Joy Twesigye, MPP, WHNP-BC C. Daniel Mullins, PhD Aurelia Laird, RN Juan-David Rueda, MD WEST BALTIMORE HEALTH ENTERPRISE ZONE September 11, Evaluation Plan Project Director: Evaluation Team:

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 2

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.” 3

WEST BALTIMORE CARE OVERVIEW  HEZ Geographic and Target Population: 86,000 West Baltimore residents within the 21216, 21217, 21223, and 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 4 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 similar a) 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 utilization Measurement: visits (Outcomes) Year 1: Capacity Year2: Productivity Year 3: Quality Year 4: Outcomes 6

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

OVERARCHING EVALUATION 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? 8

EVALUATION BY DOMAINS OF WORK Population Health Goals

CLINICAL POPULATION HEALTH GOALS 2017 Reduce by 15% cardiovascular disease risk factor prevalence among West Baltimore residents served by HEZ Provider Practices 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). 10

PROGRAMMATIC POPULATION HEALTH GOALS AND PROGRESS ActivityProcess MeasureCapacity CreatedMaximum 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 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 slotsNew Partnership 11

Workforce Development EVALUATION BY DOMAINS OF WORK

WORKFORCE DEVELOPMENT GOALS AND PROGRESS 2017 Increase by 16 the number of skilled primary care professionals on HEZ provider practices’ care teams 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. 13

PROGRAMMATIC WORKFORCE DEVELOPMENT GOALS AND PROGRESS ActivityProcess MeasureCapacity 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 New Goal Identify 50 community members to receive a scholarship  # of awarded scholarships 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 14

Care Coordination EVALUATION BY DOMAINS OF WORK

CARE COORDINATION GOALS 2017 Reduce by 5% the number of preventable hospitalizations of high utilizers enrolled in WB CARE care coordination program 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%. 16

PROGRAMMATIC CARE COORDINATION GOALS AND PROGRESS ActivityProcess MeasureCapacity 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 CHW35 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 CHW42 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 CHW12 people will be connected to a PCP per month, 17

EVALUATION Cost of Readmissions and Emergency Department Utilization

COST REDUCTION GOALS 2017 Reduce by 10% unnecessary costs of caring for high utilizers in the WB CARE care coordination program 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. 19

PROGRAMMATIC COST REDUCTION GOALS ActivityProcess MeasureCapacity 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/AGoal is 10% reduction in cost. Pilot reporting mechanism Completion of pilot. 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 20

SEMI-STRUCTURED INTERVIEWS AND FOCUS GROUPS 21  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)

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? 22

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

QUESTIONS? 24