Supporting Statement B

2014 Health Center Patient Survey

Main Study

Supporting Statement B

Request for OMB Review (SF83i)

Submitted by

Health Resources and Services Administration

U.S. Department of Health and Human Resources

February 14, 2014

Supporting Statement B

2014 Health Center Patient Survey

OMB Control No. 0915-0368

2. Collection of Information Employing Statistical Methods

1. Respondent Universe and Sampling Methods

The respondents for the survey are patients who receive services from Section 330-funded Health Center (HC) grantees. These respondents are clustered within HC sites in each grantee. The grantee, site, and patient universes are described in greater detail in the subsections that follow. Please see Attachments 10 and 11, the Statistical Design Plan and the Survey Methodology and Selection Specifications for further detail.

a. Grantee Universe

The grantee sample will be selected from eligible grantees. The 2012 Bureau of Primary Health Care (BPHC) Uniform Data System (UDS) grantee-level data file will be used to identify eligible grantees. All grantees within the UDS and funded by section 330 will be eligible except the following:

• Grantees located in U.S. territories or possessions (i.e., those in Puerto Rico,

the Virgin Islands, and the Pacific Basin);

• Grantees funded by section 330 that have been operating less than 1 year;

• Grantees funded through the CHC funding program that only operated school-based sites;

• Grantees that received Migrant Health Center funding program only and that served clients only through a voucher program; and

• Any grantee that is no longer a section 330-funded grantee.

b. Site Universe

Many grantees operate multiple HC sites. The sites eligible for the survey within selected grantees are required to participate in at least one of the four specific funding programs: Community Health Center (CHC), Health Care for the Homeless (HCH), Migrant Health Center (MHC), and Public Housing Primary Care (PHPC). All sites within selected grantees are eligible unless:

• The site has been operating under the grantee for less than 1 year;

• The site is a school-based HC;

• The site is a specialized clinic, excepting clinics providing OB/GYN service;

• The site provides services only through a migrant and seasonal farmworker

voucher-screening program; and.

• The site serves fewer than 100 patients.

c. Patient Universe

The patients eligible for the survey must satisfy the following eligibility requirements:

• Patients must have received face-to-face services at the site from a clinical

staff member who exercises independent judgment in the provision of service

at least once in the 12 months prior to the current visit.

• If the patient is under the age of 18, the patient must be accompanied by an adult.

2. Procedures for the Collection of Information

a. Sample

As noted, the Section 330-funded grantees operate one or more sites. The sites are clustered within grantees, and the patients are clustered within the sites within the grantee. A three-stage sample design will be employed in which the grantees are selected as the primary sampling units (PSUs), sites are selected within participating grantees, and patients are selected within selected sites. Our goal is to recruit 165 grantees and complete 6,600 interviews, among them 3,630 for the CHC funding program, 1,210 for the MHC funding program, 1,210 for the HCH funding program, and 550 for the PHPC funding program. In addition, to meeting BPHC’s research interests in race/ethnicity groups, patients of American Indian/Alaska Native (AIAN), Native Hawaiian/Pacific Islanders (NHPI), and Asian race groups will be oversampled. Patients aged 65 or older will also be oversampled. The target sample sizes in three design domains, namely funding program, race/ethnicity and age group, are shown in Table 1.

Table 1. Target Sample Sizes for the 2014 Health Center Patient Survey

Funding Program	Target Sample Size	Race / Ethnicity	Target Sample Size	Age Group	Target Sample Size
CHC	3,630	Hispanic	2,044	0–17	2,200
MHC	1,210	Non-Hispanic White	1,558	18–64	3,200
HCH	1,210	Non-Hispanic Black	1,618	65+	1,200
PHPC	550	Non-Hispanic AIAN	409
		Non-Hispanic Asian	647
		Non-Hispanic NHPI	251
		Non-Hispanic Others	73

b. Grantee Sample

The sampling frame is constructed from all the eligible grantees (the grantee universe) in the BPHC’s current UDS data file. A total of 165 grantees will be selected through a stratified probability proportional to size (PPS) for participation from seven strata with a pre-specified sampling rate for each stratum using PROC SURVEYSELECT in SAS 9.3. Independent site and patient samples will be selected for each funding program if the grantee receives multiple Section 330 funds. The seven strata will be formed as shown in Attachment 12. They are defined as follows:

(1) First-Stage Strata

Four mutually exclusive strata by grouping grantees according to the types of funding they receive (Stratum1, Stratum2, Stratum3, and Stratum4). Those first-stage strata are used to ensure that the selected grantees are representative to the four funding programs.

• Stratum 1: Grantees received PHPC funding solely or in combination with other programs.

• Stratum 2: Grantees received MHC funding solely or in combination with other programs.

• Stratum 3: Grantees received HCH funding solely or in combination with other programs.

• Stratum 4: Grantees received CHC funding solely.

(2) Second-Stage Strata

AIAN, Asian, and NHPI patients are not evenly distributed among all grantees. They tend to be clustered in a few grantees. To achieve target sample sizes in three race/ethnicity groups, grantees with concentrated patients in those three race/ethnicity categories must be obtained and selected at the first-stage selection. Grantees with more than 20% of patients in one of the three race/ethnicity categories are considered patient-concentrated grantees. In the 2012 UDS, Stratum 4 (CHC funding solely) has over 89% of such grantees, and very few such grantees are from Strata 1, 2, and 3. Therefore, to effectively select grantees with concentrated patients in three race/ethnicity categories, Stratum 4 is further divided into four second-level strata according to whether a grantee has concentrated patients (over 20%) in one of the three race/ethnicity categories. The result is a total of seven final grantee strata, shown in Attachment 12.

c. Site Sample

Once the grantees are recruited, our recruiters will work with the grantee’s administration staff to identify eligible sites using the eligibility criteria discussed in Health Center Site Universe. Specifically, the following information will be collected from each participating grantee on their sites (using the Grantee Recruitment Guidelines):

• number of eligible sites serving each patient type (i.e., migrant and seasonal farmworkers, homeless, public housing, and general patients);

• address and contact information for each eligible site;

• number of patients served in each eligible site, overall and by type of patient (CHC, MHC, HCH, and PHPC); and

• sites with concentrated patients in one of the three race/ethnicity categories (AIAN, Asian, or NHPI)

To achieve our target sample sizes of AIAN, Asian, and NHPI patients, we will not only oversample grantees with concentrated patients in these three race groups at the first stage of selection, but we will also identify sites with concentrated patients in at least one of the three targeted race/ethnicity categories. These sites will be selected with higher probabilities than sites without concentrated patients.

A maximum of three sites will be selected for each funding program within a grantee. If t three or fewer sites are serving a patient population type (i.e., migrant/seasonal farmworkers, homeless, public housing, and general community), all of the sites will be included in the sample unless the distance between sites is too great for one interviewer to cover all of them. For grantees with more than three sites for a specific funding program, we will use a PPS sampling method to select three sites out of all the sites that are within a reasonable distance for one interviewer to cover. The number of patients for the sites of a specific funding program will serve as the size measure in the PPS sampling. The PPS selection is independent for each funding program in the grantees with multiple funded programs. We will select three sites using the PPS sample using PROC SURVEYSELECT in SAS 9.3.

d. Patient Sample

Because some of the target populations for this study are fairly mobile, a random sample of patients will be chosen for interviews as they enter the site and register with the receptionist for services. The survey patients will be selected using onsite recruitment procedures. Project staff will not be allowed to approach any of the HC’s patients or obtain any identifying information about a patient unless the selected patient initiates such contact with a field interviewer.

Patient Sample Allocation. We will evenly allocate the targeted number of completed interviews for each funding program to all the grantees serving a special population. For example, if we recruit 47 grantees that serve farmworkers (MHC), then 27 (1,210/47 is rounded to 27) interviews will be completed for each grantee. Within each grantee, we will use two different methods to allocate patient interviews to multiple sites for grantees with three or fewer sites in a funding program and grantees with more than three sites in a funding program. For grantees with three or fewer sites, the number of patient interviews within that grantee will be allocated proportionally to the patient size of the sites. For grantees with more than three sites that are selected through PPS, the number of selected patients will be divided equally among three selected sites.

Patient Screening. We will design a screening sheet that the receptionist can use to screen and select patients when a patient enters the site and registers for service. A patient will be considered eligible if the patient received service through one of the grantees supported by BPHC funding programs at least once in the past 12 months prior to the current visit. Patients under 18 must be accompanied by parent or guardian. The receptionist will ask eligible patients questions about patients’ race/ethnicity and age to determine whether they belong to the oversampling groups as shown in Table 2.

Table 2. Oversampling and Nonoversampling Patient Group

Patient Group	Oversampling Group
65+, All Race/Ethnicity	Yes
0–64, AIAN	Yes
0–64, Asian	Yes
0–64, NHPI	Yes
0–64, Other Race/ethnicity	No

The receptionist will be asked to keep track of the number of patients who enter the site, the number of patients who are eligible, and number of patients selected while the field interviewer is at the site to conduct data collection for each patient group (Patient Arrival and Selection Tracking Form as shown in Attachment 4). The receptionist will either use tally marks to count patients as they enter or complete a table based on the sign-in sheet or appointment list before the field interviewer leaves the site. The patient count sheets for each field interviewer data collection visit will be sent to RTI for data entry, and counts will be used to calculate the analysis weights for the study. If sites have more than one receptionist, all receptionists must track number of visited, eligible, and selected patients even though we may only recruit patients using one receptionist. If a site is chosen for multiple funding programs, the receptionist at the site will be asked to track and select patients on the interviewing visiting dates for all funding programs.

Patient Selection. If a patient belongs to a group that will not be oversampled, the receptionist will select the first eligible patient registered after the field interviewer has informed the receptionist that he/she is ready for the next interview. The receptionist will read a brief script about the study to the selected patient and direct the patient to the field interviewer for questions or participation. If a patient belongs to one of the oversampling groups, the receptionist will select the patient and send the patient to the field interviewer if he/she is available. When the field interviewer is working on an interview or unavailable, the receptionist will give the selected patient a yellow laminated card and instruct him/her to wait in a designated area. When the field interviewer is available and ready, she/she will look for a patient holding a yellow laminated card.

Patient Interviewing. When selected patients approach the interviewer, the field interviewer will screen participating patients to determine eligibility and patient population types (i.e., homeless, migrant/seasonal farmworker, public housing, or general community). After the field interviewer explains the study, interested patients will be taken to a private location at the health center and administered the survey.

3. Methods to Maximize Response Rates and Deal with Nonresponse

Response rates for the study will be a function of success in two basic activities: (1) identifying eligible patients and (2) obtaining those patients’ cooperation and time to complete the interview. We will train site staff to use a patient recruiting script, train all field interviewers on critical cooperation-gaining techniques, regularly debrief with data collection staff, conduct in-person interviews, allow interviewers to schedule interviews at a later time if necessary, make multiple attempts to reach and reschedule respondents who miss appointments, and offer a $25-value remuneration to all participants. Given those plans (which are discussed further below), a 90% cooperation rate is anticipated.

1. Training Site Staff

Site staff will determine whether patients are new or have had services previously, which would deem them potentially eligible for selection. Prior to speaking with potential respondents and using the patient tracking and selection form, site staff will have adequate training to assist in obtaining high levels of patient cooperation.

RTI International will arrange and conduct site staff trainings. These trainings will last approximately 1.5 hours and will be conducted via telephone with key HC staff and administrative staff at each site immediately before data collection begins. It is anticipated that on average two project staff members per site will attend.

Prior to the training, self-study materials will be distributed for the site staff to review, which will describe the study and instruct staff how to create and modify an anonymous roster of patients. In addition, the self-study materials will serve as a reference guide during data collection with mock scenarios demonstrating how to handle various situations.

Training will be provided on the study purposes and procedures. Particular attention will be paid to the role of the site staff in patient recruitment for the patient survey and as recipients of referrals for mandatory reporting issues. In addition, training will emphasize the appropriate use of project-provided recruitment materials and the importance of privacy. During data collection contract staff will stay in close contact with site staff to ensure that project protocols are followed and assist with any data collection concerns that may arise.

2. Training Field Interviewing Staff

RTI will provide a comprehensive multiday training to the field interviewing staff. They will be trained on the study purpose and procedures, interview administration, and the protection of human subjects. Part of the interviewer training will address in detail specific techniques for gaining cooperation and averting and converting a respondent refusal. Reasons for refusals and barriers to participation will be continually evaluated in light of the experience gained during the data collection process.

3. Regular Debriefings with Data Collection Staff

The project staff will regularly meet with data collection staff to discuss issues related to data collection operations. Methods to enhance response rates will be a standard agenda item at these meetings.

4. On-site Data Collection

When surveying a hard-to-reach population, such as HC patients, interviewer-administered modes yield higher response rates than self-administered modes. Additionally, allowing the option to interview respondents in person at the site right after selection will assist in maximizing cooperation and response rates. Interviews will, therefore, be conducted in-person via computer-assisted personal interview (CAPI).

If a respondent is interested in participating but unable to complete the interview at the site at that time, the interviewer will have the option of scheduling an appointment at a later time. Future appointments will take place either back at the site, in a conveniently located library with a private room, or at the respondent’s home (if applicable). Multiple attempts to reach respondents who do not appear for scheduled interviews will be a standard protocol.

5. Offering Remuneration

Providing respondent remuneration during the interviewing phase of data collection increases the likelihood that sample members will participate, particularly for the low-income populations. Respondents will be provided with remuneration valued at $25 for their participation.

In addition, a nonmonetary benefit in the form of data analysis and summarization will be provided to participating grantees with grantee-specific data on patient satisfaction, behavior, and other characteristics in table format. Comparisons to results from all participating grantees may also be provided. These data will provide the organization’s management and board with useful information on patient characteristics, barriers to care, and grantee performance.

6. Bilingual Approach

The questionnaire and other respondent materials have been translated into Spanish, Mandarin, Cantonese, Korean, and Vietnamese. The bilingual approach allows respondents with limited English skills to fully understand their participation. Further, this approach increases the likelihood that those respondents will complete interviews because they will be given the choice of using the language with which they feel more comfortable. An bilingual-certified interviewer will be available for grantees that have a substantial non-English speaking population. Bilingual interviewers will be available to complete interviews in Spanish, Mandarin, Cantonese, Korean and Vietnamese, or English, depending on respondent preference.

4. Tests of Procedures or Methods to be Undertaken

The procedures and methods to be undertaken have been tested in various ways. Cognitive interviewing was used to test and finalized the ease of use of the survey instrument. In addition, all procedures and methods are based on those successfully implemented during the previously executed HCPSs. Additional details are supplied below.

Cognitive Interviewing

During the survey questionnaire development phase, three rounds of cognitive interviews were conducted to finalize a questionnaire that was comprehensible in different languages, could be administered within approximately 75 minutes, and generated accurate data.

Methods from Past Studies

As mentioned in Statement A, the data collection procedures and materials of this survey were built upon the Health Care for the Homeless User/Visit Survey (HCH) conducted in 2003, the 1995 Community Health Center User/Visit Survey, and the 2002 Community Health Center (2002 CHC), the National Health Service Corps Site User/Visit Survey, and the 2009 Primary Health Care Patient Surveys. All of these surveys achieved high response rates and were found to be easily administered correctly by site and field staff.

5. Individuals Consulted on Statistical Aspects and Individuals Collecting and/or Analyzing Data

Names of individuals consulted on statistical aspects of study design along with their affiliation and telephone numbers are provided below.

Name Title Telephone

Mr. Patrick Chen Sampling Task Leader 919-541-6309

Ms. Cynthia Augustine Analysis Task Leader 919-541-6154

Ms. Kathleen Considine Project Director 919-541-6612

In addition to these statisticians and survey design experts, HRSA staff have also reviewed and approved the statistical aspect of the study.

Other Contractors’ Staff Responsible for Conducting the Study

RTI International is assisting BPHC with subcontracted activities. Principal professional staff from RTI assigned to the study (but not listed above) are as follows:

Name Title Telephone

Mr. Tim Flanigan Instrumentation Task Leader 919-485-7743

Ms. Azot Derecho Data Collection Task Leader 919-541-7231

Mr. Mai Nguyen Programmer 919-541-8757

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