REVISED Supporting Statement Section A

Supporting Statement A

Area Health Education Centers Project on the Mental and Behavioral Health and Substance

Abuse Issues of Veterans/Service Members and Their Families

OMB Control No. 0915-NEW

Terms of Clearance: None.

A. Justification

1. Circumstances Making the Collection of Information Necessary

This is a request for Office of Management and Budget (OMB) approval to conduct the Area Health Education Center (AHEC) Project for the Mental/Behavioral Health of Veterans, Service Members, and their Families evaluation (OMB No. 0915-NEW). The Area Health Education Program is authorized under Section 751 of the Public Health Service Act (42 U.S.C. 294a), as amended by the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148, Sec. 5403). The AHEC Project for the Mental/Behavioral Health of Veterans, Service Members, and their Families (VMH) is funded through an interagency agreement between the Health Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration (SAMHSA).

The AHEC program provides support for cooperative agreements designed to encourage the establishment and maintenance of community-based training programs in off-campus rural and underserved areas. The 57 AHEC programs and their 253 affiliated centers, along with state and local partners, implement student training programs, continuing education for healthcare providers and health careers outreach activities responsive to current healthcare workforce and service needs of underserved populations in a state or region. Currently AHEC programs are operating in 48 states, the District of Columbia, and the U.S. territories of Guam, Palau, and Puerto Rico.

A mission of AHEC programs is to support efforts to increase access to quality, culturally competent health care for underserved populations, including veterans and their families. Numerous curricula have been developed to better prepare health care providers to respond to the unique needs of this population, specifically mental and behavioral health and substance abuse issues including post-traumatic stress disorder, traumatic brain injury, substance abuse, anxiety, bipolar disorder, panic disorders, suicide, and prescription drug abuse. The AHEC network is uniquely positioned to increase the competency of health care providers and improve their practice related to the mental and behavioral health issues of veterans and their families through quality continuing education offerings, existing relationships with state and national professional organizations to provide continuing education credits towards licensure, a community-based training approach, and ongoing interaction with health care providers and employers.

A part of this project to provide continuing education to health care providers is to evaluate whether or not providers change their practice after receiving continuing education. Trained AHEC staff will provide continuing education (CE) for civilian primary care, mental and behavioral health, and other healthcare providers to improve the quality and cultural competency of the care they offer to veterans/service members and their families and will conduct an evaluation of those offerings. Two instruments will be used in the evaluation, including the CE evaluation results form and the CE evaluation follow-up form. These instruments will provide aggregate information about the providers trained and project activities and will assess through a follow-up survey whether a provider changed their practice after receiving the CE offering.

2. Purpose and Use of Information Collection

This project aims to complement the Bureau of Health Profession’s performance measurement goals. The goal of the project is to improve the quality of the nation’s health professions workforce by integrating core competencies into continuing education offerings. The addition of competencies regarding the mental and behavioral health and substance abuse issues facing veterans and their families to these offerings will better prepare the healthcare workforce to identify and address these issues and provide better quality care to returning veterans and service members.

Evaluation Overview

The project’s goals are for AHEC Centers to provide continuing education offerings to health professionals dispersed throughout the country that accomplish the following:

• increase knowledge of veterans mental/behavioral health issues,

• raise awareness of the impacts of military culture on health care service delivery, and

• increase access to mental/behavioral health services for veterans and their families by

fostering change in health professionals’ individual practice.

These outcomes of the evaluation will have three impacts: to document a change in provider practice, to determine participant satisfaction with CE offerings, and to improve the quality and transmission of the curriculum.

An important focus of the VMH project is on quality improvement, specifically as it relates to continuing education. Information will be collected to inform and improve continuing education curriculum and offerings and contribute to the larger efforts from the Bureau of Health Professions (BHPr) to measure the performance of grantees.

Current AHEC grantee staff will coordinate continuing education offerings for health care providers to improve their practice related to the mental and behavioral health issues of veterans and their families. By collecting demographic and evaluative information from participants, grantee staff will be able to report required annual aggregate CE performance data and evaluative responses that will document outcomes of these educational offerings to BHPr.

HRSA will use the information collected for continuous quality improvement of the CE offering, to examine the reach and impact of the project, and to determine the level of change in practice providers report after attending a CE session. Data may be disseminated in a variety of forms, including conferences, publications, and HRSA reports.

The justification for collecting the following data is to be able to evaluate the extent to which the above goals are met and to use that information for program improvement.

All continuing education offered through this project must include discussion of the following:

1. Military culture competency

2. Identification of veterans/service members and their families in the population served by the health professional

3. Mental/behavioral health issues of veterans/service members

Additional issues that should also be considered for inclusion as appropriate for the audience and CE plan include the following:

4. Signs and symptoms of Post Traumatic Stress Disorder (PTSD)

5. Signs and symptoms of Traumatic Brain Injury (TBI)

6. Enrollment in the War Within database (http://warwithin.org/fhp.php) by primary care and behavioral health professionals to increase access to care for veterans/service members and their families

7. Acceptance of TRICARE (Military Health Care Insurance) by primary care and behavioral health professionals to increase access to care for veterans/service members and their families

This project will use a Change in Practice Evaluation Methodology model described in the University of Massachusetts/Harvard University research article titled The impact on medical practice of commitments to change following CME lectures: A randomized controlled trial by Frank J. Domino, Sanjiv Chopra, Marissa Seligman, Kate Sullivan, and Mark E. Quirk; Medical Teacher, 2011; 33: e495–e500.

This article describes a methodology that relates to the VMH project:

• Commit to Change (CTC) can be successfully applied to large audience CE and result in positive change in clinical practice.

• Electronic tools can assist in making CTC theory an ‘‘easy to integrate’’ educational tool.

• Making commitments, whether selecting them from a predefined list or generating them spontaneously is positively associated with practice change.

• Once providers complete a commit to change cycle, the change persists and remains stable.” (Page 495)

The authors state that the “….study’s findings further add to the evidence already in the literature that spontaneously generated commitments lead to self-reported change (Mazmanian et al. 1998, 2001).“

Therefore, the evaluation methodology for this project includes commitment to change (CTC) assessments both at the immediate conclusion of the CE offering and again within 30 days after the offering. The first CTC assessment will be part of the participant evaluation processes immediately following the CE offering. The second CTC assessment will be a follow-up brief email and/or telephone survey implemented by grantee staff with a randomly selected sample of 20% of participants within 30 days after the offering. In implementing the survey, grantee staff will email the questions to the randomly selected participants, asking for an emailed response. If a response is not received within 2 working days, grantee staff will contact that CE participant by phone to obtain responses to the survey. Grantee staff will record the responses.

Each AHEC site implementing the CE project will compile a final report of aggregate responses for all participants that will be emailed to the evaluation contractor in Microsoft Excel format. This report will include data related to the BHPr Continuing Education Performance Measures (currently submitted to OMB for clearance in OMB package 0915-0061, expiration 4/30/2014). Additional information that will be collected includes aggregate responses to the CE participant evaluation and aggregate responses for a randomly selected sample of 20% of participants on the CE participant follow-up evaluation. The questions and format for those reports are included in Appendix A.

The justification for collecting this data is to be able to document valid and reliable outcomes from the project and that it has met its stated goals.

CE Participant Evaluation:

The CE Participant evaluation will be completed by all participants at the immediate conclusion of each CE offering and collects data related to the participants self-report of increased knowledge on a number of topics, including military culture and the mental/behavioral health needs of veterans and their families. The evaluation also collects participant self-report data for intent to improve their practice, based on the educational offering and a retrospective pre-test assessing the participant’s level of knowledge before the CE offering. The entire report can be found in Attachment A.

CE Participant Follow-Up Evaluation.

This evaluation will be completed by a random sample of 20% of participants within 30 days of the CE offering. Participants will be selected based on the randomizing methodology presented by The Web Center for Social Research Methods, which can be found at http://www.socialresearchmethods.net/kb/sampprob.php. The evaluation collects data on the content included in the CE offering, a self-report of if the participant committed to changing their practice based on the training, and if they have begun or are planning to begin modifications to their practice based on the CE offering. The entire report can be found in Attachment A.

Specific fields that overlap both the BHPr Performance Measures and Veteran’s Mental Health Project required data are noted in Appendix A by identifying the table and column where the information is requested in the BHPr Performance Measures. These data fields are not included in the burden statement for this clearance request because they are already being requested as part of the BHPr Performance Measures package. No additional data fields or burden is being requested of participants who will complete these forms.

3. Use of Improved Information Technology and Burden Reduction

Improved information technology is utilized where appropriate. Evaluative responses are being collected from participants in continuing education trainings held throughout the US and its territories in a variety of locations and training settings with different levels of access to technology. Spreadsheet files will be provided to data collection personnel at each site to enter, organize, and report the data. These files will be emailed to the evaluation contractor and merged for final data analysis.

4. Efforts to Identify Duplication and Use of Similar Information

The information collected through the AHEC Project for the Mental/Behavioral Health of Veterans/Service Members and their Families performance evaluation tools is not available from another source. The required information can only be supplied by the participating AHEC grantees.

5. Impact on Small Businesses or Other Small Entities

Because collection of this information impacts small businesses and other small entities (physicians and behavioral and mental health providers attending these CE offerings), information being requested has been held to the absolute minimum required for the intended use of the data.

To help minimize the impact of data collection on small business, the Program Evaluation strategy employs a follow-up survey completed by a random sample of 20% of participants rather than by all participants. That survey (multiple choice responses to no more than 7 questions) will first be sent electronically through email, asking for an email response. If the participant does not respond within a designated time frame, he/she will be contacted by phone and asked to respond verbally at that time.

6. Consequences of Collecting the Information Less Frequent Collection

Performance data will be collected on an ongoing basis and reported to HRSA at the end of each continuing education offering and at the end of the period of performance for each participating AHEC grantee. Data will be checked for errors upon each submission and once the grantee submits their final performance report. CE participants will respond one-time only at the conclusion of the CE offering they attend. Those randomly selected for the follow-up evaluation will respond a second time through email or by phone.

If this information is collected less frequently than after each CE offering, it will not be possible to collect complete data, to accurately analyze the data or to conduct a valid and reliable evaluation of program outcomes and impact.

There are no legal obstacles to reduce the burden.

7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

The information collection fully complies with 5 CFR 1320.5

8. Comments in Response to the Federal Register Notice/Outside Consultation

Section 8A:

The notice required by 5 CFR 1320.8(d) was published in Volume 76, No. 249, pages 81514-81515 of the Federal Register on December 28, 2011. No comments were received from the public.

Section 8B:

The following three Area Health Education Center staff were consulted on the clarity and overall burden of the data collection tools. The respondents thought the data collection measures were clear and the requested information was reasonable and available within their respective organizations.

Sandy Viau-Williams, Executive Director

Yankton Rural AHEC

Yankton, SD 57078

605-655-1400

SViau@avera.org

Scott Denlinger, Outreach Librarian

Magnolia Coastlands AHEC, Georgia Southern University

Statesboro, GA 30460

912-478-5030

sdenlinger@georgiasouthern.edu

Paula Overfelt, Executive Director

Northwest Missouri Area Health Education Center

St. Joseph, MO 64507

816-271-7199

Paula.Overfelt@heartland-health.com

9. Explanation of any Payment/Gift to Respondents

There will be no payments or gifts provided to participants.

10. Assurance of Confidentiality Provided to Respondents

No personally identifiable information (PII) is being collected in this evaluation. All evaluative responses will be reported to HRSA in the aggregate and any unique identifiers assigned by sites will not be transmitted to HRSA at any time. This project does not require IRB approval.

11. Justification for Sensitive Questions

No questions of a sensitive nature will be asked of participants

Type of Respondent	Form Name	Number of Respondents	No. Responses per Respondent	Total Responses	Average Burden per Response (in hours)	Total Burden Hours
Physicians, nurses, physician assistants, and mental and behavioral health professionals	CE Evaluation Results Form	10,000	1	10,000	.5	5,000No additional burden is anticipant beyond standard practice
Physicians, nurses, physician assistants, and mental and behavioral health professionals	CE Evaluation Follow-up Form1	2,00011401	1	2,000140	.17	34024
AHEC Centers	CE Evaluation Results Report	150	7	1,050	1	1,050
AHEC Centers	CE Evaluation Follow-up Report	150	7	1,050	1	1,050
TOTAL AVERAGE ANNUAL BURDEN		10,150	216	12,240		5,3402,124

12. Estimates of Annualized Hour and Cost Burden

The hour-burden estimates are based on the time for reviewing instructions, responding to the questions, gathering and maintaining the data needed, and completing and reviewing the collection of information. It does not require searching existing data sources. No formal pretest of the form was conducted. The hour burden estimates were derived based on prior experience.

Estimated Annualized Burden Costs to Respondents

13. Estimates of other Total Annual Cost Burden to Respondents or Recordkeepers/Capital Costs

There will be no costs to respondents or recordkeepers/capital costs for this activity.

14. Annualized Cost to Federal Government

An estimated .33 FTE at the GS 13 level is needed to serve as the Contracting Officer’s Representative (COR) for the evaluation contract and offer technical assistance to grantees regarding the evaluation at an estimated cost of $29,385 annually. In addition HRSA, through an Inter-Agency Agreement (IAA) with SAMHSA, maintains a contract with the National AHEC Organization at an annual cost of $500,000 for this project. The evaluation aspects of this contract are estimated at $83,000 annually.

15. Explanation for Program Changes or Adjustments

As this is a new request to collect information there are no changes or adjustments.

16. Plans for Tabulation and Publication and Project Time Schedule

OMB Approval	Anticipated	July 1, 2012
Data Collection Starts	Immediately following OMB clearance	July 1, 2012
Data Collection Ends	4 weeks before EOC (End of Contract)	September 1, 20122013
Report due to HRSA	By EOC	September 29, 20122013
EOC		September 29, 20122013

17. Reason(s) Display of OMB Expiration Date is Inappropriate

No exemption is requested and the expiration date will be displayed.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification.

1 The CE Evaluation Follow-Up Form will only be completed by a sample of the total CE participants. Thus, the 1402,000 respondents will not be unique respondents, but instead a sub-set of the CE Evaluation Results Form respondents.

9