2024 NPALS SS B 070824_final

Supporting Statement B for Paperwork Reduction Act Submission for

Revision

Data Collection for the Residential Care Community and Adult Day Services Center Components of the National Post-acute and Long-term Care Study

OMB No. 0920-0943

Exp. Date: 07/31/2025

Manisha Sengupta, Ph.D.

Acting Chief, Planning and Operations Branch

Division of Health Care Statistics

National Center for Health Statistics

Phone: 301.458.4754

Email: msengupta@cdc.gov

July 8, 2024

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

List of Attachments

Attachment A Authorizing Legislation

Attachment B-1 Sixty-day Notice in Federal Register

Attachment C-1 2024 RCC Questionnaire

Attachment C-2 2024 ADSC Questionnaire

Attachment D-1 2024 RCC Question Changes

Attachment D-2 2024 ADSC Question Changes

Attachment E Advance Notification NCHS Letter with FAQs

Attachment F-1 Questionnaire Packet NCHS Letters with FAQs

Attachment F-2 Resident and Participant Data Briefs

Attachment F-3 Letter of Support

Attachment F-4 Confidentiality Brochure

Attachment G Thank You/Reminder Letters and Emails

Attachment H Data Retrieval Call

Attachment I Human Subjects Determination/ERB Letter

B. Statistical Methods

1. Respondent Universe and Sampling Methods

The National Post-acute and Long-term Care Study (NPALS), formerly known as the National Study of Long-Term Care Providers or NSLTCP (OMB No. 0920-0943 Exp. Date: 07/31/2025) includes nationally representative surveys of residential care communities (RCCs) and adult day services centers (ADSCs). The primary goal of the survey component of NPALS is to provide a general purpose database on RCCs and ADSCs that 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 and the data collection protocol are similar 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 2024 NPALS as was used for defining a residential care community in the 2022 NPALS. As such, the following criteria will be used to determine the universe of RCCs that are eligible for selection in the 2024 NPALS 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 NPALS 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 2023 (OMB No. 0920-1030, Exp. Date 02/28/2026). 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 NPALS 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 2022 for the 2022 NPALS, we estimate that there are about 46,049 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 target response rate is 55%. This is based on the response rates in the previous waves and other recent mail surveys which were similar in design to the planned 2024 NPALS. Although NCHS will make a concerted effort to obtain a minimum response rate of 65% using the mail/web protocol, if the actual response rate is lower this could result in states for which state-level estimates are not possible.

Following the strategy used in the all the previous 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 percent 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 2024 wave, as we did in 2020, 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 2016 and 2020 also hold in 2024, these assumptions will result in a sample size of 10,245. Because NCHS budgeted for a sample size of 11,600 (the same as the 2020 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, where 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 experienced in 2016 and 2020 hold true in 2024.

We will be using 2020 eligibility rates and response rates by state and size categories to inform the sampling design needed to determine the expected numbers of 2024 completions.

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

Centers included in the 2024 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 accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), or authorized or otherwise set up to participate in Medicaid (Medicaid state plan, Medicaid waiver, or Medicaid managed care), or part of a Program of All-Inclusive Care for the Elderly (PACE); and 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 previous survey waves, the frames that NCHS will use for the ADSC component of the 2024 NPALS 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 2024 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 2024 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 database. 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 2024 survey wave, we will field a census of ADSCs contained in the 2024 NADSA frame.

2. Procedures for the Collection of Information

NPALS includes a series of mailings (Attachments E and F). The first step in data collection is mailout of an advance notification letter on NCHS letterhead to directors of all RCC and ADSC cases (Attachment E). 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, will be mailed to them in the next few weeks.

After sending the advance letter, NCHS will send a questionnaire mailing packet (Attachments F-1 to F-4) that will contain:

• a cover letter signed by the Director of NCHS (separate versions for RCCs and ADSCs) (Attachment F-1)

• FAQs on the back of the cover letter (separate versions for RCCs and ADSCs) (Attachment F-1)

• A resident/participant data brief using 2020 data (Attachment F-2)

• an NCHS brochure about confidentiality in surveys (Attachment F-4), and

• a letter of support from national provider associations (separate versions for RCCs and ADSCs) (Attachment F-3).

The cover letter in the advance packet 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 NPALS help desk.

The cover letter will also include the web survey URL and unique credentials for the director to access the web provider questionnaire. 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 letters of support were obtained from associations that represent RCCs and ADSCs and include the following organizations:

• RCC provider associations

  • The Center for Excellence in Assisted Living (CEAL)

  • LeadingAge

  • American Seniors Housing Association (ASHA)

  • Argentum

  • National Center for Assisted Living (NCAL)

• ADSC provider associations

  • National Adult Day Services Association (NADSA).

  • LeadingAge

  • ADvancing States

After the first questionnaire mailing, NCHS will send a reminder/thank you letter to RCCs and ADSCs (Attachment G). 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. For respondents that we obtain email addresses, we will also email the reminder/thank you letter.

After the reminder/thank you letter is sent, there will be three follow-up mailing packets (Attachments F-1 to F-4) to initial non-respondents that contain a slightly modified cover letter with FAQs and a hard copy of the questionnaire. Respondents will be referred to the NPALS website where they can find the data brief, confidentiality brochure, and letter of support that were in the first questionnaire mailing. In between these three follow-up mailings, a second reminder/thank you letter will be sent (Attachment G). For respondents that we obtain email addresses, we will also email the reminder/thank you letter.

Later into the field period, NCHS will contact non-responding RCC and ADSC directors by telephone to prompt them to complete the questionnaire.

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 I). 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.

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. 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 does not answer a critical item, no action will be taken.

The entire process of completing the questionnaire is estimated to take on average 30 minutes per eligible respondent.

Training interviewing staff is an important requirement for implementing the NPALS 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 NPALS 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. Trainings will be conducted virtually.

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 NPALS prompting and data retrieval calls, and job aids to assist interviewers in their work.

At the end of training, interviewers must be certified 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 NPALS. 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 prompting and data retrieval call 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 September 2024 to March 2025. 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. 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 the earliest 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, 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 NPALS. To maximize response rates, NCHS will use methods similar to those used in previous establishment surveys (e.g., 2012-2022 NSLTCP/NPALS, 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. NPALS’s advance and questionnaire 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 previous waves (OMB No. 0920-0943).

Low burden. We estimate that it will take 30 minutes on average to answer the questionnaire items (Attachments C-1-C-2).

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 missing data 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.

CATI prompting. 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 NPALS’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.

Use of Proxies. In 2024, we will use proxies 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—an assistant director, director of nursing, owner, operator, or manager knowledgeable about the services offered and the residents or participants the RCC/ADSC serves.

Emailing Respondents. In 2024, we will email respondents that provide an email address. We will email these cases thank you/reminder letters (See Attachment G). We expect that emailing respondents in this way will help to increase response rates, particularly for web completion.

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 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). NCHS will also examine whether there are differences between mail and web respondents.

4. Tests of Procedures or Methods to be Undertaken

The lists of survey question items in 2024 are in Attachments C-1-C-2. The majority of the 2024 NPALS survey question items have been (1) drawn from previously fielded NCHS LTC provider surveys (NNHS, NHHCS, NSRCF or NSLTCP/NPALS) 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), have reviewed the question lists in the past and provided feedback. The Collaborating Center for Questionnaire Design and Evaluation Research also conducted a record keeping-question alignment project (OMB No. 0920-0222). The purpose of this project was to determine whether there were data quality (measurement and response generation) challenges with the use of aggregate-level services users surveys questions in NPALS, and if there were, how this could inform future study design and questionnaire development through a better understanding of record keeping practices among providers, the tasks involved in using records to calculate answers/responses to aggregate services user questionnaire items, the perception of the burden in looking up the records, and the impact of the perceived burden on data quality. Externally, experts from organizations such as the office of the Assistant Secretary of Planning and Evaluation and Administration for Community Living 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 NPALS question items.

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

• 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, to address respondent queries about response options, and to respond to OMB revised race and ethnicity question guidelines;

• Revising the number of response categories to decrease respondent burden;

• Adding back in NPALS items that are not asked each wave; and

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

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

Manisha Sengupta, Ph.D.

Acting Chief, Planning and Operations Branch

National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

Phone: (301) 458-4754

E-Mail: msengupta@cdc.gov

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

Angela M. Greene, M.A.

Project Director

Program on Aging, Disability and Long-Term Care

RTI International

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