CMS-10651 - Supporting Statement A (rev OSORA PRA)

Supporting Statement – Part A

CMS Tribal Long Term Services and Supports (LTSS) Program Survey

CMS-10651, OMB 0938-New

Background

The Centers for Medicare and Medicaid Services (CMS) requests clearance to conduct an annual survey

of tribally run long-term services and supports (LTSS) programs (the CMS Tribal LTSS Program Survey). CMS contracted with Kauffman and Associates, Inc., (KAI) as the data collection agent that will develop and distribute the survey. LTSS cover a broad set of services, including health care, personal care, and social services for the chronically ill, people with disabilities, or older adults who need assistance with basic activities of daily living over an extended period of time.¹ Health problems and demographic shifts in American Indian and Alaska Native (AI/AN) communities, including a rapidly increasing elderly population and high disability and chronic disease rates, have led to a very high need for LTSS in Indian Country.²

The purpose of the proposed survey is to update and add to an inventory of LTSS programs managed by AI/AN tribes that KAI created for CMS through in-depth internet research. For this inventory, KAI created a QuickBase database to track and store publically available contact and programmatic information for tribal LTSS programs. Due to the limitations of internet research, the survey will allow KAI to gather the most accurate data as possible. Pending OMB approval, it is expected that the survey data will be available to the public on the CMS website in spring of 2018. Access to this AI/AN LTSS data provides a wealth of resources for program directors of tribal LTSS and researchers. The data will help identify AI/AN programs in the United States, encourage collaboration and the sharing of best practices, and add to AI/AN LTSS research.

CMS, an agency of the U.S. Department of Health and Human Services, upholds its mission to effectively steward public funds and strengthen and modernize “the nation’s health care system to provide access to high quality care and improved health at lower cost.”³ An annual survey assessing LTSS programs in

¹ National Quality Forum. (2015). Addressing Performance Measure Gaps in Home and Community-Based Services to Support Community Living: Initial Components of Conceptual Framework. Retrieved from http://www.qualityforum.org/Projects/h/Home_and_Community-Based_Services_Quality/Interim_Report.aspx

² CMS. (2015). LTSS Research: Annotated Literature Review – Caregiver Support in Indian Country. Retrieved from https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/pdf/ltss- research-annotated-literature-review.pdf

³ CMS. (2013). CMS Strategy: The Road Forward 2013–2017. Retrieved from https://www.cms.gov/About- CMS/Agency-Information/CMS-Strategy/Downloads/CMS-Strategy.pdf

Indian Country will advance CMS’ efforts to expand the development and delivery of LTSS in AI/AN communities.

AI/AN nations have a unique relationship with the federal government that is unlike that of any other population in the United States. Part of this relationship stems from treaties negotiated between sovereign Indian nations and the U.S. federal government. These treaties have established a unique government-to-government relationship that is based upon the cession of millions of acres of tribal lands in exchange for certain promises, benefits, and reserved rights for federally recognized AI/AN tribes. These treaties have also helped secure the federal obligation to provide health services to AI/AN communities. All federal agencies, including CMS, have an obligation to fulfill the trust responsibility to AI/ANs.⁴ The survey’s focus on improved access to LTSS contributes to CMS fulfilling its obligation to provide health services in Indian Country.

The survey will collect information on the operation and provision of tribal LTSS programs and services, including facilities, medical care, in-home care, personal care, caregiver support, and functional services, and on the partnerships and funding that support LTSS programs. In addition, the survey will also collect information on LTSS tribe and program contact information (e.g., tribe/program name, tribe/program contact, etc.) and contact information for current tribal leaders. Because not all tribes have websites where they can provide updated tribal leader contact information, collecting this information directly from the tribes through this survey will allow CMS to gather the most accurate data.

The survey will be sent to a total of 425 tribally run LTSS programs. These programs will be pulled from the QuickBase database described above. KAI’s timeline for distributing the survey includes six different phases of follow-up emails, faxes and phone calls to encourage survey participation. This data collection procedure is based on best practices recommended by survey expert Don Dillman in his most recent book,⁵ which are explained in detail in the Supporting Statement – Part B.

All 425 programs will initially receive the survey by email (via SurveyMonkey). After three follow-up emails, KAI will contact survey non-respondents by phone and introduce the option of receiving the survey via fax. Sending the surveys by fax provides individuals who do not have internet access with the opportunity to participate. In Indian Country, approximately 63% of residents lack access to high speed internet.⁶ Therefore, a non-internet-based survey option is essential. Additionally, in his most recent book Don Dillman states that mixed-mode surveys can result in higher response rates.⁵

⁴ Exec. Order No. 13175, 65 Fed. Reg. 67249 (Nov. 6, 2000) reprinted in 2000 U.S.C.C.A.N. at B77; White House Memorandum for Heads of Executive Departments and Agencies, Nov. 5, 2009; Department of Health and Human Services Tribal Consultation Policy (Dec. 14, 2010); Centers for Medicare and Medicaid Services Tribal Consultation Policy (Nov. 17, 2011); Cramer v. United States, 261 U.S. 219 (1923).

⁵ Dillman, D., Smyth, J., & Christian, L. (2014). Internet, Phone, Mail and Mixed-Mode Surveys: The Tailored Design.

(4th ed.). Hoboken, New Jersey: John Wiley & Sons, Inc.

⁶ Federal Communications Commission. (2016). Native Nations. Retrieved from https://www.fcc.gov/general/native-nations

1. Justification

1. Need and Legal Basis

CMS seeks to implement this data collection of tribal LTSS programs as part of the its obligation to improve LTSS in Indian Country. The American Reinvestment and Recovery Act (ARRA) of 2009 included provisions that statutorily recognized the Tribal Technical Advisory Group (TTAG), which CMS established in 2004 as part of its ongoing efforts to increase the accessibility of its programs to AI/AN beneficiaries.⁷

The CMS Administrator requested TTAG to prepare an AI/AN Strategic Plan to help identify opportunities and challenges for CMS programs in Indian Country. That original plan was presented to the Administrator in 2006, updated in 2009, and updated again in 2013 to cover the period of 2013 through 2018. The plan has five key goals, which apply to all CMS programs, including Medicare, Medicaid, CHIP, and the Health Insurance Marketplace. One of the goals is for CMS to “improve and expand opportunities for development and delivery of Long Term Services and Supports (LTSS) throughout Indian communities.”⁸

The Affordable Care Act (ACA) includes provisions that promote community-based LTSS and improved access. These provisions include:

• Section 2401. Community First Choice. This section provides enhanced federal funding to states that elect to provide person-centered home- and community-based services (HCBS) that help increase the abilities of individuals with disabilities to live in their communities.⁹

• Section 2402. Removal of Barriers to Providing Home and Community-Based Services (HCBS). This section allows states more flexibility to provide HCBS to Medicaid beneficiaries.¹⁰

In addition, there are a number of provisions within the ACA that specifically impact LTSS in Indian Country. When President Obama signed the ACA into law on March 23, 2010, it included the permanent

⁷ H.R.1. American Recovery and Reinvestment Act of 2009. SEC. 5006. Protections for Indians Under Medicaid and CHIP. Retrieved from https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska- Native/AIAN/Downloads/Section-5006-Protections-for-Indians-under-Medicaid-and-CHIP.pdf

⁸ CMS. (2014). Tribal Technical Advisory Group: American Indian and Alaska Native Strategic Plan 2013-2018. Retrieved from https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska- Native/TTAG/Downloads/CMSAIAN-StrategicPlan2013-2018.pdf

⁹ United States Government Publishing Office. (2010). Patient Protection and Affordable Care Act, Public Law 111-

148. Section 2401: Community First Choice Option. Retrieved from https://www.gpo.gov/fdsys/pkg/PLAW- 111publ148/pdf/PLAW-111publ148.pdf

¹⁰ United States Government Publishing Office. (2010). Patient Protection and Affordable Care Act, Public Law 111-

148. Section 2402: Removal of Barriers to Providing Home and Community-Based Services. Retrieved from https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf

reauthorization of the Indian Health Care Improvement Act (IHCIA).¹¹ Within the reauthorization of the IHCIA, there a several provisions specific to LTSS. These provisions include:¹¹

• Section 201. Indian Health Care Improvement Fund. This section includes the authorization of IHS funds for health services, including LTSS, such as home health care and community health representatives.

• Section 822. Shared Services for Long-Term Care. This section authorizes the sharing of facilities and staff between IHS and tribally operated long-term care programs.

• Section 408. Nondiscrimination under Federal Health Care Programs in Qualifications for Reimbursement for Services. This section addresses nondiscrimination under federal health care programs by providing that IHS, tribal, and urban Indian health programs (ITUs) (which are assumed to include long-term care programs) are eligible for participation in and payment from any federal health care program, pending they meet the requirements for participation.

The Tribal LTSS Program Survey will help CMS track the utilization of community-based LTSS in Indian Country, which will allow for more efficient promotion of the ACA provisions related to LTSS in AI/AN communities.

Finally, in 2011, the Administration on Aging (AOA), IHS, and CMS signed a Memorandum of Understanding (MOU) to establish a coordinated effort between the agencies to develop methods and means for providing technical support to IHS, tribal health providers and urban Indian health providers (I/T/Us) in order to expand the development and delivery of LTSS in tribal communities.¹² The AI/AN LTSS Program Survey results will provide the MOU group with information about the utilization of and needs regarding LTSS in Indian Country.

2. Information Users

CMS will use the information collected in the Tribal LTSS Program Survey to update and develop a list of LTSS programs managed by AI/AN communities. Documentation of these programs will support the sharing of LTSS best practices and innovative models employed in Indian Country. CMS will use the survey data to generate further content on LTSS in Indian Country, including literature reviews and reports on best practices.

Once the Tribal LTSS Program Survey has been distributed and collected, KAI will enter the survey data into the AI/AN LTSS QuickBase database. Creation and maintenance of the LTSS inventory database is part of KAI’s contracted work with CMS. CMS will feature the survey data, specifically a list of AI/AN-

¹¹ Sec. 10221. Indian Health Care Improvement. Public Law 111-148 Mar. 23, 2010. Retrieved from https://www.congress.gov/bill/111th-congress/senate-bill/1790/text

¹² CMS. (2014). Tribal Technical and Advisory Group: American Indian and Alaska Native Strategic Plan. Retrieved from https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/TTAG/Downloads/CMSAIAN- StrategicPlan2013-2018.pdf

managed LTSS programs, on the CMS LTSS Technical Assistance Center website,¹³ which will allow tribal communities and the general public to access this important data.

The Tribal LTSS Program Survey is a new collection. While the information has never been collected by CMS through a formal survey, KAI has collected this information on behalf of CMS via internet research. However, as stated above, internet research has limitations due to infrequent updates and a lack of tribal websites.

2. Use of Information Technology

The Tribal LTSS Program Survey will be available electronically and will be sent to respondents via email and fax. The email version of the survey will be distributed and collected via SurveyMonkey. KAI will make every effort so that the electronic, SurveyMonkey version of the Tribal LTSS Program Survey will be available to 100% of the respondents. However, as stated above in the Introduction, the sporadic nature of internet connections in some tribal communities may make access to an internet-based survey difficult for some respondents. Therefore, the Tribal LTSS Program Survey respondents will have the option to complete an electronically delivered version (sent through an email via SurveyMonkey) of the survey or a hard copy version (sent via fax). KAI staff will also engage in survey follow-up by phone and respondents will have the opportunity to complete the survey by phone.

This collection does not require a signature from participants. The directions at the top of the survey explain that the survey is voluntary. In addition, the directions explain that the data from the survey will be shared on the CMS LTSS Technical Assistance Center website.¹³

Attachment C contains a screenshot of the SurveyMonkey version of the Tribal LTSS Program Survey.

2. Duplication of Efforts

While the majority of information collected in the Tribal LTSS Program Survey is publicly available online via tribal websites, obtaining the information in a survey will provide more accurate information. As mentioned above, some tribal websites are not updated frequently, so publicly available tribal LTSS information has limitations and may not be accurate.

¹³ CMS.gov. (2016). Long-Term Services and Supports Technical Assistance Center. Retrieved from https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/ltss-ta-center/

Prior data collection efforts external to CMS that involve the availability and needs of AI/AN LTSS programs include:

• The Office of Rural Health Policy, HRSA, supported a survey of 305 tribes and tribal consortia conducted from 2005 to 2007 on the needs and availability of LTSS programs in AI/AN communities. This survey is the most comprehensive inventory of AI/AN LTSS programs to date. The 2017 AI/AN LTSS Survey will build on this 2010 survey and capture the updates, additions, and improvements to AI/AN LTSS programs that have occurred since 2010.¹⁴

2. Small Businesses

The proposed Tribal LTSS Program Survey instrument was designed to minimize the respondents’ burden as small entities. The number of survey questions was limited to 26 short “yes” or “no” responses to ensure a short survey completion time. KAI estimates an average survey completion time of 15 minutes. Respondents who lack the capability to get the survey instrument via email will receive a paper-based survey by fax with paper-based instructions. If neither email or fax is a viable option, respondents will have an opportunity to complete the survey over the phone with the assistance of KAI staff.

2. Less Frequent Collection

The potential negative or inadvertent consequences of not conducting this collection include delaying the progress and improvements of LTSS in Indian Country. The Tribal LTSS Program Survey will provide the most accurate information on Tribal LTSS programs to date. Although some of the information is publicly available via internet research, tribal websites and program information (e.g., staffing and funding updates) are not always updated on a regular basis, nor is the information always available on the internet. Obtaining LTSS program information directly from tribal and program staff will result in more accurate data. Once CMS obtains this data, sharing it with tribal communities is essential to the promotion and uptake of LTSS best practices and innovative models employed in Indian Country.

2. Special Circumstances

No special circumstances have been identified for this project.

2. Federal Register/Outside Consultation

Federal Register

The 60-day notice published in the Federal Register on July 6, 2017 (82 FR 31331). We did not receive any comments.

¹⁴ Goins, R. T., Bogart, A., & Roubideaux, Y. (2010). Service Provider Perceptions of Long-Term Care Access in American Indian and Alaska Native Communities. Journal of Health Care for the Poor and Underserved, 21 (4), 1340-1353.

Outside Consultation

The Tribal LTSS Program Survey questionnaire design and development was discussed with an outside subject matter expert, R. Turner Goins, Ph.D., M.S. Dr. R. Turner Goins is the Ambassador Jeanette W. Hyde Distinguished Professor at Western Carolina University. She is a nationally known expert in AI/AN aging issues and has extensive experience researching LTSS needs, utilization, and perceptions in Indian Country.

2. Payments/Gifts to Respondents

Neither CMS nor KAI will provide any payment or gift of any type to respondents. Respondents will participate on a voluntary basis.

2. Confidentiality

The fact that participation in this survey is voluntary is included on the first page of the survey instrument.

2. Sensitive Questions

There are no questions of a sensitive nature in the Tribal LTSS Program Survey.

2. Burden Estimates (Hours & Wages)

Wage Estimates

To derive average costs, we used data from the U.S. Bureau of Labor Statistics’ May 2016 National Occupational Employment and Wage Estimates for all salary estimates (http://www.bls.gov/oes/current/oes_nat.htm). In this regard, the following table presents the mean hourly wage, the cost of fringe benefits and overhead (calculated at 100 percent of salary), and the adjusted hourly wage.

Estimated Occupation Title and Hourly Wages¹⁵

Occupation Title	Occupation Code	Mean Hourly Wage Rate ($/hr)	Fringe Benefits and Overhead ($/hr)	Adjusted Hourly Wages ($/hr)
Community and Social Service Specialists, All Other	21-1099	21.89	21.89	43.78
General and Operations Managers	11-1021	58.70	58.70	117.40
Health Care Social Worker	21-1022	26.69	26.69	53.38
Office and Administrative Support Worker	43-9000	16.31	16.31	32.62

As indicated, we are adjusting our employee hourly wage estimates by a factor of 100 percent. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly from employer to employer, and because methods of estimating these costs vary widely from study to study. Nonetheless, there is no practical alternative and we believe that doubling the hourly wage to estimate total cost is a reasonably accurate estimation method.

Burden Estimates

KAI anticipates receiving 425 completed Tribal LTSS Program Surveys, with each response requiring 15 minutes to complete. To determine this time estimate, KAI distributed the survey internally among staff and timed how long it took them to complete the survey. The frequency of response for the survey is once per year. Based on these numbers, KAI estimates the total annual hour burden for the proposed Tribal LTSS Program Survey at 106.25 hours.

KAI estimated survey respondent types by identifying job titles available for the 425 tribal LTSS programs in KAI’s QuickBase database and aligning them with federal job titles. Based on this process, of the 425 surveys, approximately 75%, or 320, will come from General and Operations Managers; approximately 1%, or 5, will come from Health Care Social Workers; approximately 8%, or 33, will come from Office and Administrative Support Workers; and approximately 16%, or 67, will come from individuals that do not have an identified job title in the LTSS database. For individuals without job titles who are working in health and human services, KAI used a general job title (Community and Social Service Specialists, All Other)

Estimated Annual Burden Hours¹⁵

Respondent Type	No. of Respondents	No. Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours
Community and Social Service Specialists, All Other	67	1	0.25	16.75
General and Operations Managers	320	1	0.25	80
Health Care Social Worker	5	1	0.25	1.25
Office and Administrative Support Workers	33	1	0.25	8.25
Total	425	1	0.25	106.25

Estimated Annual Cost Burden¹⁵

Respondent Type	Total Hours	Hourly Wage ($/hr)	Total Cost ($)
Community and Social Service Specialists, All Other	16.75	43.78	733.32
General and Operations Managers	80	117.40	9,392.00
Healthcare Social Worker	1.25	53.38	66.76
Office and Administrative Support Worker	8.25	32.62	269.12
Total	106.25	n/a	10,461.20

2. Capital Costs

There are no anticipated costs to respondents beyond the employee time expended during completion of the survey instrument and as addressed in the above section.

2. Cost to Federal Government

The Tribal LTSS Program Survey will occur annually for the duration of the contract; no fluctuations in cost are expected. The estimated annual cost to the government is $91,896.00, which includes all costs related to labor, data collection, analysis, reporting activities, and communication between the contractor and CMS.

The total costs of $91,896.00 consists of $62,262 in labor and $29,634 in other direct costs (ODCs). Labor costs are for the following positions:

• Corporate Monitor, Project Manager, Project Lead, Research Associate, Project Support, Communications Associate, Technical Writer, and Web Developer

2. Changes to Burden

This is a new collection, therefore there are no changes to the burden.

2. Publication/Tabulation Dates

The results of the Tribal LTSS Program Survey will be collected and tabulated in a QuickBase database and made available on the CMS.gov website, specifically on the LTSS Technical Assistance Center page.¹⁶ Pending OMB approval, it is expected that the data will be available to the public on the CMS website in spring of 2018. Access to this AI/AN LTSS data provides a wealth of resources for program directors of tribal LTSS and researchers. The data will help identify AI/AN programs in the United States, encourage collaboration and the sharing of best practices, and add to and increase AI/AN LTSS research.

2. Expiration Date

HCFA would like an exemption from displaying the expiration date as these forms are used on a continuing basis. To include an expiration date would result in having to discard a potentially large number of forms.

2. Certification Statement

There are no exceptions to the certification statement identified in Item 19, "Certification for Paperwork Reduction Act Submissions," of OMB Form 83-I.

¹⁶ CMS.gov. (2016). Long-Term Services and Supports Technical Assistance Center. Retrieved from https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/index.html