Score Card Pilot ResultsSarah A. Redding, MD, MPH

Executive DirectorCommunity Health Access Project

Mansfield, Ohio

Pathway Model: A Tool to Measure Outcomes

Target PopulationEngage those at

greatest risk

Confirm connection to evidence-based

intervention

Measure the Outcome

1 - Find

2 - Treat

3 - Measure

Client’s Perspective

Health Social

From the client’s perspective, social issues are as important as health issues. Both must be

addressed.

Example – Pregnancy Pathway

Identify/enroll at risk

Care Coordination

Evidence -based

Intervention

Measureable Outcome

$

$

$

Initiation StepDefined “at risk” pregnant women engaged and

enrolled in care coordination

Determine and document barriers:1. Insurance Status2. Transportation3. Prenatal Care

Prenatal care provider establishedFirst and ongoing prenatal visits confirmed

Completion StepHealthy baby > 5 pounds, 8 ounces

(2500 grams)

Community HUB

Primary Health Home

State- funded

outreachprogram

Schools

Health Department

County agency

Mental Health

Hospital

Community- based agency

One Care Coordinator One Outcome (Pathway) • No duplication• Measurable results, tied to funding

Central Registration – Agencies as a Team

• Albuquerque, New Mexico• Central Oregon• Dallas, Texas• Indianapolis, Indiana• Ohio:

• Cincinnati• Mansfield• Toledo

Participating CCCLN Members

March April May June July August

203238

219198 209

188

75

70

49 8841

40

23

23

3126

3539

39

57

2342

2719

10

17

22

26

26

27

Client Population by Site and MonthMarch through August 2010

Site 1 Site 2 Site 3 Site 4 Site 5

To

tal

Nu

mb

er

of

Cli

en

t In

tera

c-

tio

ns

Client0

500

1000

1500

2000

2500

Female 1615

Male, 514

Number of all Clients by Gender, 5 SitesMarch through August 2010

To

tal

Nu

mb

er o

f C

lien

t In

tera

ctii

on

s

American In-dian

Asian Black/African Amer-

ican

Hispanic Pacific Is-lander

White Other DNK Not Recorded

Site 1 3 0 668 16 0 559 22 1 0

Site 2 50 0 13 247 4 39 5 3 249

Site 3 0 1 127 9 0 22 1 2 17

Site 4 3 1 22 5 0 177 3 0 1

Site 5 0 0 76 33 0 35 0 0 0

50

150

250

350

450

550

650

Client Ethnicity by Site, March through August 2010

American Indian

2%

Asian0%

Black/African

American38%

Hispanic13%

Pacific Is-lander

0%

White34%

Other1%

Do Not Know0%

Not Recorded11%

Percent of all Clients by Ethnicity, 5 Sites, March through August 2010

Yes80%

No18%

Do Not Know1%

Percent of Clients Who Reported They Have a Source of Insurance, 5 Sites, March through August 2010

Typ

e o

f In

sura

nce

0 200 400 600 800 1000 1200 1400 1600 1800

Clients' Insurance Status at Time of Enrollment in Program,by Insurance Type, 5 Sites, March through August 2010

Public

Private

Other

DNK

No Answer

Number of Client Interactions

Barriers Referrals

Child Care 32 108

Food 137 156

Housing 395 325

Insurance 290 264

Prescription 64 46

Transportation 123 86

Other 187 326

25

75

125

175

225

275

325

375

425

Total Number of Barriers to Care and Referrals by Category, 5 Sites, March through August 2010

Nu

mb

er

of

Ba

rrie

rs &

Re

ferr

als

March April May June July August

0%

20%

40%

60%

80%

100%

1%8% 12%

9%

29% 28%

Percentage of Clients Connected to at Least One Social Service by Month, 5 Sites, March through August 2010

March April May June July August0

50

100

150

200

250

300

350

400

Number of Barriers to Care and Social Service Referrals by Month, 5 Sites, March through August 2010

Total Social Service ReferralsTotal Barriers to Care

Nu

mb

er

of

ba

rrie

rs &

re

ferr

als

Child Assistance; 108 Clothing Assistance, 15 Domestic Violence Services; 18

Employment Services; 181

Financial Assistance; 75 Food Assistance

(WIC); 156

Housing Assistance, 325

Insurance Services; 264

Medication Assistance, 46

Transportation Assis-tance; 86

Other; 326

Number of Social Service Referrals Initiated by Category, 5 Sites, March through August 2010

March April May June July August0%

10%

20%

30%

40%

50%

60%

70%

80%

Percent of Clients with No Source of Primary Ongoing Care who were Connected to Care by Month, 5 Sites,

March through August 2010

March April May June July August0%

20%

40%

60%

80%

100%

Percent of Pathways Completed by Month, 5 Sites, March through August 2010

Percent of social service path-ways completed

Percent of con-going source of care pathways completed