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

Supporting Statement – Part B

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

CMS-10651, OMB 0938-New

1. Describe (including a numerical estimate) the potential respondent universe and any sampling or other respondent selection method to be used. Data on the number of entities (e.g., establishments, State and local government units, households, or persons) in the universe covered by the collection and in the corresponding sample are to be provided in tabular form for the universe as a whole and for each of the strata in the proposed sample. Indicate expected response rates for the collection as a whole. If the collection had been conducted previously, include the actual response rate achieved during the last collection.

The Tribal Long Term Services and Supports (LTSS) Program Survey will provide the Centers for Medicare and Medicaid Services (CMS) with an inventory of LTSS programs for older adults or disabled individuals run by American Indian and Alaska Native (AI/AN) tribes. The respondent universe includes 424 LTSS programs run by AI/AN tribes. These programs are pulled from a QuickBase database that Kauffman and Associates, Inc., (KAI) created for CMS. The QuickBase database houses program contact information, including program names, email addresses, phone numbers, and fax numbers. The tabular form of this sample is presented in Attachment A. The 424 programs are all operated by federally recognized tribes, rancherias, pueblos and Alaska Native villages. The programs include a myriad of LTSS that tribal communities provide to older adults or disabled individuals, such as assisted living facilities, nursing homes, home maintenance and repair, physical therapy, and palliative care.

KAI populated and continues to routinely update this database through intensive online research of tribal websites. However, tribal websites are not updated regularly and the available data on program updates and contact information is limited. Therefore, CMS requested that KAI create and administer a survey of the programs to obtain the most accurate information possible. This survey has not been conducted previously, and CMS has not set a required minimum response rate for the survey.

2. Describe the procedures for the collection of information including:

   • Statistical methodology for stratification and sample selection,

   • Estimation procedure,

   • Degree of accuracy needed for the purpose described in the justification,

   • Unusual problems requiring specialized sampling procedures, and

   • Any use of periodic (less frequent than annual) data collection cycles to reduce burden.

The sample for the Tribal LTSS Program Survey is a convenience sample, which uses available tribal LTTS program data pulled from the QuickBase database, as contracted and requested by CMS. The data collected from the Tribal LTSS Program Survey will undergo basic analysis, including raw counts and the calculation of percentages. Therefore, statistical methodology for stratification and sample selections is not applicable and neither is an estimation procedure or degree of accuracy. There are no anticipated, unusual problems that require specialized sampling procedures. As requested by CMS, the survey will be conducted on an annual basis.

The procedures for collecting data for the Tribal LTSS Program Survey includes email and fax distribution of the survey and follow-up by KAI staff via phone. These procedures, which are divided into six phases, are detailed below and are presented in a timeline in Attachment B.

Phase 1: Once finalized and approved by OMB, KAI will distribute the Tribal LTSS Program Survey to the

424 programs in the QuickBase database via email. KAI will send an initial email invitation (Attachment

C) to the program staff. Email addresses and program staff names will be pulled from the database. The email explains the purpose of the survey, provides instructions on how to complete the survey, and includes a link to the survey via Survey Monkey (a screen shot of the survey is provided in Attachment D). The email also highlights the benefits of participating in the survey, which includes sharing LTSS best practices and innovative models employed in Indian Country. The email and survey also explain that the survey is voluntary and that the data from the survey will be shared on the CMS LTSS Technical Assistance Center website.¹

Phase 2: Approximately 3 days after the distribution of the initial email invitation, a follow-up email will be sent to the entire mailing list. The email (Attachment E) explains that an initial invitation to participate in the survey was sent. The email also thanks those who have responded and ask those that have not responded to do so. The email also includes a link to the survey in SurveyMonkey.

Phase 3: Approximately 1 week after the first reminder email is sent, a second follow-up email will be sent to the non-respondents. The email (Attachment F) emphasizes the importance of participating in the survey and includes a link to the survey.

Phase 4: Approximately 2 weeks after the second follow-up email, a third follow-up email will be sent to the remaining non-respondents. This email (Attachment G) encourages survey participation and includes a link to the survey. The email also explains that KAI staff will reach out to any non-respondents by phone to determine whether non-respondents are unable to complete an electronic version of the survey or if they prefer to complete a paper version of the survey sent via fax.

Phase 5: Approximately 1 week after the third follow-up email is sent, KAI staff will call the remaining non-respondents (based on telephone information available in the QuickBase database and online at tribal websites). KAI staff will follow a telephone call script (Attachment H) and inquire whether non- respondents received the emails about the survey. KAI will provide a description of the survey and ask respondents whether they would like to complete the survey by phone or have the survey sent to them via email or fax. If non-respondents do not answer, KAI will leave a voicemail following a script (Attachment I), with a contact telephone number. If non-respondents do not respond to the voicemail, two more phone attempts will be made.

Phase 6: Immediately after outreach calls to survey non-respondents have been completed, KAI staff will send a follow-up email or fax (based on non-respondent preference) to all individuals that KAI staff spoke to on the phone. Both the email and fax (Attachments J and K) will thank the participants for speaking with KAI staff and provide directions on how to complete the survey. The email will include a link to the survey in SurveyMonkey, and the fax text will include a fax number to send the survey once completed.

The outlined data collection procedures are based on best practices created by a recognized expert on survey design, Don Dillman.²

¹ 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/

² 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. Method. Hoboken, New Jersey: Wiley.

3. Describe methods to maximize response rates and to deal with issues of non-response. The accuracy and reliability of information collected must be shown to be adequate for intended uses. For collections based on sampling, a special justification must be provided for any collection that will not yield 'reliable' data that can be generalized to the universe studied.

As stated above, KAI is employing a mixed-mode approach. Research conducted by Dillman et. al. suggests that mixed-mode approaches can improve response rates.² A mixed-mode approach that includes paper and email surveys can improve response rates in its consideration of preferred modes of response. College- and working-age adults tend to prefer electronic surveys, while older, lower income and less educated individuals may not have access to internet or the technology literacy to complete an online survey.² Mixed-mode approaches are in keeping with KAI’s commitment to meet community members where they live and provide different ways for members to participate in important research efforts.

Based on Dillman’s recommendations,² KAI will also maximize response rates through the use of multiple follow-up emails for the electronic version of the Tribal LTSS Program Survey. Dillman also recommends introducing the option of a paper-based survey after the introduction of a web response option, which KAI will do in Phase 6 of the data collection process described above. In addition, KAI will use the same question format and wording for the email and fax-based versions of the survey, which Dillman emphasizes as being essential for maximizing response rates.²

4. Describe any tests of procedures or methods to be undertaken. Testing is encouraged as an effective means of refining collections of information to minimize burden and improve utility. Tests must be approved if they call for answers to identical questions from 10 or more respondents. A proposed test or set of tests may be submitted for approval separately or in combination with the main collection of information.

Due to resource limitations, no survey testing will be undertaken. However, KAI engaged in a rigorous process and review to create and improve the survey. The topics for survey questions were based on categories of LTSS programs stored in the LTSS database and those that CMS hopes to gain updated information about. Questions were also informed through the input of an LTSS expert, Dr. R. Turner Goins who conducted a survey on access to long-term care among AI/ANs in 2007.³

5. Provide the name and telephone number of individuals consulted on statistical aspects of the design and the name of the agency unit, contractor(s), grantee(s), or other person(s) who will actually collect and/or analyze the information for the agency.

Individuals consulted on statistical aspects of the survey design will comprise:

R. Turner Goins, Ph.D.

Ambassador Jeanette W. Hyde Endowed Professor of Gerontological Social Work Western Carolina University

(828) 227-3515

³ Goins, R., 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: 1340–1353.

Susan Silberman, Ph.D.

Vice President, Research & Evaluation Kauffman & Associates, Inc.

(301) 980-7965

Jo Ann Kauffman, M.P.H. President

Kauffman & Associates, Inc. (509) 789-2662

Jonathan Collins, M.P.H.

Project Manager, Research & Evaluation Kauffman & Associates, Inc.

(202) 823-3969

Meredith Anderson, M.P.H.

Project Manager, Research & Evaluation Kauffman & Associates, Inc.

(202) 794-2548

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