Changing the Focus to

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Changing the Focus to Outcomes
AHRQ Annual Conference September 27, 2007 Mark
Redding Community Health Access Project
(CHAP) www.CHAP-Ohio.net
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Find
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Treat
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Measure
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(No Transcript)
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The lower 48 is not doing so well!
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Find
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Treat
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Measure
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Care Coordination Engage at Risk Individual
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Confirm Evidence Based Service - Intervention
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Measure - Health Improvement Cost Savings
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We know how to find those most at risk
Doctors Offices
Low Birth Weight Babies by Census
TractRichland County
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Outcome Focused Care ManagementCommunity Health
Workers, Social Workers and Nurses
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(No Transcript)
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Care management must address health and social
barriers
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We can define the conditions and we know what
works to treat them
Evidence Based Interventions
Diabetes Asthma Pregnancy Homelessness Adult
Education Unemployment
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Pathways
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Identify/enroll at risk Care Coordination

Evidence based Intervention

Final Outcome

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Youngstown Healthy Moms Healthy BabiesHealth
and Social Service Referral Pathways Produced
Per Six Month Period Per CHW

Figure 3-3
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Pathways Across the Community- No Duplication
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Pathways Across the Community No Duplication
2005-2006 Dollars tied to Performance
Duplication Removed146 At Risk Served
2004-2005
Contracting for Process 19 At Risk Served
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Outcome Based Accountability and Care Management
Make a Difference
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Starr Principal

• First - specifically define what you will make,
  produce, or provide

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Not Driven by Meaningful Work Products
Pools of funding No quality unit driver.
Unknown admin fees, no meaningful work products
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Care Coordination Meaningful Work Products

• Not Meaningful
• On a list
• Phone call
• Hour of service
• Chart documentation

• Meaningful
• Evidence based intervention received
• Evidence based education received
• Housing, food clothing, education, employment
  received

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Care CoordinationWell funded, No basic
requirements for quality/duplication
Pregnancy
 
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Ask Your State Legislature Regarding Care
Coordination

• What is the cost per person served per year?
• What meaningful work product does the money buy?
• How do the dollars focus on those most at risk?

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Disparity Awaits

• Focus on the most basic Fundamentals
• Ensure each individual, at risk are reached,
• Connected to proven intervention
• Result measured
• Efficiencies and effectiveness improved

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We can change the focus from activities to
outcomes