0920-0943 SupSta B_4-12-16

Supporting Statement B for Paperwork Reduction Act Submission for

Reinstatement with Nonsubstantive Changes

Data Collection for the Residential Care Community and Adult Day Services Center Components of the National Study of Long-Term Care Providers

OMB No. 0920-0943 Exp. Date: 07/31/2015

April 12, 2016

Lauren Harris-Kojetin

Chief, Long-Term Care Statistics Branch

Division of Health Care Statistics

National Center for Health Statistics

Phone: 301.458.4369

Fax: 301.458.4693

Email: lharriskojetin@cdc.gov

TABLE OF CONTENTS

B. Collections of Information Employing Statistical Methods

1. Respondent Universe and Sampling Methods............................................. 3

2. Procedures for the Collection of Information.............................................. 5

3. Methods to Maximize Response Rates and Deal with Nonresponse........... 9

4. Tests of Procedures or Methods to be Undertaken...................................... 13

5. Individuals Consulted on Statistical Aspects and Individual Collecting

and/or Analyzing Data................................................................................... 13

Attachments

Attachment A NCHS Legislation

Attachment B Federal Register Notice

Attachment C-1 Comparison of 2014 and 2016 RCC Questionnaire Items

Attachment C-2 Comparison of 2015 and 2016 ADSC Questionnaire Items

Attachment D-1 2016 NSLTCP RCC Questionnaire Items-Version A

Attachment D-2 2016 NSLTCP RCC Questionnaire Items-Version B

Attachment D-3  2016 NSLTCP ADSC Questionnaire Items-Version A

Attachment D-4  2016 NSLTCP ADSC Questionnaire Items-Version B

Attachment E-1 Advance Notification letters- Experiment 1

Attachment E-2 First Mailing packet

Attachment E-3 Thank You Reminder letters

Attachment E-4 Follow-up #1 packet

Attachment E-5 Follow-up #2 packet

Attachment F Chain packet

Attachment G Human Subjects Determination

Attachment H Data Retrieval Call

Attachment I-1 Residential Care Web Questionnaire Screenshots

Attachment I-2 Adult Day Services Centers Web Questionnaire Screenshots

B. Statistical Methods

1. Respondent Universe and Sampling Methods

The National Study of Long-Term Care Providers (NSLTCP) (OMB No. 0920-0943 Exp. Date: 07/31/2015) includes nationally representative surveys of residential care communities (RCCs) and adult day services centers (ADSCs). The primary goal of the survey component of NSLTCP is to provide a general purpose database on RCCs and ADSCs which researchers and policymakers can use to address a wide variety of questions. As a general purpose survey, it will provide broad descriptive data and does not presuppose any particular typology of communities/centers or residents/participants. The main focus is on RCCs and ADSCs, with the survey gathering as much information about their residents/participants as possible while keeping response burden low and within budget constraints.

While the survey content is similar and the data collection protocol is the same for RCCs and ADSCs, each provider type has its own universe and sampling methods. The remainder of this section discusses the universe definition, sampling frame, and sampling methods for RCCs followed by a corresponding discussion for ADSCs.

RCCs: NCHS will use the same definition for RCC in the 2016 NSLTCP as was used for defining a residential care community in the 2014 NSLTCP. As such, the following criteria will be used to determine the universe of RCCs which are eligible for selection in the 2016 NSLTCP survey:

Places that are licensed, registered, listed, certified, or otherwise regulated by the state to provide room and board with at least two meals a day, around-the-clock on-site supervision, and help with activities of daily living (e.g., bathing, eating, dressing) or health-related services (e.g., medication supervision); serve primarily an adult population; have at least four beds; and are serving at least one resident at the time of the survey.

The eligibility definition encompasses many types of RCCs, including assisted living places that arrange for personal care services from an outside vendor, as in Connecticut and Minnesota. Excluded are nursing facilities; facilities serving exclusively people with intellectual disabilities or developmental disabilities; group homes and residential care facilities serving exclusively people with severe mental illness; and other residential care settings where personal care or health related services are not arranged or provided. Unregulated communities are also excluded.

The sampling frame for the RCC component of the NSLTCP survey will be constructed from lists of licensed RCCs acquired from the licensing agencies in each of the 50 states and the District of Columbia in 2015 (OMB No. 0920-0912, Expires 7/31/16). State data on the number of licensed beds for each community and the licensure categories will be used to determine the list of eligible communities. The RCC sampling frame for NSLTCP will contain all of the state-licensed RCCs that are licensed for four or more beds. Based on the frame developed by RTI International in 2012 for the 2012 NSLTCP (OMB No. 0920-0912, Expired 1/31/13) and 2014 for the 2014 NSLTCP (OMB No. 0920-0912, Expired 7/31/16), we estimate that there are about 39,635 RCCs nationally.

NCHS aims for the sampling design for RCCs to enable reliable estimates to be made for (1) states, including the District of Columbia; (2) RCC bed size categories using the same definitions used for the 2010 NSRCF (small - 4 to 10 beds, medium - 11 to 25 beds, large - 26 to 100 beds, and extra large - more than 100 beds); (3) MSA status (metropolitan, micropolitan, neither); and (4) Census geographic regions (Northeast, Midwest, South, and West). Using the sample size estimates calculated to enable state-level estimation, the goal is to optimally allocate the sample to allow for as many state-level estimates as possible, while still providing sufficient sample sizes for estimates by Census region, MSA status and community bed size.

The expected response rate of 65% is based on the response rates in the 2012 and 2014 NSLTCP surveys and other recent mail surveys. For instance, the unweighted response rates of the 2010 and 2011 EMR/EHR mail components of NCHS’s National Ambulatory Medical Care Survey (NAMCS) were 68% (66% weighted) and 64% (61% weighted) (http://www.cdc.gov/nchs/data/databriefs/DB79.pdf). Although NCHS will make a concerted effort to obtain a minimum response rate of 65% using the mail/web/telephone protocol, if the actual response rate is lower this could result in states for which state-level estimates are not possible. The weighted response rates were 55.4% and 49.6% in 2012 and 2014, respectively. The eligibility rate was 67.1% in 2012 and 80.7% in 2014.

Following the strategy used in the 2012 and 2014 NSLTCP waves, the overall sample will be allocated to the four bed size strata: (1) to detect a 7 percentage point difference in medium, large, and extra large RCCs for two groups of RCCs of equal size. This difference can be for two groups of equal size within a size stratum (e.g. rural vs. urban large facilities), or two groups of equal size between strata (e.g. comparing %nonprofit between equal numbers of medium and large facilities). (2) to detect a 7 percentage point difference between small RCCs and RCCs of all other sizes, and (3) to detect an 8 percentage point difference between small and medium or large RCCs, all with 80% power.

For each primary stratum defined by bed size and state, RCC selection will be done by systematic random sampling from lists of RCCs in which the RCCs will be sorted by MSA status (metropolitan. micropolitan, neither) and randomly ordered within each MSA status.  Census regions are non-overlapping groups of states and by design, the sample will be sufficient to make census region-level estimates if the sample is sufficient to make state-level estimates. For the 2016 wave, as we did in 2014, we will assume a 17% RSE for a 30% estimate requires a minimum of 81 eligible completes per state and a census for states with insufficient providers to meet the minimum of 81completes.  If the response rates and eligibility rates for 2014 also hold in 2016, these assumptions will result in a sample size of 10,245. Because NCHS budgeted for a sample size of 11,690 (the same as the 2014 sample size), we will reallocate the remaining cases to states that were designated to be sample states. Our goal in reallocating the additional sample is to increase expected completes sufficiently for the sample states to assure that more state-level estimates are reportable. Given that response rates were relatively low among extra-large residential care communities (100 or more beds) and these communities disproportionately represented more residents, the reallocation was focused on the extra-large group: for all sample states, except California, all extra large communities were included in the sample. The remaining cases were allocated to the small and medium residential care communities (4 – 25 beds; 26 beds or more) such that estimates for this size category will be publishable (i.e., have RSEs 30 percent and have at least 30 completions) if the response rates and eligibility rates experienced in 2014 hold true in 2016.

We will be using 2014 eligibility rates and response rates by state and size categories to inform the sampling design needed to determine the expected numbers of 2016 completions.

ADSCs: Establishments eligible for the ADSC component of NSLTCP consist of:

Centers included in the 2015 National Adult Day Services Association’s data base and in operation; were licensed or certified by the State specifically to provide adult day services or authorized or otherwise set up to participate in Medicaid; had one or more average daily attendance of participants based on a typical week and one or more participants enrolled at the center at the location at the time of the survey.

The National Adult Day Services Association (NADSA), a professional trade association, is the leading voice of the rapidly growing adult day services industry and the national focal point for ADSCs (www.nadsa.org). According to NADSA, ADSCs provide a coordinated program of services for adults in a community-based group setting. Services are designed to provide social and health services to adults who need supervised care in a safe place outside the home during the day, and to provide respite for caregivers. ADSCs generally operate during normal business hours five days a week. Although each ADSC may differ in terms of features, most ADSCs provide social activities, transportation to/from the ADSC, meals and snacks, assistance with activities of daily living, and therapeutic activities such as exercise and mental interaction.

As we did for the 2012 and 2014 survey waves, the frames that NCHS will use for the ADSC component of the 2016 NSLTCP survey will be a comprehensive listing of ADSCs that NCHS will purchase from NADSA. Purchasing these lists from NADSA represents a substantial cost-savings over collecting, cleaning and concatenating licensing lists of ADSCs from each of the 50 states and the District of Columbia. In addition, the NADSA’s list include ADSCs located in states that do not license ADSCs. The 2015 NADSA list will be the most complete listing of ADSCs in the United States that NCHS is aware exists at this time. The approach that NADSA used in creating and maintaining the 2015 frame is inclusive; any program that self-identified as adult day care, adult day services, or adult day health services was included.  ADSCs were included if they offered socialization, nutritional support,   and “hands-on”   assistance with activities of daily living, at a congregate site, which had daytime hours. Hands on assistance could include offering an arm as support to the bathroom.  Frame construction started with an existing NADSA data base.  NADSA staff contacted all ADCSs to verify they were still providing adult day care, and updated the contact information.  Several methods were used to identify additional ADSCs.  These included contacting state government offices with oversight of ADSCs to identify ADSCs that met state requirements. Other ADSCs were identified through phone books, the internet, and state adult day services associations not affiliated with NADSA.

The goals of the survey for ADSCs is to enable reliable estimates to be made for (1) states, including the District of Columbia and (2) MSA status (metropolitan, micropolitan, neither). For the 2016 survey wave, we will field a census of ADSCs contained in the 2015 NADSA frame

2. Procedures for the Collection of Information

NSLTCP includes a series of mailings (Attachments E and F). The first step in data collection is mailout of the chain outreach package (Attachment F), which is sent for all RCC and ADSC cases that have been identified as being part of a national or regional chain. NCHS will then mail an advance notification letter on NCHS letterhead to directors of all RCC and ADSC cases (Attachment E-1). The letter will describe and encourage participation in the survey. The letter informs the RCC and ADSC directors that a survey packet, including a hard copy of the questionnaire and a link to the web survey that will be mailed to them in the next few weeks.

After sending the advance letter, NCHS will send the first questionnaire mailing packet (Attachments E-2 and F) that contains:

• a cover letter signed by the Director of NCHS (separate versions for RCCs and ADSCs),

• FAQs on the back of the cover letter (separate versions for RCCs and ADSCs)

• Resident/Participant data brief using 2014 NSLTCP data

• an NCHS brochure about confidentiality on surveys

• a hard copy of the survey questionnaire (separate versions for RCCs and ADSCs)

• a business reply envelope to return the hardcopy survey, and

• a letter of support from national provider associations (separate versions for RCCs and ADSCs).

The cover letter in the first questionnaire mailing will be personalized with the name of the RCC and ADCS directors. The letter will inform the administrator of the purpose and content of the survey. In addition to explaining the confidentiality of the information provided and the voluntary nature of participation, the letter includes a reference to the legislative authority for the survey and an explanation of how the data will be used. This letter will emphasize that data collected about the RCC or ADSC and its residents/participants will never be linked to their names or other identifying features and that the web survey is administered over a safe and secure network. The cover letter will provide a toll-free number that survey participants/respondents can call with any questions. Anticipated topics include problems logging in and questions about the survey. This toll-free number will be directed to the NSLTCP help desk.

The cover letter will also include the web survey URL and unique credentials for the director to access the web survey. Respondents can answer some questions, exit the questionnaire, and return later to the point where they stopped. The web questionnaire option will remain available until the end of the data collection period. The web link will also provide a pdf version of the questionnaire, so that respondents to the web survey can see all questions prior to completing the survey by web.

On the back of the cover letter are frequently asked questions (FAQ), designed to address what are expected to be the primary concerns of RCC and ADSC directors and staff.

The first questionnaire mailing will include a hardcopy of the survey questionnaire with a pre-addressed, postage-paid return envelope. Attachments D-1-D-4 contain a current list of questionnaire items. We plan to have two versions of the RCC and ADSC questionnaires with select items on a version A questionnaire and select items on a version B questionnaire. We have highlighted those select items in the Attachments D-1-D-4. We estimate that it will take 30 minutes on average to answer the questionnaire.

The letters of support were obtained from associations that represent RCCs and ADSCs. We have sought and obtained support from the following organizations:

• RCC provider associations

  • The Center for Excellence in Assisted Living (CEAL)

  • LeadingAge

  • American Seniors Housing Association (ASHA)

  • Argentum (formerly the Assisted Living Federation of America)National Center for Assisted Living (NCAL)

• ADSC provider associations

  • National Adult Day Services Association (NADSA).

  • LeadingAge

  • National Association of States United for Aging and Disabilities (NASUAD)

After the first questionnaire mailing, NCHS will send a reminder/thank you letter to RCCs and ADSCs (Attachment E-3). This reminder/thank you letter informs RCC and ADSC directors that a survey packet was sent recently, encouraging them to participate in the survey, and thanking those who have already responded.

After the reminder/thank you letter is sent, there will be two follow-up mailing packets (Attachments E-4, E-5 and F) to initial non-respondents that contain the same materials as the first questionnaire mailing but with a slightly modified cover letter and envelope. Small RCCs will get a unique first follow-up cover letter and will not receive the second follow-up mailing because we plan to start CATI a month early for them.

About two months into the field period, NCHS will contact directors of small RCCs to administer the CATI survey when they are non-responders to the mail and web surveys. A month later into the field period, NCHS will contact the remaining non-responding RCC and ADSC directors to administer the CATI survey. The CATI survey questionnaire has the same content as the mail/web versions.

There will also be data retrieval calls to RCC and ADSC directors who have submitted hard copy questionnaires with missing information for critical items (Attachment H). Critical items are limited to a small set of eligibility screener items located at the beginning of each ADSC and RCC questionnaire. In terms of respondent burden, we have assumed that retrieval telephone calls will average 5 minutes and that no more than 5% of cases will require retrieval.

The hardcopy questionnaire will not have check boxes for “don’t know” except for one item (on HIPAA because we expect some directors may not know if their ADSC or RCC is a HIPAA-covered entity). If the respondent has left any critical items blank, written “don’t know” for the item, or provided an answer that is inconsistent with another question, NCHS’ contractor will review the case data. If they can logically resolve the issue using decision rules approved by NCHS, they will edit the case data (saving the original version of the data) and retrieval will not be undertaken. However, if the contractor cannot resolve the issue using these decision rules, the case will be set for data retrieval and loaded into the CATI system. CATI interviewers will perform the retrieval for non-complex retrievals. As noted previously, complex retrievals will be handled by contractor project staff. Retrievers (interviewers and other contractor staff) will attempt to collect answers to all missing critical items. If the respondent indicated “refusal” on a critical item, no action will be taken.

Training interviewing staff is an important requirement for implementing the NSLTCP data collection effort. The general training covers standardized contacting and interviewing skills and educates interviewers on the concepts of data confidentiality and data security. This training is available as an interactive web-based self-learning program that interviewers access over the internet. It includes quizzes on each topic covered to assess the interviewers’ understanding of the information.

Prior to project-specific training, all interviewers will be provided an NSLTCP Telephone Interviewer Manual and will be required to complete a home study exercise using their manual. We have found that requiring the completion of the home study exercise before training helps to familiarize trainees with background information, project terminologies, and job expectations.

Project-specific trainings will be conducted over 2 days immediately before CATI production is scheduled to begin in July and August. Trainings will be conducted in a state-of-the-art training facility located in Raleigh, North Carolina.

Training materials will include a manual for telephone interviewers, a manual for Quality Control Supervisors, a training agenda, a training guide with PowerPoint presentation, FAQs for answering respondent questions, mock scenarios for averting/converting refusals, mock interview scripts for conducting the NSLTCP interview, mock scripts for conducting data retrievals, and job aids to assist interviewers in their work.

At the end of training, interviewers must be certified for data collection by successfully completing a certification interview. Certification will be conducted by approved project personnel who will evaluate the interviewers’ mastery of the required skills and knowledge for NSLTCP. The certification process will consist of:

• a brief oral exam covering selected FAQs to ensure that Interviewers are able to answer the most frequently asked questions from survey participants/respondents;

• a full-length mock interview with another trainee under the observation of project staff to demonstrate knowledge of proper interviewing techniques;

• a mock interview with another trainee under the observation of project staff to demonstrate knowledge of retrieval and callback procedures; and

• a short exercise on selecting appropriate event (disposition) codes and working in CATI to demonstrate knowledge of how to work in the data collection systems.

The period of data collection is scheduled to last from May 2016 to mid-November 2016. Field staff will closely monitor RCCs/ADSCs that have not responded to the mail or web surveys. There will be a very strong effort during the first wave of contacts, followed by persistent follow-up. CATI fielding is expected to start for nonresponding small RCCs in July 2016 and for all other nonresponding cases in August 2016. During the CATI portion of the survey protocol, a maximum of six contact attempts (calls) will be made before a case will be considered as a noncontact or refusal. Each sampled case will receive the same field effort needed for contact and response. NCHS will receive weekly production reports from its contractor that will show the contact/response trends at the national and state levels and help to identify problem spots at as early a stage in the data collection process as is feasible.

After the data have been processed, post-data collection edit checks have been completed, and weights have been developed, NCHS plans to create Research Data Center (RDC) restricted data files for the RCC and ADSC versions of the survey. All data will be weighted to national estimates—and where feasible state estimates--using the inverses of selection probabilities (for states using a sampling design), and adjusting for non-response. Sampling errors are computed using the linearized Taylor series method of approximation as applied in the SUDAAN software package.

3. Methods to Maximize Response Rates and Deal with Nonresponse

NCHS will make every reasonable attempt to encourage completion of NSLTCP. To maximize response rates, NCHS will use methods similar to those used in previous establishment surveys (e.g., 2012 and 2014 NSLTCP, National Survey of Residential Care Facilities, National Home and Hospice Care Survey, National Nursing Home Survey). To this end, we will use the refusal aversion techniques described below.

Robust mailout materials. NSLTCP’s questionnaire mailout packets convey the legitimacy of the study and help respondents understand the relevance and importance of the survey. The materials and FAQs are based on those used successfully in the 2012 and 2014 NSLTCP (OMB No. 0920-0943).

Low burden. We estimate that it will take 30 minutes on average to answer the current list of questionnaire items (Attachments D-1-D-4). We plan to have two versions of each questionnaire, with select items on a version A questionnaire and select items on a version B questionnaire. We have highlighted those items in Attachments D-1- D-4.

Multimode approach. The hardcopy and web modes offer RCCs/ADSCs the flexibility to complete the survey at their convenience. Sessions can be stopped and restarted as needed. The web mode option further reduces burden by giving the respondent only questions that apply to them based on previous responses in the questionnaire, eliminating the need for future data retrieval calls by requiring all screener items to be answered in order to progress through the instrument, and giving the respondent the option to save or print a copy of their completed web questionnaire for their records.

Industry outreach. NCHS has contacted and will continue outreach efforts to national long-term care provider associations representing the RCC and the ADSC industries to inform them of the survey and ask for their support. NCHS is working with these organizations to share information about the study with their state member affiliates and publicize the study in newsletters.

Chains outreach. We will send an outreach package with a cover letter, signed by the NCHS Director, to the corporate office of national and other large chains affiliated with one or more sampled RCCs and the five largest chains for ADSCs (Attachment F). The letter briefly describes the study and explains that one or more members of their organizations will be contacted to participate. This letter also requests that they allow and encourage members of their organization to complete the survey if it is sent to them as well as provides a link where they can view a PDF of the questionnaire. This letter will also help CATI Interviewers to convert/avert refusals. The package also includes an NCHS data brief, an NCHS brochure about confidentiality on surveys, a hard copy of the survey questionnaire (separate versions for RCCs and ADSCs), and letters of support from national provider associations (separate versions for RCCs and ADSCs).

CATI follow-up. Some sample members will not be persuaded to complete a survey using only mailing or web techniques. Telephone work will be required, and the CATI follow-up is therefore an important part of NSLTCP’s refusal aversion/conversion program. It is important that the CATI Interviewers be extremely professional, efficient, and convey to respondents the legitimacy and importance of the survey for U.S. LTC policy. Interviewers will be trained how to convey the importance of this work.

Early CATI for small RCCs. In 2016 we will implement CATI nonresponse follow-up a month early for small RCCs instead of sending them a third questionnaire packet. We believe that devoting more time to CATI, the mode that most mimics in-person interviews, will help to increase response rates among the smaller RCCs.

Use of Proxies. In 2016, we will use proxies to complete the eligibility questions in situations when it is difficult to reach the director or administrator and there is the risk of a non-complete. We will identify a qualified proxy to complete the eligibility questions—an assistant director, director of nursing, owner, operator, or manager knowledgeable about the services offered and the residents or participants the RCC/ADSC serves. If the RCC/ADSC is eligible, we will include instructions for CATI interviewers to either continue with the interview--if the proxy is qualified to answer the remaining survey questions--or break off and ask the proxy to suggest a good time and the best telephone number to reach the director or administrator so that the CATI interviewer can schedule a soft appointment to call back to complete the questionnaire.

Emailing Respondents. In 2016, we will email approximately 500 ADSCs that provided their email addresses when they participated in the 2014 NSLTCP. When the first questionnaire mailing and the first follow-up questionnaire mailing are sent to these cases, we will at the same time email these ADSC cases with similar content as the mailings (See Attachments E-2 and E-4), except without the hardcopy questionnaire or business reply envelope. The email letter and the mailing cover letter will each reference the other. We expect that emailing respondents in this way will help to increase response rates among ADSCs, particularly for web completion.

Methods Experiments. In an effort to determine ways to further maximize response rates, NCHS is including two experiments in NSLTCP. As with the experiments built into the 2012 and 2014 NSLTCP survey waves, NCHS aims for the results of the 2016 experiments to contribute to building an evidence base for fielding the survey component of NSLTCP in future years, as well as to the establishment survey literature more generally.

Experiment 1: Advance letter

For its provider surveys, NCHS has historically included in its respondent contact materials an advance letter that notifies the respondents that they have been selected to participate in the survey, the importance of their participation, as well as some technical reference to laws that empower NCHS to conduct the survey. The rationale for referencing the data collection laws in the letter, according to conventional wisdom, is that respondents will be more willing to participate in the survey if they can see the legal authority of the data collection agency. NCHS has included this information in the advance letter believing that doing so increases response rates. The same information is also included in the cover letter that goes with the questionnaire mailings. However, with generally decreasing response rates and the time commitment to read all the technical information in multiple letters (advance letter, cover letters), it is possible that prospective respondents lose interest in reading the technical advance letter and thereby disregard participation. In addition, the legal references in the advance letter may turn off some respondents, who then avoid or discard the subsequent survey mailings. NCHS would like to conduct an experiment to assess whether sending a shorter and less technical advance letter is more welcoming to a prospective respondent and leads to higher response rates, compared to a more technical advance letter as used in earlier fielding, or not sending any advance letter.

Below is a schematic of the design.

ADSC			RCC
No advance letter	Less technical advance letter	Technical advance letter as used in 2014	No advance letter	Less technical advance letter	Technical advance letter as used in 2014
Treatment group Al	Treatment group A2	Control group	Treatment group Rl	Treatment group R2	Control group

The above design will be done for ADSCs and RCCs. This experiment will randomly assign ADSCs and RCCs to one of the treatment groups or the control from among a pool of all ADSCs and RCCs that have not received any special protocol (i.e., small RCCs, ADSC cases where 2014 email is used). For ADSCs, this will include cases that have not been contacted by email. For RCCs, this will include medium, large, and extra­ large RCCs. Small RCCs are excluded from this experiment because smalls will be worked through a special protocol to implement early CATI. Cases will be randomly assigned to one of the three groups using the following approach: 1. Using the random number generator in SAS each case will be assigned a random number; 2.All cases will be sorted on the random number; and 3. The first third of the cases, after sorting, will be assigned to the control group, second third to treatment group 1 and final third to treatment group 2.The advance letters for Experiment 1 are in Attachment E-1.

Experiment 2: Using Fedex for the Second Follow-up Questionnaire Mailing

In the 2012 fielding of the NSLTCP, NCHS used FEDEX to mail the advance letter and questionnaires to prospective respondents. This decision was based on the expectation that a FEDEX packet would carry more importance than a regular USPS packet and be more visible to prospective respondents, thereby increasing the likelihood of completing the survey. However, this protocol was revised in 2014 to use USPS instead of FEDEX for the mailings as a cost-saving mechanism and because some 2012 cases complained about receiving FEDEX packages. During the 2014 fielding, many directors/administrators indicated that they had not received the advance letter and other mailings that were sent through USPS. In 2016, NCHS would like to conduct an experiment to assess if using FEDEX for only the second follow-up mailing increases response rates.

Below is a schematic of the design.

ADSC		RCC
2nd follow-up questionnaire mailing using FEDEX	2nd follow-up questionnaire mailing using USPS	2nd follow-up questionnaire mailing using FEDEX	2nd follow-up questionnaire mailing using USPS
Treatment group Al	Control group	Treatment group Rl	Control group

The above design will be done for ADSCs and RCCs. This experiment will randomly assign ADSCs and RCCs to treatment and control groups, from among a pool of ADSCs and RCCs that have not received any special protocol and are non-respondents by a set date after the 1st follow-up questionnaire mailing (the date will be set by discussion between NCHS and the contractor). For ADSCs, this will include cases that have not been contacted by email. For RCCs, this will include medium, large, and extra-large RCCs. Small RCCs are excluded from this experiment because smalls will be worked through a special protocol to implement early CATI. Using a similar technique as used in experiment 1, cases will be randomly assigned using the following approach: 1. Using the random number generator in SAS each case will be assigned a random number; 2. All cases will be sorted on the random number; and 3. The first half of the cases, after sorting, will be assigned to the control group and the second half assigned to treatment group 1.

Despite efforts to avert refusals, refusals can be expected. CATI staff will be trained so that if they encounter a potential refusal, they will listen to the concerns raised and attempt to address these concerns. When appropriate, CATI staff will provide a few weeks’ cooling off period before they contact RCCs and ADSCs again. CATI staff will provide detailed notes of these exchanges, and discuss the best course of action. In some cases, NCHS staff and/or senior staff at the NCHS contractor organization will be involved.

The overall target response rate for the mail/web/telephone survey is at least 65 percent. After the field period ends, NCHS will assess nonresponse bias by examining how much the respondents and nonrespondents differed on key relevant variables available from the respective RCC and ADSC frames. These include bed size (for RCCs only), Census geographic region (Northeast, Midwest, South, and West), and MSA status (metropolitan or nonmetropolitan). Because CATI is being used as a follow-up for non-respondents to the mail and web surveys, CATI responders may be considered as a late responder and possibly as non-responder had CATI not been included in the protocol. With that in mind, as another way to examine nonresponse bias, NCHS will also examine whether there are differences between mail/web respondents and CATI respondents in their survey responses.

4. Tests of Procedures or Methods to be Undertaken

The current lists of survey question items are in Attachments D-1 and D-2. The majority of the 2016 NSLTCP survey question items have been (1) drawn from previously fielded NCHS LTC provider surveys (NNHS, NHHCS, NSRCF or NSLTCP) and (2) evaluated through expert questionnaire appraisal.

Internally NCHS staff, including staff in NCHS’s Collaborating Center for Questionnaire Design and Evaluation Research (formerly known as the QDRL), reviewed the 2014 instrument and/or draft 2016 question lists and provided feedback. Externally, experts from organizations such as the office of the Assistant Secretary of Planning and Evaluation within DHHS and provider membership associations such as the National Center for Assisted Living, LeadingAge, and the National Adult Day Services Association (NADSA) gave input on the wording of selected new and existing NSLTCP question items.

Based on the internal and external review, NCHS revised selected NSLTCP survey question items (Attachments C-1 and C-2). Question item changes included the following types of revisions:

• Wording changes to address problems 2014 respondents had understanding the intent of the question or answering the question correctly, or difficulties encountered for other reasons;

• Revising response categories to more closely align with expected analytic groupings and to address respondent queries about response options.

• Adding items on topics that reviewers saw as gaps in the substantive areas of NSLTCP.

5. Individuals Consulted on Statistical Aspects and Individuals Collecting and/or Analyzing Data

The following government employee is responsible for oversight on the design and implementation of this collection:

NCHS

Lauren Harris-Kojetin, Ph.D.

Chief, Long-Term Care Statistics Branch

National Center for Health Statistics

3311 Toledo Road, Room 3431

Hyattsville, Maryland 20782

Phone: (301) 458-4369

Fax: (301) 458-4350

E-Mail: lharriskojetin@cdc.gov

RTI International is NCHS’ contractor for the implementation of the survey data collection component for NSLTCP. The following RTI person oversees this contract:

Angela M. Greene, M.A.

Project Director

Program on Aging, Disability and Long-Term Care

RTI International

P.O. Box 2194

RTP, NC 27709

(919) 541-6675 (voice)

(919) 990-8454 (fax)

amg@rti.org

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