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Score Card Pilot Results (Text Version)

Slide Presentation from the AHRQ 2010 Annual Conference.

On September 27, 2010, Sarah A. Redding made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (133 KB). 

Slide 1

Score Card Pilot Results

Score Card Pilot Results

Sarah A. Redding, MD, MPH
Executive Director
Community Health Access Project
Mansfield, Ohio

Slide 2

Pathway Model: A Tool to Measure Outcomes

Pathway Model: A Tool to Measure Outcomes

1—Find

Target Population: Engage those at greatest risk

2—Treat

Confirm connection to evidence-based intervention

3—Measure

Measure the Outcome

Slide 3

Client's Perspective

Client's Perspective

Image: A Venn diagram with one oval labeled Health intersecting with another oval labeled Social.

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

Slide 4

Example-Pregnancy Pathway

Example—Pregnancy Pathway

Steps $
1a. Identify/ enroll at risk

Initiation Step

Defined "at risk" pregnant women engaged and enrolled in care coordination

 $
1b. Care Coordination

Determine and document barriers:

  1. Insurance Status
  2. Transportation
  3. Prenatal Care
2. Evidence-based Intervention Prenatal care provider established
First and ongoing prenatal visits confirmed		 $
3. Measurable Outcome

Completion Step

Healthy baby > 5 pounds, 8 ounces
(2500 grams)

 $

Slide 5

Central Registration-Agencies as a Team

Central Registration—Agencies as a Team

Image: A chart shows the Community Hub at the center with double-arrows leading to the following text boxes:

  • Mental Health
  • County agency
  • Hospital
  • State-funded outreach program
  • Primary Health Home
  • Health Department
  • Community-based agency
  • Schools

One Care Coordinator → One Outcome (Pathway)

  • No duplication
  • Measurable results, tied to funding

Slide 6

Participating CCCLN Members

Participating CCCLN Members

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

Slide 7

Client Population by Site and Month March through August 2010

Client Population by Site and Month March through August 2010

Image: A bar chart shows the Client Population by Site and Month March through August 2010:

Site # March April May June July August
Site 1 203 238 219 198 209 188
Site 2 75 70 49 88 41 40
Site 3 23 23 31 26 35 39
Site 4 39 57 23 42 27 19
Site 5 10 17 22 26 26 27

Slide 8

Number of all Clients by Gender, 5 Sites March through August 2010

Number of all Clients by Gender, 5 Sites March through August 2010

Total Number of Client Interactions

Image: A bar chart shows the following data:

  • Female, 1615
  • Male, 514

Slide 9

Client Ethnicity by Site, March through August 2010

Client Ethnicity by Site, March through August 2010

Image: Bar charts show the following data:

Site # American
Indian		 Asian Black/
African American		 Hispanic Pacific
Islander		 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 1 1 22 5 0 177 3 0 1
Site 5 0 0 76 33 0 35 0 0 0

Slide 10

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

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

Image: A pie chart shows the following data:

  • Whites 35%
  • Hispanic 13%
  • Black/African American 38%
  • Asian 0%
  • American Indian 2%
  • Not Recorded 11%
  • Do Not Know 0%
  • Other 1%

Slide 11

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

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

Image: A pie chart shows the following data:

  • No 19%
  • Yes 80%
  • Do Not Know 1%

Slide 12

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

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

Image: A chart shows Type of Insurance vs. Number of Client Interactions:

Public: 1200 interactions
Private: 200
Other: 5
Do Not Know: 10
No Answer: 5

Slide 13

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

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

Image: A bar chart shows the following data:

  Barriers Referrals
Child Care 32 108
Food 137 156
Housing 395 325
Insurance 290 264
Prescription 64 46
Transportation 123 86
Other 187 326

Slide 14

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

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

Image: A bar chart shows the following data:

  • March 1%
  • April 8%
  • May 12 %
  • June 9%
  • July 29%
  • August 28%

Slide 15

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

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

Image: A Line graph shows the number of total barriers to care and social services:

  March April May June July August
Total Social Service Referrals 223 269 252 360 255 205
Total Barriers to Care 283 202 230 307 101 165

Slide 16

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

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

Image: A pie chart shows the following data:

Transportation Assistance, 86
Medication Assistance, 46
Insurance Services, 264
Housing Assistance, 325
Food Assistance (WIC), 156
Financial Assistance, 75
Employment Services, 181
Domestic Violence Services, 18
Clothing Assistance, 15
Child Assistance, 108
Other, 326

Slide 17

Percent of Clients with No Source of Primary Ongoing Care who were Connected to Care by Month, 5 Sites, March through August 2010

Percent of Clients with No Source of Primary Ongoing Care who were Connected to Care by Month, 5 Sites, March through August 2010

Image: A line graph shows the following data:

  • March 69%
  • April 51%
  • May 64 %
  • June 72%
  • July 66%
  • August 71%

Slide 18

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

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

Image: A bar chart shows the following data:

  March April May June July August
Percent of social service pathways completed 1% 6% 11% 4% 28% 27%
Percent of ongoing sources of care pathways completed 57% 53% 62% 70% 64% 69%
Current as of December 2010
Internet Citation: Score Card Pilot Results (Text Version). December 2010. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/news/events/conference/2010/redding/index.html

 

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