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Impact of Convenience Care on Pediatric ED Utilization:. The El Centro de Coraz ó n Pilot Project. Outline. Project Background Intervention Evaluation Methods Time Series Pre-test Post-test Results Conclusions. Background: Overview. El Centro de Coraz ó n Pilot Project.
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Impact of Convenience Care on Pediatric ED Utilization: The El Centro de Corazón Pilot Project
Outline • Project Background • Intervention • Evaluation Methods • Time Series • Pre-test Post-test • Results • Conclusions
Background: Overview El Centro de Corazón Pilot Project • 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
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
Intervention El Centro Extended-Hours Primary Care • 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)
Sept 2006 Oct Nov Dec Jan 2007 Feb Mar Apr Sent 6,462 Memo Boards Sent 391 new HHs Memo Boards Sent 7,416 6x9 Postcards (Excess) Sent 6,459 Magnet Mailers Sent 28,335 6x9 informative Postcards Sent 2,498 new HHs Magnet Mailers Sent 7,496 6x9 Postcards (Excess) 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
Intervention TCHP Marketing and Educational Outreach MEMO BOARD MAGNET MAILER
Intervention TCHP Marketing and Educational Outreach • 6x9 Postcard • Printed in English and Spanish • Contains reminders about getting health care for a sick child: • Call physician • Call TCHP Nurse Help Line • Go to Eastwood Clinic
Intervention TCHP Marketing and Educational Outreach 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)
Evaluation Methods Study Population • Study Group • TCHP enrollees who reside in 11 ZIP codes surrounding El Centro(approx. 18,000 children) • Comparison Groups • Matched 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)
Evaluation Methods Comparison of Study Group and Matched Group Characteristics at the ZIP code level *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 Methods Targeted 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 Interrupted Time Series: Sept 2005 – Aug 2007 • 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.
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 3: Monthly Rates for ACSC ED Visits per 100 enrollees for El Centro Study Monthly Rates for ACSC ED Visits per 100 enrollees for El Centro Study Group, Control Group and TCHP Group, September 2005 - August 2007 Group, Control Group and TCHP Group, September 2005 - August 2007 5 5 4.5 4.5 4 4 Pilot Study Pilot Study 3.5 3.5 3 3 EC Study Grp EC Study Grp 2.5 2.5 Control Control ACSC ED Visits per 100 enrollees/month ACSC ED Visits per 100 enrollees/month TCHP TCHP 2 2 1.5 1.5 1 1 0.5 0.5 0 0 Jul-06 Jul-06 Jul-07 Jul-07 Jan-06 Jan-06 Jan-07 Jan-07 Nov-05 Nov-05 Nov-06 Nov-06 Sep-05 Sep-05 Sep-06 Sep-06 Mar-06 Mar-06 Mar-07 Mar-07 May-06 May-06 May-07 May-07
Conclusions Study Highlights • 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.
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.