HCIA Complex/High-Risk Patient Targeting: Third Annual . - Free Download PDF

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THIRD ANNUAL REPORT ADDENDUMHCIA Complex/High-Risk Patient Targeting:Third Annual Report AddendumAPRIL 7, 2017PRESENTED TO:Katherine GiuriceoCMMI7500 Security BoulevardBaltimore, MD 21244PRESENTED BY:Roy AhnNORC at the University of Chicago4350 East-West Hwy, Suite 800Bethesda, MD 20814312-759-4068

NORC HCIA Complex/High-Risk Patient TargetingTable of ContentsExecutive Summary . 1Introduction and Methods . 17Evaluation Design . 20Quantitative Methods (Claims Based Analyses) . 22Qualitative and Survey Methods . 25Rapid Cycle Evaluation: Revising Issues of Feasibility and Evaluability . 25Awardee-Level Analyses: Overview . 27California Long-Term Care Education Center . 30Courage Kenny Rehabilitation Institute . 38Developmental Disabilities Health Services . 46Johns Hopkins University Community Health Partnership . 50Johns Hopkins University School of Nursing . 76LifeLong Medical Care . 87Northland Healthcare Alliance . 93Palliative Care Consultants of Santa Barbara . 98Pittsburgh Regional Health Initiative . 105Providence Portland Medical Center . 115St. Francis Healthcare Foundation of Hawaii . 139Sutter Health Corporation . 151University Emergency Medical Services . 157University of New Mexico . 164University of North Texas . 170TECHNICAL APPENDICES . 174Appendix A: Awardee and Intervention Names and Abbreviations . 175Appendix B: Definition of Acronyms . 176ADDENDUM TO THE THIRD ANNUAL REPORT II

NORC HCIA Complex/High-Risk Patient TargetingAppendix C: Methods, Claims-based Analyses . 178Appendix D: Claims-based Analyses: Supporting Exhibits . 182California Long-Term Care Education Center . 185Courage Kenny Rehabilitation Center . 186Developmental Disabilities Health System . 188Johns Hopkins Community Health Partnership . 190Johns Hopkins University School of Nursing . 202LifeLong Medical Care . 205Northland Healthcare Alliance . 207Palliative Care Consultants of Santa Barbara . 209Pittsburgh Regional Health Initiative . 210Providence Portland Medical Center . 213St. Francis Healthcare Foundation of Hawaii . 233Sutter Health Corporation . 237University Emergency Medical Services. 238University of New Mexico . 240University of North Texas . 242Appendix E: List of Evaluation Questions . 246ADDENDUM TO THE THIRD ANNUAL REPORT III

NORC HCIA Complex/High-Risk Patient TargetingList of ExhibitsExhibit ES.1:Health Care Innovation Awardees, Complex/High-Risk PatientTargeting . 2Exhibit ES.2:Conceptual Framework, Evaluation of the CHRPT Portfolio of HCIAAwardees . 3Exhibit ES.3:Cost Effects Associated with HCIA One Interventions, by Awardee . 8Exhibit ES.4:Average Quarterly Total Cost of Care for Awardees with StatisticallySignificant Findings, by Awardee . 9Exhibit ES.5:Aggregate Total Cost of Care for Awardees with StatisticallySignificant Findings, by Awardee . 10Exhibit ES.6:Effects on Hospitalizations and ED Visits Associated with HCIA OneInterventions, by Awardee . 13Exhibit ES.7:Effects on Readmissions and Quality of Care Associated with HCIAOne Interventions, by Awardee . 14Exhibit 1.1:The Complex/High-Risk Patient Targeting Awardees . 19Exhibit 1.2:Conceptual Framework, Evaluation of the CHRPT Portfolio of HCIAAwardees . 21Exhibit 1.3:Data Source and Evaluation Design for Addendum, by Awardee . 23Exhibit 1.4:Claims-Based Measures of Program Effectiveness, by Awardee . 24Exhibit 1.5:Challenges to Evaluability: Representativeness of Claims Data,By Awardee . 26Exhibit 2.1:Program Effectiveness: A Visual Guide . 27Exhibit 2.2:Summary, Awardee Chapter Contents for NORC No-Cost ExtensionAddendum . 28Exhibit CLTCEC.1:Descriptive Characteristics for CLTCEC Program Participants andComparison Participants . 32Exhibit CLTCEC.2:Impact of the CLTCEC Program on Outcomes . 34Exhibit CLTCEC.3:Impact of CLTCEC Program on Outcomes, by Quarter . 35Exhibit CLTCEC.4:Impact of CLTCEC Program on Outcomes, Second Year afterProgram Enrollment . 36Exhibit CKRI.1:Descriptive Characteristics for CKRI and Comparison GroupMedicare Beneficiaries . 40Exhibit CKRI.2:Impact of CKRI Program on Outcomes for Medicare Beneficiaries . 41Exhibit CKRI.3:Impact of CKRI Program on Outcomes for Medicare Beneficiaries,by Quarter . 42Exhibit CKRI.4:Descriptive Characteristics for CKRI and Comparison GroupMedicaid Beneficiaries . 44Exhibit CKRI.5:Impact of CKRI Program on Outcomes for Medicaid Beneficiaries . 45ADDENDUM TO THE THIRD ANNUAL REPORT IV

NORC HCIA Complex/High-Risk Patient TargetingExhibit DDHS.1:Descriptive Characteristics for DD Health Home and ComparisonGroup Beneficiaries . 48Exhibit DDHS.2:Impact of the DD Health Home Program on Outcomes . 49Exhibit J-CHiP.1:Impact of the J-CHiP Hospital Arm on Medicare Outcomes . 55Exhibit J-CHiP.2:Impact of the J-CHiP Hospital Arm by Quarter, Medicare . 56Exhibit J-CHiP.3:Descriptive Characteristics for the J-CHiP Hospital Arm andComparison Group Beneficiary-Episodes, Medicaid . 58Exhibit J-CHiP.4:Impact of the J-CHiP Hospital Arm on Outcomes, Medicaid . 60Exhibit J-CHiP.5:Descriptive Characteristics for the J-CHiP Community Arm andComparison Group Beneficiaries, Medicare. 63Exhibit J-CHiP.6:Impact of the J-CHiP Community Arm on Outcomes, Medicare . 64Exhibit J-CHiP.7:Impact of the J-CHiP Community Arm by Quarter, Medicare . 65Exhibit J-CHiP.8:Descriptive Characteristics for J-CHiP Community Arm andComparison Group Beneficiaries, Medicaid . 67Exhibit J-CHiP.9:Impact of the J-CHiP Intervention’s Community Arm, MedicaidBeneficiaries . 69Exhibit JHUSON.1:Descriptive Characteristics for Project CAPABLE and ComparisonGroup Medicare Beneficiaries . 79Exhibit JHUSON.2:Impact of the Project CAPABLE Program on Outcomes for MedicareBeneficiaries . 80Exhibit JHUSON.3:Impact of the Project CAPABLE Program on Outcomes for MedicareBeneficiaries, by Quarter . 82Exhibit JHUSON.4:Descriptive Characteristics for Project CAPABLE and ComparisonGroup Medicaid Beneficiaries . 84Exhibit JHUSON.5:Impact of the Project CAPABLE Program on Outcomes for MedicaidBeneficiaries . 85Exhibit JHUSON.6:Impact of the Project CAPABLE Program on Outcomes for MedicaidBeneficiaries, by Quarter . 86Exhibit LCCI.1:Descriptive Characteristics for LCCI and Comparison GroupBeneficiaries . 89Exhibit LCCI.2:Impact of the LCCI Program on Outcomes . 90Exhibit LCCI.3:Impact of the LCCI Program, by Quarter. 92Exhibit NCCS.1:Descriptive Characteristics for NCCS Program and ComparisonGroup Beneficiaries . 95Exhibit NCCS.2:Impact of the NCCS Program on Outcomes . 97Exhibit PCCSB.1:Descriptive Characteristics for DASH and Comparison GroupBeneficiaries . 100Exhibit PCCSB.2:Impact of the DASH Program on Outcomes . 101Exhibit PCCSB.3:Impact of the DASH Program by Quarter . 103Exhibit PRHI.1:Descriptive Characteristics for PCRC and Comparison GroupBeneficiary-Episodes. 108ADDENDUM TO THE THIRD ANNUAL REPORT V

NORC HCIA Complex/High-Risk Patient TargetingExhibit PRHI.2:Impact of PCRC Program on Outcomes . 110Exhibit PRHI.3:Impact of PCRC Program on Patients with Acute MyocardialInfarction. 111Exhibit PRHI.4:Impact of the PCRC Program on Patients with Congestive HeartFailure . 112Exhibit PRHI.5:Impact of the PCRC Program on Patients with Chronic ObstructivePulmonary Disease . 113Exhibit PPMC.1:Claims-based Findings for PPMC Programs . 117Exhibit PPMC.2:Descriptive Characteristics for PPMC HRP and Comparison GroupBeneficiaries . 120Exhibit PPMC.3:Impact of PPMC HRP on Outcomes . 121Exhibit PPMC.4:Descriptive Characteristics for New Directions Program andComparison Group Beneficiaries . 123Exhibit PPMC.5:Impact of New Directions Program on Outcomes . 124Exhibit PPMC.6:Descriptive Characteristics for PPMC ED Guides Program andComparison Group Beneficiaries . 126Exhibit PPMC.7:Impact of PPMC ED Guides Program on Outcomes . 127Exhibit PPMC.8:Descriptive Characteristics for PPMC Standard TransitionsProgram and Comparison Group Beneficiaries. 129Exhibit PPMC.9:Impact of PPMC Standard Transitions Program on Outcomes . 130Exhibit PPMC.10:Descriptive Characteristics for PPMC C-TRAIN and ComparisonGroup Beneficiaries . 132Exhibit PPMC.11:Impact of PPMC C-TRAIN Program on Outcomes . 133Exhibit PPMC.12:Descriptive Characteristics for PPMC ITT and Comparison GroupBeneficiaries . 135Exhibit PPMC.13:Impact of PPMC ITT Program on Outcomes . 136Exhibit HOPE.1:Descriptive Characteristics for the H.O.P.E. and ComparisonGroup Beneficiary-Episodes, Hospital Arm . 141Exhibit HOPE.2:Impact of the H.O.P.E. Program on Outcomes, Hospital Arm . 143Exhibit HOPE.3:Impact of the H.O.P.E. Program by Quarter, Hospital Arm . 145Exhibit HOPE.4:Descriptive Characteristics for H.O.P.E. and Comparison GroupBeneficiaries, Community Arm . 147Exhibit HOPE.5:Impact of the H.O.P.E. Program on Outcomes, Community Arm . 148Exhibit HOPE.6:Impact of the H.O.P.E. Program by Quarter, Community Arm . 149Exhibit AIM.1:Descriptive Characteristics for AIM and Comparison GroupBeneficiaries, End-of-Life Analysis . 154Exhibit AIM.2:Impact of the AIM Program on Outcomes . 155Exhibit AIM.3:AIM and Comparison Group Beneficiaries with MDS AssessmentData . 156ADDENDUM TO THE THIRD ANNUAL REPORT VI

NORC HCIA Complex/High-Risk Patient TargetingExhibit UEMS.1:Descriptive Characteristics for HEALTHIER and ComparisonGroup Beneficiaries . 160Exhibit UEMS.2:Impact of the HealthiER Program on Outcomes . 161Exhibit UEMS.3:Impact of the HealthiER Intervention by Quarter . 162Exhibit ECHO.1:Descriptive Characteristics for ECHO Care and ComparisonGroup Beneficiaries . 166Exhibit ECHO.2:Impact of the ECHO Care Program on Outcomes . 167Exhibit ECHO.3:Impact of the ECHO Care Program by Quarter . 168Exhibit BSLTOC.1:Impact of the BSLTOC Program on UTIs and Falls . 172Exhibit C.1:Types of Analyses for Claims-Based Measures in NORCAddendum Report . 179Exhibit C.2:Status of Medicaid Data Sources . 180Exhibit C.3:Supplemental Measures for Post-Acute Care Awardees . 181Exhibit D.1:Analyses that Include Common Support and Covariance BalanceCharts by Awardee . 183Exhibit D.2:Analyses that Include Quarterly Fixed Effects Charts of the Impactof HCIA-Funded Innovations on Outcomes by Quarter by Awardee . 184Exhibit D.CLTCEC.1: Test of Common Support and Covariate Balance, CLTCEC Program 185Exhibit D.CKRI.1:Test of Common Support and Covariate Balance, Medicare . 186Exhibit D.CKRI.2:Test of Common Support and Covariate Balance, Medicaid . 186Exhibit D.CKRI.3:Impact of the CKRI Program on Outcomes for MedicaidBeneficiaries, by Quarter . 187Exhibit D.DDHS.1:Test of Common Support and Covariate Balance, DD Health Home . 188Exhibit D.DDHS.2:Impact of the DD Health Home Program by Quarter. 189Exhibit D.J-CHiP.1:Common Support and Covariate Balance for J-CHiP and ComparisonBeneficiary-Episodes, Medicare . 190Exhibit D.J-CHiP.2:Common Support and Covariate Balance for Dually Eligible J-CHiPand Comparison Beneficiary-Episodes, Medicaid Analysis . 191Exhibit D.J-CHiP.3:Common Support and Covariate Balance for Medicaid Only J-CHiPand Comparison Beneficiary-Episodes, Medicaid Analysis . 192Exhibit D.J-CHiP.4:Impact of the J-CHiP Hospital Arm on Outcomes by Quarter,Medicaid . 193Exhibit D.J-CHiP.5:Common Support and Covariate Balance for J-CHiP andComparison Participants, Medicare . 194Exhibit D.J-CHiP.6:Impact of the J-CHiP Community Arm on Medicare Outcomes byQuarter . 195Exhibit D.J-CHiP.7:Common Support and Covariate Balance for Dually Eligible andComparison Participants, Medicaid Analysis . 196Exhibit D.J-CHiP.8:Common Support and Covariate Balance for Medicaid Only andComparison Participants, Medicaid Analysis . 196ADDENDUM TO THE THIRD ANNUAL REPORT VII

NORC HCIA Complex/High-Risk Patient TargetingExhibit

Exhibit LCCI.2: Impact of the LCCI Program on Outcomes ..... 90. Exhibit LCCI.3: Impact of the LCCI Program, by Quarter..... 92. Exhibit N