CMS-10723.Patient Activation Survey Generic Submission Request

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: XXXX-YYYY)

TITLE OF INFORMATION COLLECTION: 12SOW Patient Activation Assessment

PURPOSE: Per Attachment 3 of the Quality Innovation Network-Quality Improvement Organization’s (QIN-QIO) 12^th Statement of Work (12SOW) task order, CMS is asking the QIN- QIO to “show better patient engagement, as indicated by a 13% increase on measures of patient activation that assess a person’s underlying knowledge, skills and confidence integral to managing his or her own health and healthcare.”

This survey is our method of establishing a baseline, and then later re-measuring to indicate success of at least a 13% increase on measures of patient activation. The questions for the survey were taken directly from Attachment 3. The results of the survey will be used first and foremost to meet the deliverable requirements as stated by CMS. Information gleaned from the responses will also inform the QIN-QIOs of opportunities to improve patients, families, and caregivers experience with the healthcare system. Without sharing the actual data from the survey, we will take what we learn and use that information to make our patient and family engagement efforts more robust. Please note that no beneficiary PII or PHI will be collected.

DESCRIPTION OF RESPONDENTS: Patients with Medicare, family members and caregivers in the US states and territories

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey [ ] Usability Testing (e.g., Website or Software) [ ] Small Discussion Group

[ ] Focus Group [X] Other: Information Gathering

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

4. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name: Marie Wagner-Clarke, COR III _

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [X] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Private sector	100,000	2 minutes	3,333 hours
Totals	100,000	2 minutes	3,333 hours

FEDERAL COST: The estimated annual cost to the Federal government is $0

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe?

[ ] Yes [X] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

QIN-QIOs will supply healthcare providers with a card or flyer that includes the link to the online survey, and we will ask that they provide that information to their patients.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[X] Web-based or other forms of Social Media [ ] Telephone

[ ] In-person [ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [X] No

Please make sure that all instruments, instructions, and scripts are submitted with the request.

Link to online survey: [INSERT ONLINE SURVEY LINK HERE] Paper copy is attached.

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