CMS-10729 BFCC-QIO TO4 Survey Questions Supporting Statement_041420

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

TITLE OF INFORMATION COLLECTION: Beneficiary Care Management Program, Beneficiary Experience Survey

PURPOSE:

Section 1153(b) of the Social Security Act (the Act) authorizes the HHS Secretary to enter into contract with the Quality Improvement Organization (QIO) for the purpose of carrying out quality improvement functions, as described in section 1154 of the Act. The QIO quality improvement functions include technical assistance, data analysis, and stakeholder engagement activities that promote evidence-based healthcare practice and patient-centered care principles. QIOs work to improve quality of care, improve outcomes to beneficiaries, and lower healthcare costs. The Beneficiary Care Management Program (BCMP) is the task order four (4) under the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) 12^th Scope of Work contract. The BCMP is a post-advocacy intermediary charged with providing Medicare Fee-For-Service beneficiaries with care management support services in the way of discharge planning, care coordination and care navigation. The foundation of this work is within the Centers for Medicare and Medicaid Services (CMS) iQuality Improvement and Innovation Group (iQIIG).

The overarching purpose of the BCMP is to ensure that beneficiary (including their families/caregivers) values are integrated into clinical practice and services as part of the CMS Person and Family Engagement (PFE) Strategy. Through the BCMP, the BFCC-QIO provides assistance to Medicare Fee-For-Service (FFS) beneficiaries with a hospital discharge or service termination type appeal and additional care management issues. The BFCC-QIO performs independent needs assessment and deliver assistance with discharge planning, care coordination, health care navigation and/or other PFE interventions. These support services include activities that address health literacy, shared-decision making, beneficiary activation, and satisfactory experience.

The purpose of this survey is to capture meaningful information/data relative to the beneficiary experience with the BCMP and the services being provided. This survey is voluntary to beneficiaries who have utilized the BCMP services through the CMS QIO. The collection of the information is governed by Section 1160 of the Act, which covers the QIO confidentiality and disclosure responsibilities related to information it is authorized to collect, acquire, or generate. Data will be used to continuously evaluate the efficiency of the program, as well as provide quality improvement strategies towards improving both access, quality and safety of services rendered. The survey results will help CMS and the BFCC-QIO to evaluate and improve performance and outcomes measures defined within contract deliverables.

DESCRIPTION OF RESPONDENTS:

The respondents to this survey include: Medicare Fee-For-Service beneficiaries receiving a hospital discharge or service termination type appeal through the BFCC-QIO contractor for case review services

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [X] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [ ] Other: ______________________

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: Dr. Confidence Gbarayor-Hyde (Deputy Director iQIIG/DBRCM)

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 [X] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [X] 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
Customers (satisfaction survey)	600	5 minutes	50 hours
Totals			50 hours

FEDERAL COST: The estimated annual cost to the Federal government is $0.00

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?

Administration of the Instrument

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

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

[X] 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.

Attachment A — Voluntary customer satisfaction survey questions

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