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TitleHCIA Disease-Specific Evaluation
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Table of Contents
                            HCIA Disease-Specific Evaluation
Disease-Specific Awardees
Table of Contents
List of Exhibits
	Executive Summary
		Evaluation Goals and Methods
		Conclusion
	Introduction
		Disease-Specific Innovation Awards
		Data Sources and Methods
			Qualitative Data and Methods
			Quantitative Data and Methods
		Implementation Effectiveness
		Program Effectiveness
			Overview of Qualitative Findings
			Overview of Quantitative Findings
		Awardee Specific Chapters
	Awardee-Specific Findings
	Christiana Care Health System
		Introduction
		Summative Findings of Program Effectiveness
			Subgroup Analysis: Ramp-up Period
			Qualitative Findings
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	Duke University/Southeastern Diabetes Initiative
		Introduction
		Summative Findings of Program Effectiveness
			Qualitative Findings
		Cross-Site Variation
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	FirstVitals Health and Wellness, Inc.
		Introduction
		Summative Findings of Program Effectiveness
			Qualitative Findings
		Cross-Site Variation
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	The George Washington University
		Introduction
		Summative Findings of Program Effectiveness
			Qualitative Findings
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	Health Resources in Action
		Introduction
		Summative Findings of Program Effectiveness
			Subgroup Analysis: Race and Ethnicity
			Qualitative Findings
		Cross-Site Variation
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Planned Analyses for the No-Cost-Extension Period
		Limitations
		Conclusion and Policy Implications
	Trustees of Indiana University
		Introduction
		Summative Findings of Program Effectiveness
			Condition-specific Impact Estimates
			Long-term Care Placement Analysis
			Qualitative Findings
		Cross-Site Variation
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	Innovative Oncology Business Solutions, Inc.
		Introduction
		Summative Findings of Program Effectiveness
			Cross-Site Variation
			Subgroup Analysis: Cancer Type
			Subgroup Analysis: End of Life
			Qualitative Findings
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	Joslin Diabetes Center, Inc.
		Introduction
		Summative Findings of Program Effectiveness
			Qualitative Findings
		Workforce
		Context
		Sustainability, Replicability, and Spread
		Limitations
		Conclusion and Policy Implications
	Le Bonheur Community Health and Well-Being
		Introduction
		Summative Findings of Program Effectiveness
			Qualitative Findings
			Patient Experiences
				Clinic
				Home
				Community
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	Mountain Area Health Education Center, Inc.
		Introduction
		Summative Findings of Program Effectiveness
			Qualitative Findings
		Cross-Site Variation
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	Nemours Children’s Health System of Nemours Foundation
		Introduction
		Summative Findings of Program Effectiveness
			Qualitative Findings
				Patient Experience
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	Ochsner Clinic Foundation
		Introduction
		Summative Findings of Program Effectiveness
			Subgroup Analysis: High-Risk
			Subgroup Analysis: Stroke Mobile
			Qualitative Findings
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	University of Alabama at Birmingham
		Introduction
		Summative Findings of Program Effectiveness
			Cross-Site Variation
			Subgroup Analysis: Cancer Type
			Subgroup Analysis: End of Life
			Qualitative Findings
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	Regents of the University of California, Los Angeles
		Introduction
		Summative Findings of Program Effectiveness
			Qualitative Findings
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	Trustees of the University of Pennsylvania
		Introduction
		Summative Findings of Program Effectiveness
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	Upper San Juan Health Service District
		Introduction
		Summative Findings of Program Effectiveness
			Qualitative Findings
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusions and Policy Implications
	The Rector and Visitors of the University of Virginia
		Introduction
		End-of-Life Analysis
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	Vanderbilt University Medical Center
		Introduction
		Summative Findings of Program Effectiveness
			Transitions Care Coordination Program
			Outpatient Chronic Care Management Program
			Qualitative Findings
		Cross-Site Variation
		Workforce
		Context
		Sustainability, Scalability, and Spread
		Limitations
		Conclusion and Policy Implications
	Cross-Awardee Findings
	Innovation in Care Coordination
		Care Coordination Models
		Care Coordination: Composition of Teams and Activities,  and Evidence of Program Effectiveness
		Descriptions of Care Coordination Teams
		Care Coordination and Program Effectiveness
		Limitations
		Summary
	Decreased Utilization and Improved Quality of Life for  Pediatric Asthma Patients and Families
		Research Questions
		Data Sources
		Program Components and Program Populations
		Program Effectiveness
		Drivers of Program Effectiveness
		Implications for Future Programs
		Limitations and Next Steps
		Summary
	Decreased Utilization and Improved  Quality of Care Outcomes for Patients with Cancer
		Research Question
		Reductions in Utilization and Quality-of-Life Improvements
		Methods
		Limitations
		Summary
	Decreased Utilization and Improved Caregiver Quality of Life for Patients with Dementia
		Research Questions
		Data Sources
		Program Components, Workforce Models, and Implementation
		Program Effectiveness and Core Outcomes
		Caregiver Experience
		Implications for Future Programs
		Summary
	Improved Diabetes Outcomes in Large Health Systems
		Consolidated Framework for Implementation Research:  Assessing Barriers and Facilitators to Program Implementation
		Research Questions
		Data Sources and Methods
		Adaptability and Complexity
		Innovative Use of Technology
		Partnerships
		Key Findings: Program Effectiveness
		Implications for Future Programs
		Limitations
		Conclusion
	TECHNICAL APPENDICES
	Appendix A: Quantitative Methods
		Dataset Construction
			Post-Acute Care Interventions
			Ambulatory Care Interventions
		Comparison Group Selection
		Analytic Methods
		Claims-Based Analysis:
			Difference-in-Differences
			Time Series Analysis
		Awardee Data Analysis
			Dosage Analysis
		Program costs Analysis
	Supplements for Awardee Chapters
	Christiana Care Health System
		Treatment and Comparison Group Creation
		Second Year Analysis
	Duke University’s Southeastern Diabetes Initiative
		High-Risk Intervention Analysis
	FirstVitals Health and Wellness, Inc.
		Treatment and Comparison Group Creation
	The George Washington University
		Treatment and Comparison Group Creation
	Health Resources in Action
	Trustees of Indiana University
		Treatment and Comparison Group Creation
	Innovation Oncology Business Solutions, Inc.
		Treatment and Comparison Group Creation
		End-of-Life Analysis
	Joslin Diabetes Center, Inc.
	Le Bonheur Community Health and Well-Being
		Treatment and Comparison Group Creation
	Mountain Area Health Education Center, Inc.
	Nemours Children’s Health System of Nemours Foundation
		Treatment and Comparison Group Creation
	Ochsner Clinic Foundation
		Stroke Central
		High-Risk Analysis
		Stroke Mobile Analysis
	University of Alabama at Birmingham
		Treatment and Comparison Group Creation
			End-of-Life Analysis
	Regents of the University of California, Los Angeles
		Treatment and Comparison Group Creation
	The Rectors and Visitors of the University of Virginia
		Treatment and Comparison Group Creation
			End-of-Life Analysis
	Vanderbilt University Medical Center
		Transitions Care Coordination (TCC) Program
			Treatment and Comparison Group Creation
		Outpatient Chronic Care (OCC) Management Program
			Treatment and Comparison Group Creation
	Diabetes Cross-Awardee Supplement
	Appendix B: Qualitative Methods
		Data Collection
		Qualitative Coding
                        
Document Text Contents
Page 1

T H I R D A N N U A L R E P O R T

HCIA Disease-Specific Evaluation



FEBRUARY 2016 PRESENTED TO:
Caitlin Cross-Barnet &
Erin Murphy Colligan
Center for Medicare & Medicaid
Innovation
7500 Security Blvd Mail Stop:
WB-06-05
Baltimore, MD 21244
(410) 786-0263

PRESENTED BY:
NORC at the University of Chicago
Adil Moiduddin
Vice President, Health Care Research
4350 East-West Hwy, Suite 800
Bethesda, MD 20814
(301) 634-9419
Contract No. HSSM-500-2011-00002I,
Order No. HHSM-500-T00009

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NORC | HCIA Disease-Specific Evaluation

THIRD ANNUAL REPORT | I

Disease-Specific Awardees

Awardee Name Abbreviation

Christiana Care Health Services, Inc. Christiana

Duke University’s South Eastern Diabetes Initiative SEDI

FirstVitals Health and Wellness, Inc. FirstVitals

The George Washington University GWU

Health Resources in Action, Inc. HRiA

Trustees of Indiana University Indiana

Innovative Oncology Business Solutions, Inc. IOBS

Joslin Diabetes Center, Inc. Joslin

Le Bonheur Community Health and Well-Being Le Bonheur

Mountain Area Health Education Center, Inc. MAHEC

Nemours Children’s Health System of the Nemours Foundation Nemours

Ochsner Clinic Foundation Ochsner

University of Alabama at Birmingham UAB

Regents of the University of California, Los Angeles UCLA

The Trustees of the University of Pennsylvania UPenn

Upper San Juan Health Service District USJHSD

The Rector and Visitors of the University of Virginia UVA

Vanderbilt University Medical Center Vanderbilt

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THIRD ANNUAL REPORT | 187

with high socioeconomic status, and most focus group participants from that site reported little need for
assistance following discharge. Maury served a more rural and lower-income population and included a
social worker on its team to help address social needs following discharge. VUMC’s patients had access
to an array of resources in the large academic medical center and in the urban setting of Nashville.

The three sites targeted different conditions, and the target conditions changed over time. As
described in the quantitative analysis section, the sites varied in the number and type of conditions they
targeted. For their TCC programs, VUMC and Maury targeted congestive heart failure (CHF), chronic
obstructive pulmonary disease (COPD), acute myocardial infarction (AMI), and pneumonia; Williamson
targeted only CHF. Over the course of the intervention, the OCCs at all three sites expanded their
inclusion criteria from hypertension (HTN), CHF, and diabetes mellitus to include active smokers and
individuals with multiple or complex health conditions.

Workforce

OCCs reported high satisfaction with their
work. High satisfaction was reflected in the low
turnover among OCC staff.

Maury’s single TCC was well integrated into
the hospital’s workflow, whereas multiple
TCCs at the other two sites were not. Maury’s
TCC reported having good communication with
inpatient nurses and discharge social workers, as well as support from the hospital administration. She
managed the disease-specific portion of the patient’s transition to home from the inpatient stay and
conducted follow-up, whereas social workers handled all other aspects of the discharge process. In
contrast, there was turnover among TCCs at VUMC and Williamson. Williamson’s TCCs experienced
difficulty integrating into the inpatient team’s workflow, and VUMC’s TCCs reported being asked to take
on more case management and discharge planning than expected. Over time, VUMC and Williamson did
not replace the TCCs who left, and only Maury sustained the TCC role as developed through the program.

With the addition of patients with complex concerns to the target conditions, some OCCs worried
that they may not have the skills to support patients remotely. They reported that knowledge about
CHF, COPD, and diabetes was a fundamental part of their training and practice as nurses. However,
patients with complex conditions—including those who had more than two admissions in the past year
and sought care from multiple specialists—presented challenges beyond their knowledge and expertise.

“I used to work as a PCP nurse. You would see
[patients] in clinic, send them home, and not know
outcomes. We are the resource between visits, so we
see the A1c going down because the patient is on-
board with counting carbs [so we can] help them
educate their families. You know, they see you as
someone they can call on as a resource to them. That
is the most satisfying for me.”

—Outpatient Nurse Coordinator

Context

As a large teaching and research center, Vanderbilt engaged in many other complementary
research projects; this situation might have interfered with our ability to assess the impacts of the
HCIA program. For example, Vanderbilt was the recipient of another HCIA grant aimed at reducing
hospitalizations among Medicare beneficiaries through a collaboration between VUMC and one of 23
partnering skilled nursing facilities (SNFs) in Tennessee and Kentucky. This essentially removed from the
TCC target population all of the patients who were being discharged to a SNF.

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THIRD ANNUAL REPORT | 188

Trends in health care toward value-based payments put pressure on Vanderbilt to develop a care
coordination program. Health care financing is shifting from fee-for-service to value-based payment
models. Although Vanderbilt was not an accountable care organization (ACO), there were two ACOs in
the Nashville area and six others throughout the state.

Sustainability, Scalability, and Spread

Vanderbilt sustained its OCC program beyond
the award period through internal institutional
support. In light of the environmental pressure to
move toward value-based care, program
leadership committed to sustaining the program
beyond the award period despite limited evidence of effectiveness.

Maury sustained its TCC program through internal institutional support and sought to expand it,
whereas the other two sites did not. VUMC reported that it was considering how to integrate the TCC
program into its general case management program; Williamson disbanded its TCC program altogether.
Hospital staffs at VUMC and Williamson were generally unclear regarding the role of the TCCs and
therefore had difficulty integrating the TCC role into the existing case management structure.

Working with a private payer, Vanderbilt began testing a remote model of care coordination using
claims data rather than providers’ patient panels. OCCs began to recruit patients based on their claims
records by calling and sending letters to high-risk patients. They found that many patients at first were
skeptical, so they modified their approach by offering face-to-face office visits.

“Society has demanded improved value, and the
payers are demanding it and all the consultants tell the
leadership here that care coordination has to be a part
of it. So it is sustained.”

—Program Leader

Limitations

For our quantitative analysis of the OCC program, we excluded patients with conditions other than
hypertension and/or diabetes mellitus, as those were the only enrollment criteria identifiable in claims.
Our analyses, therefore, may not capture the overall impact of the Vanderbilt OCC program. Our OCC
analysis only focused on Medicare beneficiaries in part because of the availability of claims and
Vanderbilt’s policy of not serving Medicaid patients in outpatient settings.

We developed our findings from site visits and telephone interviews with program leaders and staff
members and four focus groups with participants at VUMC and Williamson. We also conducted three
telephone interviews with patients at Maury. Program staff randomly selected participants who they knew
had interacted with a TCC or an OCC, although many participants did not recognize that either of them
was part of a special program. Only those who regularly engaged with a care coordinator (eight of 26
participants) could comment on the program.

Conclusion and Policy Implications

Vanderbilt’s award program used OCCs and TCCs in an attempt to provide better care and improve
patient health through smarter spending. They implemented programs across three sites that differed in
size, geographic setting, and technological capacity. VUMC, the largest and most urban site, invested
heavily in its HIT to create an electronic surveillance system and a care coordinator dashboard. Its OCCs

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THIRD ANNUAL REPORT | 386

Exhibit B.4: Main Code Families Used for Patient and Caregiver Interviews

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THIRD ANNUAL REPORT | 387

Exhibit B.5: Subcodes Used in Patient and Caregiver Interview Coding

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