impact of convenience care on pediatric ed utilization: the el centro de corazón pilot project
TRANSCRIPT
Outline
Project Background Intervention Evaluation Methods
Time Series Pre-test Post-test
Results Conclusions
Background: Overview
Project partners: Texas Children’s Health Plan (‘TCHP’), El Centro de Corazón (‘El Centro’) St. Luke’s Episcopal Charities and Rotary Club of Houston
Objective: To reduce ED utilization for ambulatory care sensitive conditions (ACSC) among TCHP beneficiaries who reside in east Houston.
Strategy: Provide expanded-hours primary care at a community clinic (El Centro/Eastwood Clinic) in east Houston. Pilot Project ran from Sept. 2006 – Feb. 2007
El Centro de Corazón Pilot Project
Background: Project Partners
Founded in 1996, TCHP was first group health plan exclusively for children.
Catchment area includes Harris County and 10 surrounding counties.
Provides Medicaid STAR and CHIP coverage for 170,000+ enrollees.
Primary care network includes 780+ pediatricians 1,316 specialists 52+ in-network hospitals (around greater Houston area)
Texas Children’s Health Plan
Background: Project Partners
October 2003 merged with Eastwood Health Clinic. December 2003 obtained FQHC status. TCHP network provider Provides primary, preventive, dental and mental
health services, lab and pharmacy services at 3 sites in east Houston: El Centro de Corazón Navigation El Centro/ Magnolia El Centro/ Eastwood**
El Centro de Corazón
**site of El Centro extended hours pilot project
Intervention
El Centro Extended-Hours Primary Care
Day of Week
Pre-Pilot StudyHours of Operation
Bus.Hrs.
Pilot Study Hours of Operation
Pilot StudyBus. Hrs.
Mon 8:30AM – 7PM 10.5 8AM – 8PM 12
Tues 8:30AM – 7PM 10.5 8AM – 8PM 12
Wed 1PM – 7PM 6 8AM – 8PM 12
Thurs 8:30AM – 7PM 10.5 8AM – 8PM 12
Fri 8:30AM – 5PM 8.5 8AM – 1PM 5
Sat Closed 0 Closed 0
Sun 9AM – 1PM 4 9AM – 1PM 4
Total # Business Hours 50 57
Intervention
Clinic and Office Personnel
Daytime (8AM – 5PM): 1 nurse practitioner, 1 P/T and 2 F/T medical assistants, 3 staff members in front office
Extended hours (5PM – 8PM) and Sundays: 1 physician assistant, 2 medical assistants 1 staff member in front office (2 on Sunday AM)
El Centro Extended-Hours Primary Care
Intervention
TCHP Marketing and Educational Outreach
Campaign ran Sept 2006 – Feb 2007 Outreach products printed in English and Spanish Sent to targeted TCHP enrollee households (HHs), not individuals
Sept 2006 Oct Nov Dec Jan 2007 Feb Mar Apr
Sent 391 new HHs Memo Boards
Sent 28,335 6x9 informative PostcardsSent 2,498 new HHs Magnet Mailers
Sent 6,459 Magnet Mailers
Sent 6,462 Memo Boards
Sent 7,4166x9 Postcards(Excess)
Sent 7,4966x9 Postcards(Excess)
Intervention
TCHP Marketing and Educational Outreach
6x9 Postcard
Printed in English and Spanish
Contains reminders about getting health care for a sick child:1. Call physician2. Call TCHP Nurse Help Line 3. Go to Eastwood Clinic
Intervention
Between Sept 2006 – Feb 2007:
Distributed Rx Pads to 420 network PCP offices
Made 274 visits to community based organizations, churches, apt. complexes, school nurses in study area (177 locations)
Distributed 21,730 promotional flyers
Auto dialer campaign delivered 10,000+ promotional messages over 2 months (number of messages received is unknown)
TCHP Marketing and Educational Outreach
Evaluation Methods
Study GroupTCHP enrollees who reside in 11 ZIP codes surrounding El
Centro (approx. 18,000 children)
Comparison GroupsMatched Comparison group (approx. 7,600 children)
Enrollees who reside in 7 ZIP codes with similar race/ethnicity, poverty levels, education, and use of English in household
TCHP enrollee base excluding study group (approx. 140,000 children)
Study Population
Evaluation Methods
Comparison of Study Group and Matched Group Characteristics at the ZIP code level
Population Characteristics
El Centro Zip Codes
(N = 283,774)
Control Zip Codes
(N = 219,818) n % n % Latino or Hispanic Ethnicity of any race 178,308 62.8 142,899 65.0 White 106,843 37.7 126,834 57.7 African-American 70,178 24.7 22,043 10.0 Families below poverty level 15,663 5.5 10,132 4.6 High School grad or higher 76,134 26.8 65,861 30.0 Speak language other than English at home
149,331 52.6 116,944 53.2
*Data Source: http://factfinder.census.gov/home/saff/main.html?_lang=en *The Census Bureau allows survey respondents to report one or two races, therefore some individuals are double counted and the percentages for race will not equal 100%. Likewise, an individual of Latino or Hispanic ethnicity may report no race or identify with one or two races.
Evaluation MethodsTargeted EC Zip Codes, Matched Comparison Zip Codes and
Surrounding EDs and Community Clinic* Network
*Community health centers are local, non-profit, community-owned health care providers serving low income and medically underserved communities. (http://www.nachc.com/client/documents/America's_Health_Centers_updated_1.08.pdf)
Evaluation Methods
Population perspective Measured monthly rates for ED use/100
enrollees (ED for ACSC visits and Total ED visits).
Compared utilization trends for study group and 2 comparison groups.
Interrupted Time Series: Sept 2005 – Aug 2007
Evaluation Methods
Clinical perspective Defined pre-pilot and post-pilot periods:
6 months prior to and subsequent to pilot period
Identified users and non-users of El Centro’s after hours services.
Calculated user and non-user ED rates for pre-pilot, pilot and post-pilot time frames.
Pre – Post Test
Results
Figure 2: EC Study Group Utilization of El Centro de Corazon Office Visits March 2006 - August 2007 and Extended Hours Visits September 2006 - August 2007
0
20
40
60
80
100
120
Mar-06 May-06 Jul-06 Sep-06 Nov-06 Jan-07 Mar-07 May-07 Jul-07
Office Visits Extended Hours Visits
Results
Figure 3: Monthly Rates for ACSC ED Visits per 100 enrollees for El Centro Study Group, Control Group and TCHP Group, September 2005 - August 2007
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Sep-0
5
Nov-05
Jan-0
6
Mar
-06
May
-06
Jul-0
6
Sep-0
6
Nov-06
Jan-0
7
Mar
-07
May
-07
Jul-0
7
AC
SC
ED
Vis
its
pe
r 1
00
en
roll
ee
s/m
on
th
EC Study Grp
Control
TCHP
Pilot Study
Monthly Rates for ACSC ED Visits per 100 enrollees for El Centro Study Group, Control Group and TCHP Group, September 2005 - August 2007
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Sep-0
5
Nov-05
Jan-0
6
Mar
-06
May
-06
Jul-0
6
Sep-0
6
Nov-06
Jan-0
7
Mar
-07
May
-07
Jul-0
7
AC
SC
ED
Vis
its
pe
r 1
00
en
roll
ee
s/m
on
th
EC Study Grp
Control
TCHP
Pilot Study
ResultsFigure 4: Monthly Rates for Total ED Visits per 100 enrollees for El Centro Study Group, Control Group and TCHP Group, September 2005 - August 2007
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Sep-0
5
Nov-05
Jan-
06
Mar
-06
May
-06
Jul-0
6
Sep-0
6
Nov-06
Jan-
07
Mar
-07
May
-07
Jul-0
7
To
tal E
D V
isit
s p
er 1
00 e
nro
llees
/mo
nth
EC Study Grp
Control
TCHP
Pilot Study
Figure 4: Monthly Rates for Total ED Visits per 100 enrollees for El Centro Study Group, Control Group and TCHP Group, September 2005 - August 2007
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Sep-0
5
Nov-05
Jan-
06
Mar
-06
May
-06
Jul-0
6
Sep-0
6
Nov-06
Jan-
07
Mar
-07
May
-07
Jul-0
7
To
tal E
D V
isit
s p
er 1
00 e
nro
llees
/mo
nth
EC Study Grp
Control
TCHP
Pilot Study
Results
Tab le 2 : S ix-Mo n th Utiliza tio n R a te s fo r AC SC ED Vis its p e r 1 0 0 e n ro lle e sd u r in g Pre -p ilo t, P ilo t a n d Po st-p ilo t p e r io d s fo r EC G ro u p , u se rs a n dn o n -u se rs, C o n tro l G ro u p a n d T C HP G ro u p
Pre -P ilo ta Pilo tb Po st-P ilo tc Pre - Po stR a te D iffe re n ce
EC G ro u p 0 .8 4 1 .1 3 0 .8 6 0 .0 2
u se rs d 1.59 1 .8 0 1.17 - 0 .42
n o n -u se rs e 0 .6 0 0 .7 8 0 .6 4 0 .0 4
C o n tro l 1 .0 1 1 .3 9 1 .0 6 0 .0 5
T C HP 0 .9 5 1 .3 8 1 .1 0 0 .1 5a Pre -p ilo t: Ma rch - Au g u st 2 0 0 6b Pilo t: Se p te mb e r 2 0 0 6 - F e b ru a ry 2 0 0 7c Po st-p ilo t: Ma rch - Au g u st 2 0 0 7d u se rs: T C HP e n ro lle e s in ta rg e t ZIP co d e s with a t le a st o n e a fte r-h o u rsv is it to E l C e n tro C lin ic .e n o n -u se rs: T C HP e n ro lle e s in ta rg e t ZIP co d e s with n o a fte r-h o u rs v is itsto E l C e n tro C lin ic .
Results
Tab le 3 : S ix-Mo n th Utiliza tio n R a te s fo r T o ta l ED Vis its p e r 1 00 en ro llee sd u r ing Pre -p ilo t, P ilo t a nd Post-p ilo t pe r iod s fo r EC G ro up , u se rs an dn on -use rs, C on tro l G rou p an d T C HP G ro u p
Pre -P ilo ta Pilo tb Po st-P ilo tc Pre - Po stR a te D iffe re nce
EC G ro up 2 .90 3 .16 2 .97 0 .07
use rs d 5.02 5 .50 2.53 - 2 .49
n on -u se rs e 2 .05 2 .13 2 .19 0 .14
C o n tro l 3 .40 3 .65 3 .25 - 0 .1 5
T C HP 3 .30 3 .78 3 .46 0 .16
a Pre -p ilo t: Ma rch - Aug ust 20 0 6b Pilo t: Se p temb e r 20 0 6 - F e b rua ry 2 00 7c Po st-p ilo t: Ma rch - Au g ust 2 0 07d u se rs: T C HP e n ro lle es in ta rge t ZIP co de s with a t le a st o ne a fte r-h ou rsv is it to E l C e n tro C lin ic .e n on -use rs: T C HP e n ro lle es in ta rge t ZIP co de s with no a fte r-h ou rs v is itsto E l C e n tro C lin ic .
Conclusions
At population level, pilot program did not successfully divert patients away from ED.
At clinical-user level, effect was seen among users of El Centro’s after hours services: 26% decrease in pre-post ED for ACSC utilization rate; 50% decrease in pre-post total ED utilization rate.
Study group’s utilization of El Centro’s services increased during study period. Post-pilot drop in after hours visits might suggest
continued outreach is needed.
Study Highlights
Conclusions
Paid claims data might contain measurement error due to: Timing of claim submission, clinical error and necessary
adjustments; Extended hours visits might be underestimated due to
level of coding accuracy at provider level.El Centro hours of operation printed on outreach
materials did not reflect the clinic’s actual hours. Effect of error on study group is unknown.
We were unable to conduct statistical test of significance on pilot program’s effect. We are currently working on a retrospective panel study to
address this issue.
Study Limitations
Acknowledgements
We would like to thank St. Luke’s Episcopal Charities and Rotary Club of Houston for their support of the El Centro After Hours Pilot Program, without which this project would not have been possible. Additionally, we thank Rose Calhoun and Xuan Tran with Texas Children’s Health Plan for their assistance during the early stages of the project.