2018 Supp Statement B 10APR2018

Supporting Statement B for Paperwork Reduction Act Submission for

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: 5/31/2019

Revision Package

February 21, 2018

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 Individuals Collecting

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

Attachments

Attachment A Public Health Service Act (306ab and 308d)

Attachment B Sixty-day Notice in Federal Register

Attachment C-1 ADSC Provider Questionnaire Items

Attachment C-2 RCC Provider Questionnaire Items

Attachment C-3 Services User Questionnaire Items

Attachment D External Expert Reviewers

Attachment E Protocol Flow Chart

Attachment F  Contact Confirmation Call Script

Attachment G-1 Advance Package-NCHS Cover Letter with FAQs

Attachment G-2 Advance Package Resident and Participant NCHS Data Briefs

Attachment G-3 Advance Package Letters of Support

Attachment G-4 Advance Package ERB Approval Letter

Attachment G-5 Advance Package NCHS Strictly Confidential Brochure

Attachment H Screening and Appointment Setting Script

Attachment I-1 First Provider Questionnaire Email or Mail Text

Attachment I-2 Provider Questionnaire Follow-up Email or Mail Text

Attachment I-3 Provider Questionnaire Thank You Email or Mail Text

Attachment J Services User CATI Confirmation and Prep Email or Mail Text

Attachment K Services User CATI Call and Sampling Instructions Script

B. Collections of Information Employing Statistical Methods

1. Respondent Universe and Sampling Methods

The National Study of Long-Term Care Providers (NSLTCP) (OMB No. 0920-0943 Exp. Date 5/31/2019) 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 their residents and ADSCs and their enrolled participants 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 RCC communities/ADSC centers or residents/participants.

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 2018 NSLTCP as was used for defining a residential care community in the 2016 NSLTCP. As such, the following criteria will be used to determine the universe of RCCs which are eligible for selection in the 2018 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 RCCs that are licensed, registered, listed, certified, or otherwise regulated by the state, acquired from the licensing agencies in each of the 50 states and the District of Columbia in 2017 (OMB No. 0920-1030, Exp. Date 04/30/2020). 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.

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

Centers included in the National Adult Day Services Association’s data base and in operation; were licensed or certified by the State specifically to provide adult day services, accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), authorized or otherwise set up to participate in Medicaid, or part of a Program of All-Inclusive Care for the Elderly (PACE); had one or more average daily attendance of participants based on a typical week; and, had 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 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, 2014, and 2016 NSLTCP, the frame that NCHS will use for the ADSC component of the 2018 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 list includes ADSCs located in states that do not license ADSCs. The 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 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 ADSCs 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.

Two separate random national samples, one of RCCs and the other of ADSCs, will be drawn from among the universe of these providers on the two respective sector-specific frames.

The 2018 NSLTCP will involve a two-stage probability-based sample design. In the first stage, stratified (by Census Region) samples of providers (RCCs and ADSCs) will be selected using systematic random sampling; in addition to explicit stratification by region, the providers will be sorted by bed size categories (RCCS only) and MSA. The second stage will involve the selection of current residents/participants from these providers. Within each eligible, participating ADSC/RCC, a random sample of two participants/residents will be selected.

The resident/participant sampling list will be prepared from the sampled RCC’s/ADSC’s resident/participant census as of midnight the day before the date of the telephone interview.

Collecting individual services user-level data requires that a sample of participants be selected in each participating ADSC and a sample of residents be selected in each participating RCC, which raises challenges for a self-administered mail or web survey. In the absence of an in-person interviewer being present to assist with or perform the sampling routine, the sampling procedure must be simple enough for the busy ADSC or RCC director to be willing and able to follow and not be burdensome. To assess the feasibility of randomly selecting services users without the assistance of an in-person field interviewer, and correctly completing the steps involved in sampling via a telephone protocol, NCHS conducted a feasibility project in 2016 (OMB No. 0920-1030 Exp. Date 04/30/2020). Key findings from the feasibility project included: correct sampling is feasible, respondents received and used show cards when needed for selected survey items, but many respondents were not willing to spend an hour on the telephone for the services user sampling and data collection stage. Results from the feasibility project have informed the protocol for the 2018 service user-level data collection. In particular, the 2018 protocol has been designed in order to limit the services user sampling and data collection telephone interview to a maximum average of 30 minutes (10 minutes for sampling and 20 minutes for collecting data about two residents/participants). In the debriefing questions for the feasibility project, participants said they were not willing to give more than an hour on the phone. To achieve this goal, we will sample only two services users per provider, and separate the provider questionnaire and screening questionnaire into separate stages from the services user sampling and data collection telephone call.

Since the NSLTCP is a general purpose survey, no specific outcomes were used to prepare the sample size and precision requirements, but rather conservative estimates of the subgroup comparison tests were calculated. The sample sizes for ADSCs and RCCs are based on the ability to detect a 7% point difference in residents with 80% statistical power between two groups of ADSCs/RCCs with equal size. These resident groups were defined by various characteristics, such as race, ADLs emergency department visits.

All data will be weighted to national estimates using the inverse selection probabilities. Because the 2018 NSLTCP uses sample surveys, data analyses must include survey weights, to inflate the sample numbers to national estimates. The weight associated with each sampled provider and each sampled services user is constructed to account for the multistage sampling design. The final weight for each sampled unit (provider or services user) is the product of two components: 1. inverse of the probability of selection and 2. nonresponse adjustment. The first component of the weight for each sampled unit is the inverse of the unit’s selection probability. For the services user, the selection probability is the product of two selection probabilities: the probability of selecting the provider to the sample and the probability of selecting the services user within the sampled provider. The inverse of the product of these probabilities is used for weighting. The second component for calculating the weight is adjustment for nonresponse. This adjustment is made for three types of nonresponse. The first two types are provider level, and the third is services user level. The first type occurs when in-scope providers do not respond to NSLTCP. In NSLTCP, the second type occurs when an in-scope provider does not provide the number of current services users within the respective provider. The third type occurs when the provider does not provide information requested in the survey about the sampled services user. Adjustments for unknown eligibility and non-response will be applied to the RCC/ADSC selection weights to obtain unbiased estimates of the number of eligible RCCs and current residents and ADSCs and current participants in the U.S.

. In 2012, NSLTCP response rates were 67% for ADSCs and 60% for RCCs; 2014 saw a decline in the response rates to 58% for ADSCs and 54% for RCCs; and in 2016, the response rate improved for ADSCs to 62% and decreased slightly for RCCs at 51%. Because we are assuming response rates of less than 90%, non-response bias analysis will be conducted and non-response adjustments will be necessary for the provider and resident/participant analysis weights. The standard errors of the outcome estimates will be computed by NCHS staff using SUDAAN software.

2. Procedures for the Collection of Information

The steps in the protocol are laid out in Attachment E. After a sample of RCCs and ADSCs are selected, the main sequential steps in the multi-mode data collection protocol will be as follows:

• Contact confirmation call (Attachment F) will be done for each sampled provider to confirm ADSC/RCC name and mailing address; and, to confirm or obtain director’s name, title, telephone number, and email address for future contact during the field period.

• Advance package (Attachments G-1 – G-5) will be mailed to sampled directors to provide information about the study (including all elements of informed consent), establish study legitimacy, and indicate that they will be called soon. It will contain the following:

  • An NCHS cover letter with all elements of consent, confidentiality assurance, FAQs, explanation of the project, what respondents will be asked to do, and that a project team member will be contacting them soon (Attachment G-1).

  • 2016 NSLTCP participant or resident data brief, respectively (Attachment G-2)

  • Letter of support from provider associations, respectively (Attachment G-3)

  • ERB approval letter (Attachment G-4)

  • NCHS Strictly Confidential Brochure (Attachment G-5)

• Screener call (Attachment H) will be conducted by computer-assisted telephone interviewing (CATI) starting 3 days after sending the package via UPS advance delivery, to determine ADSC/RCC eligibility and, for the eligible cases, schedule an appointment to complete the services user sampling and data collection and determine whether the provider questionnaire will be completed by web or mail.

• Provider questionnaire (Attachments C-1 and C-2) will be completed either by web or mail and the contact steps involved will vary by mode. The following paragraph describes the contact steps for the completion of the Provider questionnaire.

• First Provider Questionnaire email or mailing (Attachment I-1)

For eligible respondents who are interested in completing the Provider questionnaire by web and have provided an email contact (Approach A in Attachment E), a Provider Web Questionnaire Email (including url and login information) will be sent to them and the services user CATI interview will be set 4-10 weeks away. The email will also include instructions for filling out the Provider questionnaire, a request to send it back within two weeks, and a reminder of the date and time for the Services user CATI interview to do services user sampling and data collection. The respondent will also be alerted during the screener call that the Provider questionnaire needs to be completed before the Services user CATI call can take place, and that they will receive reminder emails if the Provider questionnaire is not submitted by 2 weeks. For eligible respondents who do not want to complete the Provider questionnaire by web or do not have email (Approach B in Attachment E), the Provider questionnaire will be mailed, along with instructions for filling out the questionnaire, instructions for returning it within four weeks, and a reminder of the date and time for the Services user CATI call. For Approach B respondents, a services user CATI call will be scheduled 8-10 weeks away, to allow time to mail out/back the Provider questionnaire and for follow-up for nonresponse on the Provider questionnaire.

• Provider Questionnaire Follow-ups by email, mail, or CATI (Attachment I-2) Respondents opting to complete the Provider questionnaire by web will receive 3 follow-ups and those opting for mail will receive 2 follow-ups. For the group opting to complete the Provider questionnaire by web (Approach A in Attachment E): (1) the first follow-up email will be sent if the Provider web questionnaire is not received by 10 business days after the screener and set appointment call, (2) the second follow-up email will be sent if the Provider web questionnaire is not received by 10 business days before the scheduled Services user CATI call, and (3) the third follow-up will be using the scheduled Services user CATI call to prompt the respondent to complete the provider web questionnaire and reschedule the Services user CATI call.

For the group opting to complete the Provider questionnaire by mail (Approach B in Attachment E): (1) the first contact will be through email (if available) or UPS to remind respondents to complete the provider mail questionnaire if it is not received by 4 weeks after the Provider mail questionnaire packet was sent, and (2) the second contact will be using the scheduled Services user CATI call to prompt the respondent to complete the provider questionnaire and reschedule the Services user CATI call.

• Provider Questionnaire Thank you (Attachment I-3)

Within 3 business days of receiving the provider questionnaire by web or mail, a thank you email (if have email address) or letter (if not have email address) by USPS 2-day priority mail will be sent to the respondent.

• Services user CATI confirmation and prep email or mail (Attachment J) will be sent to arrive 5 business days before the services user CATI appointment. UPS Next Day delivery with tracking will be used if no email is available. This email/letter will confirm the date and time of call, and provide instructions for preparing the list of services users.

• Services user CATI call (Attachments K and B-3)—the final step in study participation for respondents—will involve sampling of two services users and answering questions about the selected services users. The Services user CATI call will only be done for cases after they have submitted the Provider questionnaire, either by mail or web. Directors or their designated staff are the target respondents; residents/participants will not be contracted.

The entire process of completing the contact confirmation call (5 mins), screener and appointment setting phone call (15 mins), Provider questionnaire (30 mins), and Services user sampling and questionnaires CATI interview (30 mins) is estimated to take on average 80 minutes per eligible respondent.

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.

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 include:

• 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; 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.

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 round of contacts, followed by persistent follow-up. During the CATI portions 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. NCHS will receive weekly production reports from its contractor that will show the contact/response trends 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 and public-use data files for the RCC and ADSC versions of the survey. All data will be weighted to national estimates. 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, 2014, and 2016 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 are designed to 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, 2014, and 2016 NSLTCP (OMB No. 0920-0943).

Low burden. We estimate that it will take a total of 60 minutes on average to answer the current list of provider and services user questionnaire items (Attachments C-1-C-3).

Multimode approach. The hardcopy and web modes offer RCCs/ADSCs the flexibility to complete the Provider 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 member affiliates and publicize the study in newsletters.

CATI. Telephone surveying will be part of the 2018 NSLTCP. It is important that the CATI Interviewers be extremely professional, efficient, and convey to respondents the legitimacy and importance of the survey. Interviewers will be trained how to convey the importance of this work.

Use of Proxies. In 2018, we will use proxies to complete the surveys 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 surveys—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 2018, we will use email for directors/administrators of RCCs and ADSCs that consent to that form of contact. We expect that emailing respondents will help to increase response rates, particularly for web completion of the Provider questionnaire.

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).

4. Tests of Procedures or Methods to be Undertaken

The current lists of survey question items for the Provider questionnaire and the Services User questionnaire are in Attachments C-1 through C-3. The majority of the 2018 NSLTCP survey question items have been (1) drawn from previously fielded NCHS LTC provider surveys (NNHS, NHHCS, NSRCF or NSLTCP) and (2) evaluated by subject matter experts.

Internally NCHS staff reviewed the 2018 instrument and/or draft 2018 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 (see Attachment D).

Based on the internal and external review, NCHS revised selected NSLTCP survey question items (Attachments C-1 through C-3). Question item changes included the following types of revisions:

• For previously used questions:

  • wording changes to address problems 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.

• New for 2018, adding items to the services user questionnaires.

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

1