[Federal Register Volume 77, Number 114 (Wednesday, June 13, 2012)]
[Notices]
[Pages 35396-35398]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2012-14206]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Agency for Healthcare Research and Quality


Agency Information Collection Activities: Proposed Collection; 
Comment Request

AGENCY: Agency for Healthcare Research and Quality, HHS.

ACTION: Notice.

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SUMMARY: This notice announces the intention of the Agency for 
Healthcare Research and Quality (AHRQ) to request that the Office of 
Management and Budget (OMB) approve the proposed information collection 
project: ``Adapting Best Practices for Medicaid Readmissions.'' In 
accordance with the Paperwork Reduction Act, 44 U.S.C. 3501-3521, AHRQ 
invites the public to comment on this proposed information collection.
    This proposed information collection was previously published in 
the Federal Register on March 28th, 2012 and allowed 60 days for public 
comment. No comments were received. The purpose of this notice is to 
allow an additional 30 days for public comment.

DATES: Comments on this notice must be received by July 13, 2012.

ADDRESSES: Written comments should be submitted to: AHRQ's OMB Desk 
Officer by fax at (202) 395-6974 (attention: AHRQ's desk officer) or by 
email at [email protected] (attention: AHRQ's desk officer).
    Copies of the proposed collection plans, data collection 
instruments, and specific details on the estimated burden can be 
obtained from the AHRQ Reports Clearance Officer.

FOR FURTHER INFORMATION CONTACT: Doris Lefkowitz, AHRQ Reports 
Clearance Officer, (301) 427-1477, or by email at 
[email protected].

SUPPLEMENTARY INFORMATION: 

Proposed Project

Adapting Best Practices for Medicaid Readmissions

    One particular mission of AHRQ is to improve the efficiency of 
health care through reducing unnecessary health care costs while 
maintaining or improving quality. The proposed data collection supports 
this goal through developing strategies to assist safety net hospitals 
in reducing readmissions for Medicaid patients. Previous research has 
shown that a focus on transitional care, including needs assessment, 
discharge planning, post-discharge intervention, and care coordination 
can reduce avoidable readmissions. Based on this evidence, there have 
been a number of strategies and resources developed for hospitals to 
reduce avoidable readmissions, including:
     The Aging & Disability Resource Centers Evidence-Based 
Care Transitions program by the Administration on Aging & CMS to 
support state efforts in implementing evidence-based care transition 
models for older adults and individuals with disabilities.
     The State Action on Avoidable Rehospitalizations (STAAR) 
initiative by the Institute for Healthcare Improvement to improve care 
transitions and care coordination through state-based multi-stakeholder 
collaborative efforts.
     The Hospital-to-Home (H2H) initiative by the American 
College of Cardiology to reduce readmissions for patients with 
cardiovascular conditions.
     Project Re-Engineered Discharge (RED), funded by AHRQ and 
the National Institutes of Health (NIH) National Heart, Lung, and Blood 
Institute, to reduce re-hospitalizations by improving hospital 
discharge processes.
    However, the majority of these strategies and resources focuses on 
general patient populations or specifically targets the elderly and/or 
disabled, primarily Medicare populations. Recent research finds that 
rates of readmission among Medicaid-insured non-elderly adults equals 
that of the elderly, Medicare-insured population and is 60 percent 
higher than a privately-insured population. It is not known whether 
existing resources and strategies to reduce readmissions address the 
circumstances and characteristics of Medicaid-insured patients. 
Particular socio-demographic characteristics more prevalent in 
populations insured through Medicaid, such as low-income, racial and 
ethnic minority, low literacy, housing instability, mental illness, 
substance abuse disorders, chronic and disabling conditions, language 
barriers, and discontinuous insurance coverage may mean that strategies 
for reducing readmissions need to be tailored specifically to the 
unique needs of this population.
    Additionally, safety net hospitals, which serve large populations 
of the most vulnerable in society and where Medicaid is often a major 
payer, face unique conditions. Not only do they serve more vulnerable 
populations, they are often constrained by their financing and 
governance structures. Safety net hospitals generally operate on lower

[[Page 35397]]

financial margins than other hospitals because they are often underpaid 
for many services provided to Medicaid recipients and the uninsured. 
Faced with declining contributions from state and local governments and 
payment reduction from both public and private payers, many are 
struggling to meet the growing demand for their services with stagnant 
or declining revenues. Resources addressing hospital readmissions may 
also have to be tailored to meet the unique circumstances of safety net 
settings.
    This project will recruit six safety net hospitals to assess the 
existing resources and strategies and suggest and test modifications to 
address the particular circumstances related to Medicaid readmissions 
and safety net hospital settings. The goals of this project are to:
     Identify factors at the patient, provider, and community 
levels that especially contribute to hospital readmissions for Medicaid 
patients;
     Assess and test existing strategies to reduce avoidable 
readmissions for their adequacy and applicability to Medicaid-insured 
populations and safety net hospital settings;
     Modify and test modifications of existing strategies as 
necessary for applicability to Medicaid-insured populations and safety 
net hospital settings; and
     Develop a package of revised strategies for reducing 
avoidable readmissions that are specific to the factors contributing to 
Medicaid-insured patient readmissions in safety net settings.
    Four cycles of testing will be conducted to collect data on samples 
of patient readmissions in each of the participating hospitals. The 
data will be collected and analyzed by the hospital staff after each 
cycle. The first cycle will identify factors related to Medicaid 
readmissions, as well as establishing baseline measures, while the next 
3 cycles will be a quality improvement effort to test the existing 
strategies, or modifications to existing strategies, to address the 
factors identified in the first cycle. Each cycle will use a different 
sample of Medicaid readmission patients.
    This study is being conducted by AHRQ through its contractor, John 
Snow, Inc. (JSI), pursuant to AHRQ's statutory authority to conduct and 
support research on healthcare and on systems for the delivery of such 
care, including activities with respect to the quality, effectiveness, 
efficiency, appropriateness and value of healthcare services and with 
respect to quality measurement and improvement. 42 U.S.C. 299a(a)(1) 
and (2).

Method of Collection

    To achieve the goals of this project the following data collections 
will be implemented:
    (1) Medical records review--The medical records review will gather 
background information about a patient's index admission and 
readmission. Data to be abstracted from the medical record includes 
patient demographic information, living arrangements, dates and timing 
of index and readmissions, lengths of stay, diagnoses on admission, 
source of admission, discharge disposition, and other transition 
factors, as well as the name and setting of the patient's primary care 
provider (PCP), and whether an appointment was made with the PCP before 
discharge.
    (2) Patient/family/caregiver interview--After completion of the 
patient's medical record review, interviews will be conducted with the 
patient and a family member or caretaker (using the same tool for all) 
who has permission to discuss the patient's case. The purpose of the 
patient/family/caregiver interviews is to obtain the patient/family 
perspective, in their own words, of their index admission, their 
transition period, and their readmission. Data to be collected includes 
perspectives on reasons for readmission, discharge experience, extent 
to which they were able to follow any discharge instructions provided, 
setting to which they were discharged, and any other assistance needed.
    (3) Provider interview--Provider interviews will complete the 
patient readmission data. Two providers involved in each readmission 
case will be interviewed. Providers are likely to be from the hospital 
setting (e.g., hospitalists, admitting physicians, emergency room 
physicians) but also may be from the larger care community (e.g., 
primary care, skilled nursing facility, home health). Providers 
selected will change from case to case, although any particular 
provider may be asked about more than one readmission over the course 
of the project. Providers will be asked why they believe the patient 
was readmitted and what they think could have been done to avoid the 
readmission.
    The purpose of the primary data collections is to add insight and 
direct patient/family and provider input and experience into all phases 
of the project. The first data collection will provide patient/family 
and provider insight into the process of identifying factors related to 
Medicaid readmissions. Based on these factors, existing readmissions 
strategies will be assessed for their suitability in addressing these 
factors. Participating hospitals will then select existing or modified 
strategies to test in their settings using a rapid cycle QI process. 
Primary data collection will occur during each of the three testing 
cycles for purposes of gathering patient and provider insight into the 
factors associated with readmissions of Medicaid patients and gauging 
the extent to which the modified strategies would be able to address 
those factors.

Estimated Annual Respondent Burden

    Exhibit 1 shows the estimated annualized burden for the 
respondent's time to participate in the project. The medical records 
review will be performed by one QI nurse at each of the 6 participating 
hospitals for 80 readmission cases (20 from each of 4 cycles) and will 
take about 20 minutes per case. In that the primary data collections 
are intended to inform the factors related to Medicaid readmissions and 
inform the testing of existing or modified strategies, there is no set 
number of readmissions cases required during each of the four data 
collection cycles. Participating hospitals will be instructed that it 
is a process that should continue until patterns of response converge 
and little new information is being learned, with 20 cases as the 
maximum during any one of the four cycles of data collection.
    For each readmission case interviews will be conducted by the QI 
nurse with a total of 120 patients and family member or care giver (20 
of each from each of the 6 hospitals) during each of the 4 cycles of 
data collection. The interviews are estimated to require 10 minutes 
each. The QI nurse will also conduct interviews with 2 providers 
associated with each readmission case (a total of 240 providers across 
the 6 hospitals) during each of the 4 cycles and will take about 5 
minutes. The total burden is estimated to be 640 hours annually.
    Exhibit 2 shows the estimated cost burden associated with the 
respondent's time to participate in this project. The total cost burden 
is estimated to be $23,398 annually.

[[Page 35398]]



                                  Exhibit 1--Estimated Annualized Burden Hours
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                                                                     Number of
                    Form name                        Number of     responses per     Hours per     Total burden
                                                    respondents     respondent       response          hours
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Medical records review..........................               6              80           20/60             160
Patient/family/caregiver interviews.............             120               4           10/60              80
Patient interview...............................             120               4           10/60              80
Family/caregiver interview QI Nurse to conduct                 6             160           10/60             160
 interviews.....................................
Provider interviews:
Provider interviews                                          240               4            5/60              80
    QI Nurse to conduct interviews..............               6             160            5/60              80
                                                 ---------------------------------------------------------------
    Total.......................................             498              na              na             640
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                                   Exhibit 2--Estimated Annualized Cost Burden
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                                                     Number of     Total burden   Average hourly    Total cost
                    Form name                       respondents        hours        wage rate*        burden
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Medical records review..........................             120             160          $32.56          $5,210
Patient/family/caregiver interviews:
    Patient interview...........................             120              80          $21.35          $1,708
    Family/caregiver interview..................             120              80          $21.35          $1,708
    QI Nurse to conduct interviews..............               6             160          $32.56          $5,210
Provider interviews:
    Provider interviews.........................             240              80          $86.96          $6,957
    QI Nurse to conduct interviews..............               6              80          $32.56          $2,605
                                                 ---------------------------------------------------------------
    Total.......................................             498             640              na        $23,398
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* Based upon the mean of the average wages, National Compensation Survey: Occupational wages in the United
  States May 2010, ``U.S. Department of Labor, Bureau of Labor Statistics;'' 29-1111 (Registered Nurse, $32.56/
  hr); 00-0000 (All Occupations, $21.35/hr); 29-1069 (Physicians and Surgeons, All Other, $86.96/hr).

Estimated Annual Costs to the Federal Government

    The total cost to the government is estimated to be $253,033, which 
includes costs for project development, data collection, data analysis, 
publication, project management, and overhead as shown in Exhibit 3. 
The data collection occurs throughout the 2.5 year project term (30 
months); thus, it has an estimated annual cost of $101,212.

  Exhibit 3--Estimated Annual and Total Costs to the Federal Government
------------------------------------------------------------------------
                                     Estimated annual   Estimated total
           Task/activity                   cost               cost
------------------------------------------------------------------------
Project Development...............             $7,438            $18,596
Data collection...................             30,866             77,165
Data analysis.....................              9,470             23,676
Publication.......................              5,606             14,016
Project Management................             15,086             37,716
Overhead..........................             32,746             81,864
                                   -------------------------------------
    Total.........................            101,212            253,033
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Request for Comments

    In accordance with the Paperwork Reduction Act, comments on AHRQ's 
information collection are requested with regard to any of the 
following: (a) Whether the proposed collection of information is 
necessary for the proper performance of AHRQ healthcare research and 
healthcare information dissemination functions, including whether the 
information will have practical utility; (b) the accuracy of AHRQ's 
estimate of burden (including hours and costs) of the proposed 
collection(s) of information; (c) ways to enhance the quality, utility, 
and clarity of the information to be collected; and (d) ways to 
minimize the burden of the collection of information upon the 
respondents, including the use of automated collection techniques or 
other forms of information technology.
    Comments submitted in response to this notice will be summarized 
and included in the Agency's subsequent request for OMB approval of the 
proposed information collection. All comments will become a matter of 
public record.

    Dated: June 1, 2012.
Carolyn M. Clancy,
Director.
[FR Doc. 2012-14206 Filed 6-12-12; 8:45 am]
BILLING CODE 4160-90-M