1

Joy Twesigye, MPP, WHNP-BC

C. Daniel Mullins, PhDAurelia Laird, RNJuan-David Rueda, MD

WEST BALTIMOREHEALTH ENTERPRISE ZONE

September 11, 2015

Evaluation Plan

Project Director:

Evaluation Team:

2

WEST BALTIMORE PRIMARY CARE ACCESS COLLABORATIVE

Community-Based Organizations Equity Matters Light Health and Wellness

Comprehensive Services, Inc. Mosaic Community Services National Council on Alcohol and

Drug Dependence, Maryland

Academic Institutions University of Maryland, Baltimore Coppin State University

City and State Senator Verna Jones-Rodwell Baltimore City Health Department

FQHCs Baltimore Medical System Park West Health System,

Inc. Total Health Care, Inc.

Hospitals Bon Secours Baltimore

Health System University of Maryland -

Midtown Saint Agnes Hospital Sinai Hospital of Baltimore University of Maryland

Medical Center

3

BACKGROUND STUDY

John Snow Inc. June 2012 key findings were: “…in some West Baltimore zip codes as many as 55% of

emergency room visits are related to primary care preventable conditions.”

“Data from the assessment suggest that while there may be adequate capacity across all geographic areas to serve low income Medicaid insured and uninsured residents from West Baltimore, care may not always be readily or ideally accessible.”

“In addition to primary care access, many individuals would benefit by resources to support them in managing chronic disease. This includes education, case management, motivational interviewing, medication assistance and supported referrals to ensure that individuals access care.”

4

WEST BALTIMORE CARE OVERVIEW

HEZ Geographic and Target Population: 86,000 West Baltimore residents within the 21216, 21217, 21223, and 21229 zip codes

Core Disease and Target Conditions: Cardiovascular disease (CVD) and CVD risk factors (i.e., diabetes and hypertension)

Overarching Strategies: Care Coordination (hospital high-utilizers) and Community-Based Risk Factor Reduction

Figure 1. WB HEZ Geographic Area

DOMAINS OF WORK

Population Health

Workforce Development

Care Coordination

HEZ LOGIC MODEL

6

Strategy 1: Enhance existing capacity-Measurement: added providers, new visit slots, (capacity); proportion of new capacity that is being used, visits/hour for new providers (productivity)-Reach: small

Strategy 2: Increase care quality-Measurement: NQF or similara) Provider guideline adherence metrics (quality)b) Patient disease control metrics (outcomes)-Reach: medium

Strategy 3: Increase patient self-management ability (education, home visits, case managers, CHW)-Measurement: caseload (capacity); proportion of available caseload that is filled, encounters per worker (productivity); reduced use of ED (outcomes)-Reach: small to medium

Strategy 4: Community-wide enabling interventions: healthy food access, safe exercise, and any other intervention where users cannot be counted.-Reach: Large, but impact may be small

From: Defining HEZ Success: Expectations, Logic Model, and Deliverables. David Mann presentation for Maryland Community Health Resources Commission April 2015 Meeting. April 2, 2015

Goal: reduce potentially avoidable utilizationMeasurement: visits (Outcomes)

Year 1: Capacity

Year2: Productivity

Year 3: Quality

Year 4: Outcomes

6

7

EVALUATION TIMELINE HIGHLIGHTS

• March 2016

Full Evaluation Report

• February 2016

Annual Clinical Data Analysis Report (NQF and UDS measures)

• November 2015

Primary Care Workforce Assessment

• October-November 2015

Semi-Structured Interviews and Focus Groups

• April 2015

Clinical Data Trend Report

• June 2012

Background Study

Programmatic and Clinical Data Analysis and Lead Zone-Wide Technical Assistance Efforts (Ongoing)

8

OVERARCHINGEVALUATION QUESTIONS

• How are WBPCAC clinical partners enhancing their capacity?

• Are the NQF and UDS measures for patients seeing WBPCAC providers meeting national benchmarks for hypertensive, diabetes, tobacco cessation and cholesterol management?

• Are WBPCAC hospital partners experiencing a reduction in potential avoidable hospital utilization?

EVALUATION BY DOMAINS OF WORK

Population Health GoalsStrategy 1:

Increase Capacity

Strategy 2: Increase Care

Quality

Strategy 3: Increase

Patient Self-Management

Strategy 4: Community-

Wide Enabling Interventions

10

CLINICALPOPULATION HEALTH GOALS

2017

Reduce by 15% cardiovascular disease risk factor prevalence among West Baltimore residents served by HEZ Provider Practices.

2016

Increase by 3% the percentage of WBPCAC hypertensive adult patients with blood pressures lower than 140/90mmHg.

Increase by 3% the percentage of WBPCAC diabetic adult patients with LDL-C <100 mg/dL.

10% of fitness class participants will have improved biometric screens (BP, BMI and weight).

11

PROGRAMMATIC POPULATION HEALTH

GOALS AND PROGRESS

Activity Process Measure Capacity Created Maximum Possible Productivity

Year 2 Status(Goal ≥ 80% for

Year 3)Annual Clinical Data Analysis

• Completion of assessment.

1 survey/7 WBPCAC clinical members

7 WBPCAC clinical members complete the survey

80%

Fitness Classes # filled class slots

# fitness class participants

 

13 class slots 11 classes/wk (46wks of class/yr)

Average 143 class slots/wk 

70% capacity

Community Partnership Grants

# Community Partnership Grants 

3 grants 3 grants 100% capacity

Nutrition/Cooking Classes

# nutrition/cooking class participants 

15 class slots 10 classes/yr

Average 150 class slots/wk 10 classes/yr

60% capacity

Disease Management Classes

# disease management class participants

160 class slots

8 classes/yr

160 class slots New Partnership

Workforce Development

Strategy 1:Increase Capacity

Strategy 2: Increase Care

Quality

Strategy 3: Increase

Patient Self-Management

Strategy 4: Community-

Wide Enabling Interventions

EVALUATION BY DOMAINS OF WORK

13

WORKFORCE DEVELOPMENTGOALS AND PROGRESS

2017 Increase by 16 the number of skilled primary care professionals on HEZ provider practices’ care teams.

2016 Increase by 69 the number of community members who receive (new) health care career training that can support primary care practices.

5 HEZ practitioners or Qualified Employees will obtain State tax credits. Document the workforce status composition of HEZ provider practices. Document the capacity building needs of HEZ provider practices.

14

PROGRAMMATIC WORKFORCE DEVELOPMENT GOALS AND PROGRESS

Activity Process Measure Capacity Created

Maximum Possible Productivity

Year 2 Status

(Goal ≥ 80% for Year 3)

2 HEZ provider open houses held per quarter

# of provider open houses

8 open houses

8 open houses New Goal

Identify 50 community members to receive a scholarship

# of awarded scholarships

24 scholars/yr 24 scholars/yr 100%

Conduct an annual assessment of primary care workforce needs

Completion of assessment.

 

1 survey/7 WBPCAC clinical members

7 WBPCAC clinical members complete the survey

100%

Conduct an annual assessment of capacity building part of the qualitative evaluation)

Completion of assessment.

 

1 survey/7 WBPCAC clinical members Interviews

7 WBPCAC clinical members complete the survey Maximum number of interviews not determined yet.

New Goal

Strategy 1:

Increase Capacity

Strategy 2: Increase

Care Quality

Strategy 3: Increase

Patient Self-Managemen

t

Strategy 4: Community-

Wide Enabling

Interventions

EVALUATION BY DOMAINS OF WORK

16

CARE COORDINATIONGOALS

2017 Reduce by 5% the number of preventable hospitalizations of high utilizers enrolled in WB CARE care coordination program.

2015 Pilot a new care coordination program aimed at reduction in ED utilization and hospital readmissions

2016 Reduce by 2.5% diabetes-related ED visits for high utilizers in the WB CARE care coordination program.

Reduce by 2.5% hypertension-related ED visits for high utilizers in the WB CARE care coordination program.

Reduce by 2.5% the percentage of CVD- related, preventable ED visits for high utilizers in the WB CARE care coordination program.

Reduce readmissions for high utilizers in the WB CARE care coordination program by 5%.

17

PROGRAMMATIC CARE COORDINATION GOALS AND PROGRESS

Activity Process Measure Capacity Created

Maximum Possible Productivity

Successfully connect 1,125 high utilizers to a CHW and provide prolonged support to 450 high utilizers

High Utilizers to CHWs (30 days)

High Utilizers to CHWs who need prolonged support (30 days)

4 FTE CHW 35 total patient caseload, 25 a month as part of the Tier 1 30 day readmission prevention program, 10 a month as part of the Tier 2 30 day prolonged support program; 42 home visits month, and 175 total encounters per month

Community Health Workers complete 4,725 encounters via home visits, phone, health screenings and clinic visits.

Home visits Phone contact

4 FTE CHW 42 home visits month, and 175 total encounters per month

Successfully connect 100 high utilizers to a primary care provider.

# of medically homeless participants referred to a PCP

 

4 FTE CHW 12 people will be connected to a PCP per month,

EVALUATION

Cost of Readmissions and Emergency Department Utilization

19

COST REDUCTION GOALS

2017 Reduce by 10% unnecessary costs of caring for high utilizers in the WB CARE care coordination program.

2016 Reduce by 5% diabetes-related ED visits for high utilizers in the WB CARE care coordination program.

Reduce by 5% hypertension-related ED visits for high utilizers in the WB CARE care coordination program.

Reduce by 5% the percentage of CVD- related, preventable ED visits for high utilizers in the WB CARE care coordination program.

Reduce readmissions by 5% for high utilizers in the WB CARE care coordination program.

20

PROGRAMMATIC COST REDUCTION GOALS

Activity Process Measure Capacity Created

Maximum Possible Productivity

Develop process to measure reductions in cost for high utilizers in the WB CARE care coordination program with CRISP, HSCRC and The Coordinating Center.

Completion of measurement protocol.

N/A Goal is 10% reduction in cost.

Pilot reporting mechanism • Completion of pilot. N/A N/A

Successfully connect 1,125 high utilizers to a CHW and provide prolonged support to 450 high utilizers

High Utilizers to CHWs (30 days)

High Utilizers to CHWs who need prolonged support (30 days)

4 FTE CHW

35 total patient caseload, 25 a month as part of the Tier 1 30 day readmission prevention program, 10 a month as part of the Tier 2 30 day prolonged support program; 42 home visits month, and 175 total encounters per month

21

SEMI-STRUCTURED INTERVIEWS AND FOCUS GROUPS

Target Audience: HEZ activity participants and Providers

Purpose: Overall assessment of HEZ activities, engagement and satisfaction

Output: The findings will further inform additional quantitative data analysis and become part of the March 2016 full evaluation report

Timeline: November 2015 (target completion)

22

SAMPLE FOCUS GROUP QUESTIONS

How does the West Baltimore HEZ show that it understands the needs of patients, providers, and community members?

Are the needs addressed?• Health services (preventive and curative)• Health education• Community resources for health

How could the West Baltimore HEZ improve addressing the needs of the community?

Are all the right partners engaged in the West Baltimore HEZ?

23

FULL EVALUATION REPORT

Target Audience: HEZ care coordination enrollees, activity participants, scholarship awardees and Providers

Purpose: Overall assessment of HEZ activities, impact, and satisfaction

Data Source: EMRs, CHRC, CRISP, WB CARE patient tracking system, Care at Hand platform, CARMA and Passport to Health platform.

Output: The findings will further inform additional quantitative data analysis and become part of the March 2016 full evaluation report

Timeline: March 2016

24

QUESTIONS?