[Federal Register Volume 82, Number 28 (Monday, February 13, 2017)]
[Notices]
[Pages 10487-10489]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-02893]


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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 ``The Re-Engineered Visit for Primary Care (AHRQ REV).'' In 
accordance with the Paperwork Reduction Act, AHRQ invites the public to 
comment on this proposed information collection.

DATES: Comments on this notice must be received by April 14, 2017.

ADDRESSES: Written comments should be submitted to: Doris Lefkowitz, 
Reports Clearance Officer, AHRQ, by email at 
[email protected].
    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 emails at 
[email protected].

SUPPLEMENTARY INFORMATION:

Proposed Project

The Re-Engineered Visit for Primary Care (AHRQ REV)

    This project--The Re-engineered Visit for Primary Care (AHRQ REV)--
directly addresses the agency's goal to conduct research to enhance the 
quality of health care and reduction of avoidable readmissions, which 
are a major indicator of poor quality and patient safety. Research from 
AHRQ's Healthcare Cost and Utilization Project (HCUP) indicates that in 
2011 there were approximately 3.3 million adult hospital readmissions 
in the United States. Adults covered by Medicare have the highest 
readmission rate (17.2 per 100 admissions), followed by adults covered 
by Medicaid (14.6 per 100 admissions) and privately insured adults (8.7 
per 100 admissions). High rates of readmissions are a major patient 
safety problem associated with medical errors such as prescribing 
errors and misdiagnoses of conditions in the hospital and ambulatory 
care settings. Collectively these readmissions are associated with 
$41.3 billion in annual hospital costs, many of which could potentially 
be avoided. The post-hospital discharge is a handoff ripe with hazards, 
potentially leading to an array of adverse events including the 
development of new or worsening symptoms, unplanned readmissions, and 
increased costs.
    In recent years, payer and provider efforts to reduce readmissions 
have proliferated. Many of these national programs have been informed 
or guided by evidence-based research, toolkits and guides, such as 
AHRQ's RED (Re-Engineered Discharge), STAAR (State Action on Avoidable 
Readmission), AHRQ's Project BOOST (Better Outcomes by Optimizing Safe 
Transitions), the Hospital Guide to Reducing Medicaid Readmissions, and 
Eric Coleman's Care Transitions Intervention. These efforts have 
largely focused on enhancing practices occurring within the hospital 
setting, including the discharge process and handoffs to receiving 
providers or settings of care. While many of these efforts have 
recognized the critical role of primary care in managing care 
transitions, they have not had an explicit focus on enhancing primary 
care with the aim of reducing avoidable readmissions.
    Evidence-based guidance for the primary care setting to reduce 
readmissions and improve patient safety are comparatively lacking, and 
this gap in the literature is becoming more pronounced as primary care 
is increasingly being called to serve as the key integrator role across 
the health system as part of payment and delivery system reforms. This 
research project aims to address the important and unfulfilled need to 
improve patient safety and reduce avoidable readmissions within the 
primary care context.
    AHRQ's goals in supporting this 30-month project are to build on 
the knowledge base from the inpatient settings, add to the expanding 
evidence base on preventing readmissions by focusing on the primary 
care setting, and provide insight on the components and themes that 
should be part of a re-engineered visit in primary care that will 
ultimately inform an effective intervention that can be tested in a 
diverse set of primary care clinics.
    To meet AHRQ's goals and objectives, the agency awarded a task 
order to John Snow, Inc. (JSI) to conduct a combination of qualitative 
research and quality improvement techniques to investigate the primary 
care-based transitional care workflow from the primary care staff, 
patient, and community agency perspective.
    This research has the following goals:
    1. Analyze current processes in the primary care visit associated 
with hospital discharge; and
    2. Identify components of the re-engineered visit.
    This study is being conducted by AHRQ through its contractor 
pursuant to AHRQ's statutory authority to conduct and support research 
on health care and on systems for the delivery of such care, including 
activities with respect to the quality, effectiveness, efficiency, 
appropriateness and vale of health care services and with respect to 
quality measurement and improvement. 42 U.S.C. 299a(a)(1) and (2).

Method of Collection

    To analyze current processes in the primary care visit associated 
with hospital discharge, the data collection has separated into seven 
smaller data collection activities to minimize research participant 
burden while still allowing for the collection of necessary data. Each 
of these tasks will be conducted at nine primary care sites:
    1. Primary care site organizational characteristics survey: The 
purpose of this background information on the primary care site's 
organizational characteristics is to offer context for the work flow 
mapping. It will help make the work flow mapping process more efficient 
and reduce burden by only requesting information that is already known 
by a site contact at each of the nine primary care practices. One 
person per primary care site will be engaged for this task.
    2. Primary care site patient characteristics survey: The purpose of 
this background information on the primary care site's patients is to 
offer context for the work flow mapping. It will help make the work 
flow mapping process more efficient and reduce burden by only 
requesting information that is already known in the primary care 
practices' billing or clinical information systems. One person per

[[Page 10488]]

primary care site will be engaged for this task.
    3. Work flow mapping preliminary interviews: The purpose of this 
flow mapping ``pre-work'' is to engage individual primary care staff 
members to think about what the work flow map looks like, setting a 
foundation for the actual work flow mapping process. We anticipate that 
eight individuals per primary care site will participate, for a total 
of 72 participants.
    4. Process flow mapping: This collection will take place in a group 
meeting that brings together available staff from various role types to 
collaborate in identifying their workflow processes involved in 
planning for and executing post-hospital follow up services for their 
practices' patients. Based on feasibility these may be smaller or 
larger group meetings, but the total burden on each role type 
participant is the same. The end goal of this meeting is to have enough 
information to have an initial process flow map on paper. We anticipate 
that 10 individuals per primary care site will participate, for a total 
of 90 participants.
    5. Work flow mapping follow-up interviews: Once the initial process 
flow map is on paper, each role type will be asked to review to 
correct, add, or confirm detail to the document. Once the flow map has 
been edited and ratified by the primary care site staff, each role type 
will be asked specific questions regarding failure modes identified in 
the process flow for the failure mode effects analysis. We anticipate 
that eight individuals per primary care site will participate, for a 
total of 72 participants.
    6. Patient Interviews: As a complementary piece of research to the 
work flow mapping, there would also be a process flow map from the 
patient's perspective. The purpose of the patient interviews is to 
capture patient perspectives on potential breakdowns in making the 
transition from the hospital to care in the primary care settings and 
to get, in their own words, information about the initial 
hospitalization and barriers to accessing follow-up care. One of the 
widely acknowledged limitations of the existing evidence based toolkits 
is that they are not designed with input from patients. This has 
occurred despite the fact that clinical experience suggests that 
providers often fail to identify patient needs and concerns and fail to 
plan accordingly in both hospital and primary care settings. Research 
has shown that there are cultural, social and behavioral factors that 
may contribute to readmissions and assessing the patient's perspective 
can help to better understand the barriers to receiving appropriate 
follow-up care. Patient and family interviews are increasingly common 
practices in efforts to improve care transitions and reduce 
readmissions, endorsed by CMS, the Institute for Healthcare 
Improvement, and Kaiser Permanente, among others. The patient interview 
is collecting unique information on the barriers to effective care 
transitions in the post-discharge period care, information which cannot 
be collected in other ways. Ten patients post-discharge from each of 
the nine primary care sites will be interviewed for a total of 90 
patients.
    7. Community agency interviews: As a complementary piece of 
research to the work flow mapping, the process flow map will reflect 
the perspective of community agencies affiliated with the primary care 
sites to assist patients. Five community agency representatives from 
each of the nine primary care sites will be interviewed.
    The purpose of this data collection is to understand the key 
components that should be included in the re-engineered visit in 
primary care. The project team will examine the diverse settings, 
staff, and transitional care activities across a variety of primary 
care practices to identify key transitional care processes that impact 
patient outcomes, the challenges to implementing those processes, and 
ways to improve those processes. The project team will distill the 
themes/principles that should be a part of the re-engineered visit and 
develop an outline and summary of itscomponents, with a comparison/
contrast of the components across sites and discussion of the 
generalizability of these components to different settings. The 
information identified from this research will add to the expanding 
evidence base on preventing readmissions by focusing on the primary 
care setting, and provide insight on the components and themes that 
should be part of a re-engineered visit that will ultimately inform an 
effective intervention that can be tested in a diverse set of primary 
care clinics.

Estimated Annual Respondent Burden

    Exhibit 1 shows the estimated burden hours to the respondents for 
providing all of the data needed to meet the project's objectives. The 
hours estimated per responses are based on the pilot project results.
    For the primary care site organizational characteristics survey and 
patient characteristics survey, one person per each of the nine primary 
care sites will participate. Both surveys are anticipated to take 1.5 
hours to complete.
    For the work flow mapping preliminary interviews, we estimate that 
eight primary care staff per primary care site will participate, with 
each individual spending 0.5 hours in these interviews. For the work 
flow mapping group interview, we estimate that 10 primary care staff 
per primary care site will participate, with each individual spending 
1.5 hours in these interviews. Finally, we estimate that eight primary 
care staff per primary care site will participate in the work flow 
mapping follow-up interviews, with each individual spending 0.5 hours 
in this data collection activity.
    There will be 10 patients interviewed in association with each 
primary care site. These patient interviews are expected to take 0.5 
hours per individual research participant.
    Lastly, there will be five community agency staff members 
interviewed in association with each primary care site. These 
interviews are expected to take 1 hour per individual research 
participant.
    Exhibit 2 shows the estimated cost burden for the respondents' time 
to participate in the project. The total annualized cost burden is 
estimated at $11,500.30.

                                  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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Primary care site organizational characteristics               9               1             1.5            13.5
 survey.........................................
Primary care site patient characteristics survey               9               1             1.5            13.5
Work flow mapping preliminary interview.........              72               1             0.5              36
Work flow mapping group interview...............              90               1             1.5             135
Work flow mapping follow-up interview...........              72               1             0.5              36
Patient interview...............................              90               1             0.5              45

[[Page 10489]]

 
Community agency interview......................              45               1               1              45
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    Total.......................................             387             n/a             n/a           2,628
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                                   Exhibit 2--Estimated Annualized Cost Burden
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                                                                                      Average
                    Form name                        Number of     Total burden    hourly  wage     Total cost
                                                    respondents        hours          rate *          burden
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Primary care site organizational characteristics               9            13.5      \a\ $40.41         $545.54
 survey.........................................
Primary care site patient characteristics survey               9            13.5       \a\ 40.41          545.54
Work flow mapping preliminary interview.........              72              36       \a\ 40.41        1,454.76
Work flow mapping group interview...............              90             135       \a\ 40.41        5,455.35
Work flow mapping follow-up interview...........              72              36       \a\ 40.41        1,454.76
Patient interview...............................              90              45       \b\ 23.23        1,045.35
Community agency interview......................              45              45       \c\ 22.20          999.00
                                                 ---------------------------------------------------------------
    Total.......................................             387             n/a             n/a       11,500.30
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* For hourly average wage rates, mean hourly wages from the Bureau of Labor Statistics (BLS) May 2015 national
  occupational employment wage estimates were used. http://www.bls.gov/oes/current/oes_nat.htm#00-0000
\a\ Participants will include a mix of providers and front desk staff; therefore a blended rate for these tasks
  are used including Nurse ($33.55), Medical Assistant ($15.01 \1\), Front Desk Staff ($13.38 \2\), Program
  Director ($32.56), Pharmacist ($56.96), Physician ($91.60), Behavioral health provider ($22.03).
\b\ Based upon the mean wages for consumers (all occupations).
\c\ Based upon the mean wages for Social Workers.

Request for Comments
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    \1\ http://www.bls.gov/oes/current/oes319092.htm.
    \2\ http://www.bls.gov/oes/current/oes434171.htm.
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    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 health care research and 
health care 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.

Sharon B. Arnold,
Acting Director.
[FR Doc. 2017-02893 Filed 2-10-17; 8:45 am]
 BILLING CODE 4160-90-P