PACT Telehealth in the PADRECC, Healthcare experiences of patients with CHF

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-10137 HEALTH CARE EXPERIENCES OF PATIENTS WITH CONGESTIVE HEART FAILURE; NEEDS ASSESSMENT FOR CLINICAL INNOVATIONS–PACT DEMO LAB VISN20	Form and Instruction	New	Repair queued
Form 10-10136 C. HEALTH CARE EXPERIENCES OF PATIENTS WITH CONGESTIVE HEART FAILURE; NEEDS ASSESSMENT FOR CLINICAL INNOVATIONS–PACT DEMO LAB VISN20	Form and Instruction	New	Repair queued
Form 10-10135a Clinical Innovation Study: Telehealth in the PADRECC: The Key to the Patient-Centered Medical Home? Survey Component	Form and Instruction	New	Repair queued
PACT DL V4_Multi projcts Justificiaton A_FINAL_102215.doc	Supporting Statement A	Uploaded 2015-10-22	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
212919	HEALTH CARE EXPERIENCES OF PATIENTS WITH CONGESTIVE HEART FAILURE; NEEDS ASSESSMENT FOR CLINICAL INNOVATIONS–PACT DEMO LAB VISN20	Form and Instruction	New
212918	C. HEALTH CARE EXPERIENCES OF PATIENTS WITH CONGESTIVE HEART FAILURE; NEEDS ASSESSMENT FOR CLINICAL INNOVATIONS–PACT DEMO LAB VISN20	Form and Instruction	New
212917	A. V4 TELEHEALTH PADRECC: FOCUS GROUP COMPONENT – PACT DEMO LAB VISN4	Instruction	New
212916	Clinical Innovation Study: Telehealth in the PADRECC: The Key to the Patient-Centered Medical Home? Survey Component	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 201409-2900-004
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: VHA
Title: PACT Telehealth in the PADRECC, Healthcare experiences of patients with CHF
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Disapproved	Conclusion Date: 05/19/2016
	Date Received in OIRA: 10/29/2015
Terms of Clearance: We appreciate the VA Patient Aligned Care Team's (PACT) willingness to work with OMB to ensure pre-approval of future PACT initiatives. Because this study concluded, this request for approval is disapproved and VA will record and report the PRA violation.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Office of Patient Care Services, Primary Care Program Office, has undertaken an initiative to implement a patient-centered medical home model at all Veterans Health Administration (VHA) Ambulatory Primary Care sites. In addition to the VHA's Universal Health Care Services implementation of the Patient Aligned Care Team (PACT), Patient Care Services has funded 5 PACT Demonstration Laboratories across the country.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 4335	01/27/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 44202	07/24/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Clinical Innovation Study: Telehealth in the PADRECC: The Key to the Patient-Centered Medical Home? Survey Component	10-10135a, 10-10135b, 10-10135d, 10-10135c	GDS ,   PDQ-8 ,   Cost & patient outcomes questions ,   Patient Assessment of Communication during Telehealth
A. V4 TELEHEALTH PADRECC: FOCUS GROUP COMPONENT – PACT DEMO LAB VISN4
HEALTH CARE EXPERIENCES OF PATIENTS WITH CONGESTIVE HEART FAILURE; NEEDS ASSESSMENT FOR CLINICAL INNOVATIONS–PACT DEMO LAB VISN20	10-10137	C. HEALTH CARE EXPERIENCES OF PATIENTS WITH CONGESTIVE HEART FAILURE; NEEDS ASSESSMENT FOR CLINICAL INNOVATIONS–PACT DEMO LAB VISN20
C. HEALTH CARE EXPERIENCES OF PATIENTS WITH CONGESTIVE HEART FAILURE; NEEDS ASSESSMENT FOR CLINICAL INNOVATIONS–PACT DEMO LAB VISN20	10-10136	CHF PATIENT INTERVIEW GUIDES: –PACT DEMO LAB VISN20

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: All hours are an increase due to new collection.

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Annual Cost to Federal Government: $226,051

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/29/2015

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