Project Access in Wichita/Sedgwick County, Kansas
Evaluation Overview

 

Project Access connects low-income, uninsured residents of Sedgwick County to volunteer health care providers (physicians, hospitals, clinics, pharmacies, and other services), and provides a prescription medication assistance program for enrolled patients.  The overall evaluation plan tracks measures for Project Access-enrolled patients, and two additional interventions facilitated by Project Access including: 1) a hospital emergency department case management program, and 2) Call-A-Nurse telephone triage service. To allow comparison across uninsured patient populations, the evaluation design has implemented parallel outcome measures for Project Access patients, and hospital emergency department case management clients.  These measures include resource use, satisfaction with services, and health, employment and insurance status.  The following document describes 1) the overall design of the Project Access evaluation, and  2) measures for each program component. 

 

Project Access Patient Evaluation

 

Utilization

This portion of the evaluation is designed to investigate the major health-related problems of low-income uninsured residents of Sedgwick County, and the charges associated with their medical care.  The study describes major diagnostic categories, medical procedures, and charges associated with the medical care of patients enrolled in Project Access.  Using administrative data from Project Access, univariate and bivariate analysis of patient demographics, ICD-9 codes (medical diagnoses), CPT codes (medical procedures), charges, length of stay, and hospital days per 1,000 are performed.  Data from October 1, 1999 through August 2001 (Project Access operations in year one and two) were included in analyses.  Year three analyses are in progress at this time.  

 

Data on utilization of prescription medications is also tracked to assess trends in medication-type and changes in utilization regarding generic or name brands, costs and other factors.  Trends are reported on an annual basis.

 

Patient and Physician Satisfaction

Satisfaction is a key indicator of the success or failure of a program, and therefore, is critical in guiding changes in program planning.  In order to retain physician support to continue providing donated medical services, rates of physician satisfaction with Project Access operations are monitored.  Moreover, patient satisfaction rates provide feedback to Project Access leadership and staff about opportunities to improve their processes.  Patient and provider satisfaction have been monitored by Project Access staff since January 2000, and are now incorporated into the overall evaluation.  Descriptive analyses on patient and physician satisfaction with Project Access program services will be performed every six months.  Findings will be reported twice yearly to Project Access leadership, Project Access Operations Council, the Central Plains Regional Health Care Foundation (CPRHCF) Board (the non-profit organization overseeing the Project Access program), and other interested groups. 

 

Health & Insurance Status

In June 2002, assessments of health, employment, and insurance status were added for all Project Access patients.  These measures are collected at the time of enrollment and disenrollment, and assess: 

1)      Changes in health status in Project Access participants (using the SF-8, which measures physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, emotional well-being, social functioning, energy/fatigue, general health perceptions, and perceived change in health),

2)      Changes in employment status, employment productivity (sick days, work days missed for taking care of a family member, doctor visits, return to work), and insurance status.  For assistance with developing appropriate and meaningful questions for the survey, local human resource managers were interviewed.  The employment/return to work survey was constructed based upon comments elicited from telephone interviews with human resource directors at area businesses.  

 

 

CALL-A-NURSE TELEPHONE TRIAGE PROGRAM

 

Implemented in August 2002, the “Call-A-Nurse” telephone triage service provides answers to health-related questions and supports health care decision-making for Project Access patients.  The service is available on evenings and Saturdays when doctors’ offices and clinics are closed.  Project Access-enrolled patients receive a colorful magnet and a wallet-sized card with a telephone number they can call to connect with a registered nurse for health care questions and concerns.  RNs trained in telephone triage techniques use specialized health problem querying software, which guides the patient interview process.  The goal of the program is to help patients make better health care decisions, and improve appropriate use of health care resources. 

 

The software utilized by the Call-A-Nurse program also collects information about patient demographics (age, gender, education status, ethnicity), chief complaint or health concern, result of phone call, agreement with recommendation, resolution of health concern, perceived severity of health concern at time of call, perceived understanding of health complaint by nurse, satisfaction with service, and projected activity without phone call.  Approximately 1,500 new persons are enrolled into Project Access per year.  Assuming an 85% satisfaction level among patients using the Call-A-Nurse program, an estimated sample size of 110 observations per group (e.g., first time callers vs. greater than one previous phone call) would be required to detect a 10% difference in satisfaction (using the z statistic to compare proportions of dichotomous variable, satisfied vs. dissatisfied) (Hulley & Cummings, 1988).  When this rate is applied to the estimated sample size, 176 patients (per group) may be required to obtain the desired sample of 110 observations (per group). 

 

 

CASE MANAGEMENT PROGRAM

 

The goal of this evaluation component is to assess the effectiveness of a hospital case management intervention that links low-income, uninsured people to a primary care medical home.  A case management team, consisting of a nurse and a social worker, is located at each of four hospital emergency departments. Using a logic model approach (Rossi, Freeman & Lipsey, 1999), the evaluation will assess the structure, process, output, and short and long term outcomes of the intervention (see figure 2).  Local health care providers (area hospitals involved in the intervention), Project Access Operations Council and staff, and the Central Plains Regional Health Care Foundation Board will use evaluation results to adapt the intervention to improve effectiveness.  The key evaluation question is:  What is the effect of case management on program participants in relationship to health status, perceptions of control over health, client satisfaction, employment, and health resource use in program participants (use of medical care home vs. emergency department for primary care visits, community resources, medical payment support)?

 

Outcome Measures

Outcome measures for the hospital case management evaluation include: health care utilization (ED use, and associated costs), patient satisfaction, employment, insurance status, health status (SF-8), and patient empowerment and involvement in maintaining their health (Multidimensional Health Locus of Control Scales).  Short term measures will include timeliness of follow up, referrals in a timely manner, and patients’ goals are achieved (Spath, 2000), number, types of problems and barriers identified and resolved, linkage to a medical care home, and number and type of office visits in the first two to four months of enrollment in the program.   

 

 

Numbers Served

• Number of individuals who qualified (uninsured residents of Sedgwick County who made 3 ED visits in 1 year for primary care conditions)
• Number who had an initial assessment
• Number of social work contacts since program initiation
• Number of RN contacts since program initiation
• Number of clients served

 

 

Client Demographics

Age, Gender, Race/Ethnicity, Marital status, Income, Work Status, Zip Code

 

Referrals

Clinic Referrals:  Where clients are being referred. 

Non-Clinic Referrals:  Where clients are being referred

 

 

Emergency Department Utilization

Changes in ED visits pre/post

 

 

COLLABORATIVE MEMBERSHIP

 

An annual satisfaction survey instrument is mailed to all collaborative members (the Board, Operations Council and working committees) to assess satisfaction rates in meeting program goals, communicating with community members, staff performance and impact in the community.