Getting Results - Evaluating The System

Strategy 1 - Evaluate Program Implementation
Analyze population data over time to assess whether your program is reaching its target audience, Analyze process and outcomes data on an ongoing basis to identify what works and how you can improve program design and delivery
Strategies in Action:
  • BPHC tracks the communities from which clients are recruited, client retention, and participant satisfaction for their Healthy Homes program. The program’s mission is to deliver care to the underserved, so when early data indicated that the number of clients from low-income communities was not as high as intended, BPHC changed its approach to allow for word-of-mouth referrals in addition to provider referrals. As clients started telling neighbors and friends about BPHC’s services, requests from the target communities spiked.
  • To refine their training, CMFHP solicited feedback from providers and revised the standard asthma action plan to respond to the questions providers said their patients regularly asked.
  • Initially, Optima’s case managers and life coaches focused patient education on taking prescribed medication. After two years, patient self-management data indicated that adherence to a treatment plan alone often did not lead to decreased asthma severity. The leaders determined that trigger avoidance was necessary and that modifications should be gradual. Now, the coaches suggest “small changes that patients can make quickly, without too much cost or effort.”
Strategy 2 - Evaluate Program Impact
Collect health outcomes data to see if your program is improving the asthma outcomes you are pursuing
Strategies in Action:
  • Early in the program’s development, CMFHP observed a decline in the proportion of patients classified as having severe asthma. CMFHP leaders quickly realized that the new provider training was leading to better and more frequent diagnoses of mild asthma. As the size of the population with mild asthma increased, severity data for the asthmatic population was diluted. To determine if the program was truly improving asthma health outcomes, CMFHP began comparing utilization data over time against the total number of health plan members rather than the total number of members with asthma; a better constant according to the Director of Health Management.
  • Monroe tracks hospital admissions and ER visits for asthma to measure the impact of their clinical outreach worker and home visit components. Monroe saw utilization, hospitalization, and ER visits fall as the number of patients seeing PCPs and specialists and the frequency of clinical visits increased. This confirmed that the strategy to promote richer patient-provider interaction was improving asthma health outcomes.
Strategy 3 - Use Evaluation Data to Demonstrate the Business Case
Assign costs to the program’s elements and its outcomes
Strategies in Action:
  • In the program’s first year, ANWM tracked 34 children receiving home-based case management. Researchers pulled patient charts, collected cost information on ER visits and hospitalizations, and compared the costs of care from the year before to the first year of the program. ANWM demonstrated that case management cost $2,500 per person for up to 18 home visits per year leading to a 70% decrease in hospitalizations, a 46% decrease in the length of stay, a 60% decrease in ER visits, and improved medication usage. ANWM demonstrated that investments in the program resulted in a net savings of $800 per child per year.
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