
Geodon
Halcion
Haldol
Haloperidol
Hydroxyzine
Iloperidone
Imipramine
Intermezzo
Invega
Isocarboxazid
Klonopin
Largon
Latuda
Lexapro
Limbitrol
Lithium
Lithonate
Lithotabs
Lorazepam
Loxapine
Loxitane
Luminal
Lunesta
Lurasidone
Luvox
Maprotiline
Marplan
Mebaral
Memantine
Mephobarbital
Meprobamate
Milnacipran
Miltown
Mirtazapine
Namenda
Nardil
Navane
Nefazodone
Nembutal
Niravam
[72]

Norpramin
Nortriptyline
Olanzapine
Oleptro
Orap
Oxazepam
Paliperidone
Pamelor
Paral
Paraldehyde
Parnate
Paroxetine
Paxil
Pentobarbital
Perphenazine
Phenelzine
Phenobarbital
Pimozide
Precedex
Pristiq
Prochorperazine
Propiomazine
ProSom
Protriptyline
Prozac
Quazepam
Quetiapine
Ramelteon
Razadyne
Remeron
Restoril
Revastigmine
Risperdol
Risperidone
Rozerem
Saphris
Savella
Secobarbital
Seconal
Selfemra
Serafem
Serax
Seroquel
Sertraline
Sinequan
Solfoton
Somnote
Sonata
Strattera
Surmontil
Symbyax
[73]

Tacrine
Temazepam
Thioridazine
Thiothixene
Tofranil
Tranxene
Tranylcypromine
Trazodone
Triavil
Triazolam
Trifluoperazine
Trimipramine
Tuinal
Valium
Venlafaxine
Viibryd
Vilazodone
Vistaril
Vivactil
Wellbutrin
Xanax
Zaleplon
Ziprasidone
Zoloft
Zolpidem
Zolpimist
Zyban
Zyprexa

[74]

[75]

[76]

[77]

[78]

[79]

[80]

[81]

[82]

[83]

[84]

[85]

[86]

[87]

[88]

[89]

[90]

Appendix 2.g: Diagnosis Codes
The mental health ICD-9 codes in the table below are taken to indicate a visit for a mental
health disorder if used as a primary or secondary code for a visit with a mental health provider
MENTAL HEALTH DISORDERS (EXCLUDING INTOXICATION/SUBSTANCE ABUSE)
ICD9
290.0
290.10
290.11
290.12
290.13
290.20
290.21
290.3
290.40
290.41
290.42
290.43
290.8
290.9
293.0
293.1
293.81
293.82
293.83
293.84
293.89
293.9
294.0
294.10
294.11
294.8
294.9
295.00
295.01
295.02
295.03
295.04
295.05
295.10
295.11
295.12
295.13
295.14
295.15
295.20
295.21
295.22
295.23

LABEL
senile dementia uncomp
presenile dementia
presenile delirium
presenile delusion
presenile depression
senile delusion
senile depressive
senile delirium
vascular dementia,uncomp
vasc dementia w delirium
vasc dementia w delusion
vasc dementia w depressn
senile psychosis nec
senile psychot cond nos
delirium d/t other cond
subacute delirium
psy dis w delus oth dis
psy dis w halluc oth dis
mood disorder other dis
anxiety disorder oth dis
transient mental dis nec
transient mental dis nos
amnestic disord oth dis
dementia w/o behav dist
dementia w behavior dist
mental disor nec oth dis
mental disor nos oth dis
simpl schizophren-unspec
simpl schizophren-subchr
simple schizophren-chr
simp schiz-subchr/exacer
simpl schizo-chr/exacerb
simpl schizophren-remiss
hebephrenia-unspec
hebephrenia-subchronic
hebephrenia-chronic
hebephren-subchr/exacerb
hebephrenia-chr/exacerb
hebephrenia-remission
catatonia-unspec
catatonia-subchronic
catatonia-chronic
catatonia-subchr/exacerb

[91]

ICD9
295.24
295.25
295.30
295.31
295.32
295.33
295.34
295.35
295.40
295.41
295.42
295.43
295.44
295.45
295.50
295.51
295.52
295.53
295.54
295.55
295.60
295.61
295.62
295.63
295.64
295.65
295.70
295.71
295.72
295.73
295.74
295.75
295.80
295.81
295.82
295.83
295.84
295.85
295.90
295.91
295.92
295.93
295.94
295.95
296.00
296.01
296.02
296.03
296.04

LABEL (continued)
catatonia-chr/exacerb
catatonia-remission
paranoid schizo-unspec
paranoid schizo-subchr
paranoid schizo-chronic
paran schizo-subchr/exac
paran schizo-chr/exacerb
paranoid schizo-remiss
schizophreniform dis nos
schizophrenic dis-subchr
schizophren dis-chronic
schizo dis-subchr/exacer
schizophr dis-chr/exacer
schizophrenic dis-remiss
latent schizophren-unsp
lat schizophren-subchr
latent schizophren-chr
lat schizo-subchr/exacer
latent schizo-chr/exacer
lat schizophren-remiss
schizophr dis resid nos
schizoph dis resid-subch
schizophr dis resid-chr
schizo resid subchr/exac
schizoph resid-chro/exac
schizoph dis resid-remis
schizoaffective dis nos
schizoaffectv dis-subchr
schizoaffective dis-chr
schizoaff dis-subch/exac
schizoafftv dis-chr/exac
schizoaffectve dis-remis
schizophrenia nec-unspec
schizophrenia nec-subchr
schizophrenia nec-chr
schizo nec-subchr/exacer
schizo nec-chr/exacerb
schizophrenia nec-remiss
schizophrenia nos-unspec
schizophrenia nos-subchr
schizophrenia nos-chr
schizo nos-subchr/exacer
schizo nos-chr/exacerb
schizophrenia nos-remiss
bipol i single manic nos
bipol i single manc-mild
bipol i single manic-mod
bipol i sing-sev w/o psy
bipo i sin man-sev w psy

[92]

ICD9
296.05
296.06
296.10
296.11
296.12
296.13
296.14
296.15
296.16
296.20
296.21
296.22
296.23
296.24
296.25
296.26
296.30
296.31
296.32
296.33
296.34
296.35
296.36
296.40
296.41
296.42
296.43
296.44
296.45
296.46
296.50
296.51
296.52
296.53
296.54
296.55
296.56

LABEL (continued)
bipol i sing man rem nos
bipol i single manic rem
recur manic dis-unspec
recur manic dis-mild
recur manic dis-mod
recur manic dis-severe
recur manic-sev w psycho
recur manic-part remiss
recur manic-full remiss
depress psychosis-unspec
depress psychosis-mild
depressive psychosis-mod
depress psychosis-severe
depr psychos-sev w psych
depr psychos-part remiss
depr psychos-full remiss
recurr depr psychos-unsp
recurr depr psychos-mild
recurr depr psychos-mod
recur depr psych-severe
rec depr psych-psychotic
recur depr psyc-part rem
recur depr psyc-full rem
bipol i currnt manic nos
bipol i curnt manic-mild
bipol i currnt manic-mod
bipol i manc-sev w/o psy
bipol i manic-sev w psy
bipol i cur man part rem
bipol i cur man full rem
bipol i cur depres nos
bipol i cur depress-mild
bipol i cur depress-mod
bipol i curr dep w/o psy
bipol i currnt dep w psy
bipol i cur dep rem nos
bipol i currnt dep remis

[93]

Appendix 3.a: Draft Cover Letter to Introduce the Amended CAHPS Survey
DRAFT COVER LETTER
Dear Medicare Beneficiary:
As a person with Medicare, you deserve to get the highest quality medical care when
you need it, from doctors that you trust. The Centers for Medicare & Medicaid Services
(CMS), is the federal agency that administers the Medicare program and our
responsibility is to ensure that you get that high quality care at a reasonable price. One
of the ways we can fulfill that responsibility is to find out directly from you about the
care you are currently receiving under the Medicare program.
CMS is conducting a survey of people with Medicare to learn more about the care and
services you receive. Your name was selected at random by CMS from among Medicare
enrollees. We would greatly appreciate it if you would take the time, about 20 minutes,
to fill out this questionnaire. The accuracy of the results depends on getting answers
from you and other people with Medicare selected for this survey. This is your
opportunity to help us serve you better.
If you changed your Medicare plan for 2011 please answer the questions in the survey
thinking about your experiences in the last six months of 2010. All information you
provide will be held in confidence and is protected by the Privacy Act. The information
you provide will not be shared with anyone other than authorized persons at CMS and
RAND Survey Research Group, the survey research organization assisting us in this
survey. You do not have to participate in this survey. Your help is voluntary and your
decision to participate or not to participate will not affect your Medicare benefits in
any way. However, your knowledge and experiences will help other people with
Medicare make more informed choices, so we hope you will choose to help us.
If you have any questions about the survey or would like to find out how to complete
the survey by phone, please don’t hesitate to call XXXXX with RAND Survey Research
Group toll-free at XXX-XXX-XXXX, Monday through Friday, between 9:00 a.m. and 5:00
p.m. Pacific time.
Thank you in advance for your participation.
Sincerely,

Walter Stone
CMS Privacy Officer

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[102]

[103]

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B. 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 XXXX-XXXX. The time required to complete this
information collection is estimated to average [Insert Time (hours or 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 the form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

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III. Record of Information Collection Clearances
[Insert Record of Information Collection Clearances]

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