Health Care Innovation Awards Disease-Specific Evaluation

250 Pages·2016·6.94 MB·English

S E C O N D A N N U A L R E P O R T
HCIA Disease-Specific Evaluation
REVISED PRESENTED TO: PRESENTED BY:
MARCH 2016 Erin Murphy Colligan & NORC at the University of Chicago
Caitlin Cross-Barnet Adil Moiduddin
Center for Medicare & Medicaid Vice President, Health Care Research
Innovation 4350 East-West Hwy, Suite 800
7500 Security Blvd Mail Stop: Bethesda, MD 20814
WB-06-05 [phone]
Baltimore, MD 21244
[phone]
NORC | HCIA Disease-Specific Evaluation
Contributors
Rina Dhopeshwarkar
Sarah Downie
Maysoun Freij
Alison Laffan
Nina Litton
Sai Loganathan
Shriram Parashuram
Misti Paudel
Sarah Ruiz
Rachel Singer
Michelle Spafford
Megan Skillman
Tianne Wu
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Disease-Specific Awardees
Awardee Name Abbreviation
Duke University’s South Eastern Diabetes Initiative SEDI
FirstVitals Health and Wellness, Inc. FirstVitals
The George Washington University GWU
Joslin Diabetes Center, Inc. Joslin
Health Resources in Action, Inc. HRiA
Nemours Children’s Health System of the Nemours Foundation Nemours
Le Bonheur Community Health and Well-Being Le Bonheur
Mountain Area Health Education Center, Inc. MAHEC
Innovative Oncology Business Solutions, Inc. IOBS
University of Alabama at Birmingham UAB
The Trustees of the University of Pennsylvania UPENN
The Rector and Visitors of the University of Virginia UVA
Trustees of Indiana University Indiana
Regents of the University of California, Los Angeles UCLA
Ochsner Clinic Foundation Ochsner
Christiana Care Health Services, Inc. Christiana
Upper San Juan Health Service District USJHSD
Vanderbilt University Medical Center Vanderbilt
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Table of Contents
Executive Summary ..................................................................................................................9
Evaluation Goals and Methods ...........................................................................................9
Implementation Experience ............................................................................................... 10
Workforce Experience ....................................................................................................... 11
Program Effectiveness ...................................................................................................... 12
Sustainability ..................................................................................................................... 13
Conclusion ........................................................................................................................1 3
Introduction .............................................................................................................................1 5
Disease-Specific Innovation Awards ................................................................................. 15
Evaluation Goals ............................................................................................................... 17
Data Sources and Methods ............................................................................................... 17
Qualitative Data and Methods .................................................................................. 17
Quantitative Data and Methods................................................................................ 21
Cross-Awardee Findings ........................................................................................................ 26
Implementation Experience ............................................................................................... 26
Program Reach and Populations Served ................................................................. 26
Targeting and Recruiting Participants ...................................................................... 27
Program Dosage ..................................................................................................... 29
Workforce Roles ...................................................................................................... 31
Technological Challenges ........................................................................................ 35
Facilitators and Barriers to Implementation .............................................................. 36
Program Effectiveness ...................................................................................................... 38
Quantitative Findings ............................................................................................... 40
Qualitative Findings ................................................................................................. 43
Sustainability .....................................................................................................................4 6
Conclusion ..............................................................................................................................4 9
Awardee-Specific Findings .................................................................................................... 50
Christiana Care Health System ......................................................................................... 51
Duke University/Southeastern Diabetes Initiative .............................................................. 61
FirstVitals Health and Wellness, Inc. ................................................................................. 72
The George Washington University .................................................................................. 79
Health Resources in Action ............................................................................................... 87
Trustees of Indiana University ........................................................................................... 97
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Innovative Oncology Business Solutions, Inc. ................................................................. 106
Joslin Diabetes Center, Inc. ............................................................................................ 117
Le Bonheur Community Health and Well-Being .............................................................. 128
Mountain Area Health Education Center, Inc. ................................................................. 138
Nemours Children’s Health System of the Nemours Foundation ..................................... 149
Ochsner Clinic Foundation .............................................................................................. 160
University of Alabama at Birmingham ............................................................................. 169
Regents of the University of California, Los Angeles ....................................................... 179
Trustees of the University of Pennsylvania ..................................................................... 189
Upper San Juan Health Service District .......................................................................... 196
The Rector and Visitors of the University of Virginia ........................................................ 204
Vanderbilt University Medical Center .............................................................................. 210
TECHNICAL APPENDICES ................................................................................................... 223
Appendix A: Quantitative Methods .................................................................................. 223
Appendix B: Qualitative Methods .................................................................................... 238
Appendix C: IOBS Sensitivity Analyses—Difference-in-Differences Estimates for Core
Measures ........................................................................................................................ 248
Appendix D: UAB Sensitivity Analyses—Difference-in-Differences Estimates for Core
Measures ........................................................................................................................ 249
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List of Exhibits
Exhibit 1.1: HCIA Disease-Specific Awardees ...................................................................... 16
Exhibit 1.2: Overview of Qualitative Data Sources and Timeline ........................................... 18
Exhibit 1.3: Evaluation Design for Awardees ........................................................................ 21
Exhibit 1.4: Methodological Overview by Awardee Intervention Type ................................... 22
Exhibit 1.5: Measures of Program Effectiveness for Awardees Included in Annual Report ... 23
Exhibit 1.6: Analysis by Awardees ........................................................................................ 24
Exhibit 1.7: Difference-in-Differences Design for Post-Acute and Ambulatory Interventions . 25
Exhibit 2.1: Program Reach across Awardees ...................................................................... 27
Exhibit 2.2: Strategies for Identifying and Recruiting Program Participants ........................... 28
Exhibit 2.3: Dosage Levels and Examples by Awardee ........................................................ 30
Exhibit 2.4: Staff Performing Common Intervention Activities ............................................... 32
Exhibit 2.5: Examples of Mid-Level providers in Clinical Care and Disease Management .... 33
Exhibit 2.6: Quantitative Evidence of Program Effectiveness ................................................ 39
Exhibit 2.7: Difference in Utilization and Cost Measures Between Pre- and Post-HCIA
Periods .............................................................................................................. 41
Exhibit 2.8: Program Effectiveness Findings from Awardee-Provided Data .......................... 43
Exhibit 2.9: Qualitative Evidence on Improvements in Health, Quality of Life, and
Quality of Care from Focus Groups and Patient Interviews (N=419) .................. 44
Exhibit 3.1: Christiana Patient-Episodes Identified through Finder File ................................. 55
Exhibit 3.2: Christiana Common Support and Covariate Balance for Christiana and
Comparison Patient-Episodes ............................................................................ 56
Exhibit 3.3: Christiana Descriptive Characteristics of Participants and Comparison
Patient-Episodes ................................................................................................ 57
Exhibit 3.4: Christiana Difference-in-Differences Estimates for Core Measures, per 1,000 ... 59
Exhibit 4.1: SEDI Overview of Data and Measures ............................................................... 67
Exhibit 4.2: SEDI Descriptive Characteristics of High-Risk Intervention Participants ............ 68
Exhibit 4.3: SEDI Improvement in Program Outcomes for Participants ................................. 69
Exhibit 4.4: SEDI Factors Associated with Improved Outcomes for the High-Risk
Intervention ........................................................................................................ 70
Exhibit 5.1: FirstVitals Descriptive Characteristics for Participants and Comparison Pool ..... 76
Exhibit 5.2: FirstVitals Pre/Post Differences in Utilization and Costs for Participants ............ 77
Exhibit 6.1: GWU Patients Identified through Finder File ...................................................... 82
Exhibit 6.2: GWU Descriptive Characteristics of Population ................................................. 83
Exhibit 6.3: GWU Adjusted Rates for Core Measures by Quarter ......................................... 85
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Exhibit 7.1: HRiA Baseline Characteristics of Participants Overall and According to
Follow-Up Status................................................................................................ 92
Exhibit 7.2: HRiA Overview of Specific Measures ................................................................. 94
Exhibit 7.3: HRiA Outcomes in Provided Data ...................................................................... 95
Exhibit 7.4: HRiA Sustainability Plans by Site ....................................................................... 96
Exhibit 8.1: Indiana Patients Identified through Finder File ................................................ 100
Exhibit 8.2: Indiana Common Support and Covariate Balance for Indiana and
Comparison Patients ........................................................................................ 101
Exhibit 8.3: Indiana Descriptive Characteristics of Indiana and Matched Comparison
Patients ............................................................................................................ 102
Exhibit 8.4: Indiana Difference-in-Differences Estimates for Core Measures ...................... 104
Exhibit 9.1: IOBS Patients Identified through Finder File .................................................... 111
Exhibit 9.2: IOBS Common Support and Covariate Balance for IOBS and Comparison
Patients ............................................................................................................ 112
Exhibit 9.3: IOBS Descriptive Characteristics of IOBS and Matched Comparison Patients . 112
ǂ
Exhibit 9.4: IOBS Difference-in-Differences Estimates for Core Measures ........................ 114
Exhibit 10.1: Joslin Overview of Data and Measures ............................................................ 121
Exhibit 10.2: Joslin Descriptive Characteristics of Participants ............................................. 122
Exhibit 10.3: Joslin Improvement in Program Outcomes for Participants .............................. 123
Exhibit 10.4: Joslin Factors Associated with Improved Outcomes – Measures of
Health Habits in the Overall Population ............................................................ 125
Exhibit 10.5: Joslin Factors Associated with Improved Outcomes – Diabetes-Specific
Measures ......................................................................................................... 126
Exhibit 11.1: Le Bonheur Feasibility of Creating CMMI Priority Measures ............................ 135
Exhibit 11.2: Le Bonheur Feasibility of Creating CMMI Priority Measures (Detailed) ............ 135
Exhibit 11.3: Le Bonheur Services Provided to Participants ................................................. 136
Exhibit 12.1: MAHEC Workforce Variation across Sites ....................................................... 139
Exhibit 12.2: MAHEC Patients Identified through Finder File ................................................ 144
Exhibit 12.3: MAHEC Descriptive Characteristics of Population ........................................... 145
Exhibit 12.4: MAHEC Adjusted Rates for Core Measures by Quarter ................................... 146
Exhibit 13.1: Nemours Patients Identified through Finder File .............................................. 154
Exhibit 13.2: Nemours Common Support and Covariate Balance for Nemours and
Comparison Patients ........................................................................................ 155
Exhibit 13.3: Nemours Descriptive Characteristics of Nemours and Matched
Comparison Patients ........................................................................................ 156
Exhibit 13.4: Nemours Difference-in-Differences Estimates for Core Measures, per 1,000 ... 157
Exhibit 14.1: Ochsner Stroke Central Patient-Episodes Identified through the Finder File .... 164
Exhibit 14.2: Ochsner Descriptive Characteristics of Patient-Episodes for Stroke ................ 165
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Exhibit 14.3: Ochsner Adjusted Rates for Outcome Measures by Quarter - Stroke
Central ............................................................................................................. 167
Exhibit 15.1: UAB Patients Identified through Finder File...................................................... 174
Exhibit 15.2: UAB Common Support and Covariate Balance for UAB and Comparison
Patients ............................................................................................................ 175
Exhibit 15.3: UAB Descriptive Characteristics of UAB and Matched Comparison Patients ... 175
Exhibit 15.4: UAB Difference-in-Differences Estimates for Core Measures ǂ........................ 177
Exhibit 16.1: UCLA Patients Identified through Finder File ................................................... 184
Exhibit 16.2: UCLA Common Support and Covariate Balance for UCLA and Comparison
Patients ............................................................................................................ 185
Exhibit 16.3: UCLA Descriptive Characteristics of UCLA and Matched Comparison
Patients ............................................................................................................ 186
Exhibit 16.4: UCLA Difference-in-Differences Estimates for Core Measures ........................ 187
Exhibit 17.1: UPenn Descriptive Characteristics of Participants ............................................ 192
Exhibit 17.2: UPenn Overview of CLAIM Program’s Pain Management Measure ................. 193
Exhibit 17.3: UPenn Performance of CLAIM Program on Pain Management ........................ 194
Exhibit 18.1: USJHSD Overview of Wellness Program Outcome Measures ......................... 202
Exhibit 18.2: USJHSD Wellness Program Outcomes ........................................................... 202
Exhibit 19.1: UVA Descriptive Characteristics for CARE Track Participants and
Comparison Group ........................................................................................... 208
Exhibit 19.2: UVA End-of-life Outcomes for CARE Track Participants and Comparison
Group ............................................................................................................... 209
Exhibit 20.1: Vanderbilt Post-Acute Care Patient-Episodes Identified through Finder File .... 214
Exhibit 20.2: Vanderbilt Descriptive Characteristics of Patient-Episodes Included in
Analysis ........................................................................................................... 215
Exhibit 20.3: Vanderbilt Adjusted Rates for Outcome Measures for Vanderbilt TCC by
,
Quarter ............................................................................................................ 217
Exhibit 20.4: Vanderbilt’s Finder File Vanderbilt Ambulatory Care Patients Identified
through Finder File ........................................................................................... 218
Exhibit 20.5: Vanderbilt Descriptive Characteristics of OCC Participants .............................. 219
Exhibit 20.6: Vanderbilt Adjusted Rates for Core Measures OCC by Quarter ....................... 221
Exhibit A.1: Summary Quantitative Analysis Methods Population ...................................... 223
Exhibit A.2: Distinct Groups Included in PAC Analytic Files ................................................ 226
Exhibit A.3: Core Measures for PAC Interventions .............................................................. 226
Exhibit A.4: Core Measures for Ambulatory Care Interventions ........................................... 227
Exhibit A.5: Sampling Frame for Comparison Groups ......................................................... 229
Exhibit A.6: Claims Rules Used to Identify Comparison Patients ........................................ 230
Exhibit A.7: Approach and Variables Used in Propensity Score Models .............................. 232
Exhibit A.8: Functional Form for Regression Models ........................................................... 233
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Exhibit A.9: Variables in DID Models ................................................................................... 235
Exhibit A.10: Variables in the Interrupted Time-Series Models .............................................. 236
Exhibit B.1: Site Visit Schedule ........................................................................................... 238
Exhibit B.2: Interview Themes ............................................................................................. 240
Exhibit B.3: Patient Focus Group and Interview Recruitment Methods ................................ 242
Exhibit B.4: Example of Interview Protocol .......................................................................... 243
Exhibit B.5: Code Families .................................................................................................. 246
Exhibit B.6: Coder Training Timeline and Activities ............................................................. 247
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Executive Summary
In July 2012, the Center for Medicare & Medicaid Innovation (“CMMI” or “Innovation Center”)
announced the first round of 108 Health Care Innovation Awards (“HCIA Round 1” or “HCIA”). Each
award tests a health-care-delivery innovation focused on specific populations and settings. These
innovations include integration and coordination of services, use of software applications, workforce
training, and continuous quality improvement informed by rapid-cycle feedback. This report focuses on
the subset of 18 HCIA projects targeting patient populations with specific diseases or diagnostic profiles.
The HCIA disease-specific awards focus on seven conditions considered “priority” because of their cost,
prevalence, and seriousness. They are Alzheimer’s disease and dementia; cancer; cardiovascular disease
(CVD) and stroke; chronic pain; diabetes; end stage renal disease (ESRD); and pediatric asthma.
Evaluation Goals and Methods
This report contains findings from the first two years of a four-year evaluation. In it, we address research
questions on program implementation and examine overall program effectiveness—focusing on CMMI
goals to achieve better care, smarter spending, and improved overall health.
Findings in this report reflect analysis of both qualitative and quantitative data. We use qualitative data
gathered over two rounds of site visits conducted with all 18 awardees in the past 24 months. In year one,
we conducted in-person site visits to all 18 awardees. In year two, we conducted a second round of in-
person site visits to 12 awardees; and conducted phone interviews with the remaining six. For some
awardees we visited multiple sites, and ultimately visited 44 locations across the 18 awardees over the
course of two years. Site visits involved interviews with program leadership, staff, enrolled patients
(participants), and caregivers, and also focus groups with participants and caregivers. We supplemented
some in-person site visits with phone interviews with staff and patients that we could not interview during
the site visit. For awardees for which we only conducted phone interviews in year two, we used the same
interview protocols as those used in-person to discuss implementation experiences, challenges, successes,
and outcomes with leadership and staff, as well as with patients. We also draw findings from information
abstracted from awardee documents such as progress reports.
Data used to produce quantitative findings vary across the 18 awardees. We present results for the 11
awardees that had sufficient sample size to conduct analysis. Where the sample size of Medicare fee-for-
service (FFS) participants exposed to an awardee intervention allowed (nine awardees), we use Chronic
Conditions Warehouse (CCW) data from the CMS Virtual Research Data Center (VRDC) to capture
information on health care cost and utilization for participants (treatment groups). In addition, where
sample size allowed (six awardees), we identify “comparison group” cases using propensity scores
calculated for the treatment group. For these awardees, we show how the awards impact CMMI priority
measures: hospitalizations, hospital readmissions, emergency department (ED) visits, and total cost of
care for Medicare FFS patients. This analysis uses “difference-in-differences” (DID) methods in order to
take into account the specific characteristics of providers and patients as well as secular trends.
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