PERFORMANCE IMPROVEMENT 2000

Chapter III

Compendium of HHS Agency FY 1999

Evaluations Completed and In Progress

HEALTH RESOURCES AND SERVICES ADMINISTRATION

MISSION: To improve the Nation’s health by assuring equitable access to comprehensive, culturally competent, quality health care for all.

The Health Resources and Services Administration’s (HRSA) evaluation program is designed to enhance strategic planning, strengthen budget and legislative development, and improve program performance. HRSA’s evaluation priorities are to (1) develop and strengthen performance measurement and information management systems, (2) assess program implementation and identify opportunities for improvement in strategies and management, (3) determine the effectiveness of HRSA programs and strategies, and (4) conduct environmental assessments, such as analysis of crosscutting policies and issues impacting HRSA and its varied constituencies.

Performance Measurement and Information Systems–This area includes assistance, training, and support to strengthen the agency’s capacity to respond to the requirements of the Government Performance and Results Act (GPRA) and to build information systems that are needed for effective program planning, management and evaluation. HRSA has relied heavily on a completed study that established a performance measurement baseline for all operating programs, using a common framework to develop program-specific logic models. HRSA continues to invest substantial funding to provide assistance tailored to the specific needs of individual agency programs. These efforts have focused on (1) assisting with identification and verification of indicators and measures and development or refinement of information systems, and (2) helping HRSA components enhance their capacity to plan for, collect, analyze, and use information submitted by grantees for program management as well as for GPRA reporting. One result of this assistance was a partnership between the Maternal and Child Health Bureau (MCHB) and the States to develop a set of standard performance measures for the Maternal and Child Health block grant that are now being used by MCHB and the States in goal setting and in performance monitoring and reporting. The Bureau of Primary Health Care’s work on Development and Testing of Emergency Department Utilization as a Measure of Performance for the Health Care for the Homeless Program (PIC 7415) is another example of activities in this priority area. Another project begun in 1998, Crosscutting HRSA-Wide Performance Strategy (PIC 7131), builds on program-specific efforts to link the HRSA strategic plan, annual performance plans, and budgets through a set of HRSA-wide performance strategies which are to: eliminate barriers to care, eliminate health disparities, assure quality of care and improve public health and health care systems.

Program Implementation and Management–These studies provide information for developing, implementing, and modifying HRSA programs and strategies. A completed study, Data Collection and Budget Forecasting Strategies: A Primer for State AIDS Drug Assistance Programs (PIC 7159), produced a primer that will enable the State-administered AIDS Drug Assistance Programs to estimate their expenditures more accurately and, consequently, administer the federal funds more efficiently. Strategies for the Recruitment, Retention, and Graduation of Hispanics into the Baccalaureate Level of Nursing (PIC 6249) developed a model that can be used by institutions of higher education seeking to increase the proportion of Hispanic Americans admitted to baccalaureate programs as their initial entry into nursing education. A 1999 study, Assessment of Domestic Violence Interventions and Staff Training Protocols in Community-Based Primary Health Care Settings (PIC 7284), is examining the characteristics of existing domestic violence protocols and related training and referral patterns with a view to recommending how other Bureau of Primary Health Care-funded programs can develop effective domestic violence interventions.

Program Effectiveness–Studies in this area assess the intermediate and longer-term results or impact of programs in achieving specified objectives and goals. For example, the Impact of Community Health Workers on Access, Use of Services and Patient Knowledge and Behavior (PIC 6355) showed that use of community health workers in HRSA-funded programs led to increased access to care for patients, and to increased knowledge of nutrition and other topics to promote a healthy lifestyle. The study of Effectiveness of the National Health Service Corps (PIC 6357) is assessing the program over time, using retention in primary care, continued service in underserved areas, and other indicators as measures of effectiveness. The National Evaluation of the Healthy Start Program (PIC 5610) is a multi-year study that uses outcome and process measures to assess the impact of the program on infant mortality and other birth outcomes in Healthy Start sites as compared to matched comparison communities. Another example is the ongoing study of the Impact of RWCA Title I Funding on HIV Services Utilization and Health Outcomes in Las Vegas, Nevada and Norfolk, Virginia, which is examining how Title I grants affect the availability, accessibility, quality, continuity and integration of care, and HIV-related morbidity in these metropolitan areas that are newly eligible for RWCA funding.

Environmental Assessment–This area of study addresses the ways in which major policy initiatives and/or other forces in HRSA’s external environment affect HRSA’s programs, clients, or progress toward achieving strategic goals and objectives. For example, the ongoing project, Managed Care and Safety-Net Providers (PIC 6815), examines the impact of Medicaid managed care and other changes in health care coverage on the future viability of safety-net providers, including HRSA-funded Community Health Centers. A 1999 study of the Cost Implications of Providing 12 Months’ Continuous Coverage for Children Under Public Health Insurance Mechanisms (PIC 7236) assesses the effect of policies to extend eligibility for Medicaid or SCHIP on the administrative and service costs of caring for children. Recently completed, A Pilot Study to Identify Infrastructure Building Across HRSA Programs (PIC 6814) has provided information on the influence of market changes on HRSA programs and how HRSA programs synergistically interact to contribute to the development of a health care infrastructure at the community level.

Community Health Centers

Development and Testing of Emergency Department Utilization as a Measure of Effectiveness for the Health Care for the Homeless Program

The purpose of this study was to test the hypothesis that the presence of a Health Care for the Homeless (HCH) program in a community, by providing homeless clients with a medical home, reduces their use of emergency departments (EDs) for non- emergency use. The HCH program provides primary care and substance abuse services for over 450,000 homeless annually. Through outreach, case management, and linkages with social services, the program has provided homeless clients with a comprehensive medical home. This study took a sample of homeless people in six communities with HCH projects. The study assisted in developing performance measures for the HCH program, and provided a foundation for future evaluation studies. For the six study sites, the project provided information on the ability of the HCH program to divert inappropriate use of EDs.

Primary Care of Patients with Hypertension By Community Health Centers

Community health centers (CHCs) are private, not-for-profit or publicly supported organizations that provide primary health care in medically-underserved areas throughout the U.S. and its territories. These health centers play an integral role in the Nation's safety net for people who lack health insurance or face other barriers to health care. As such, they receive substantial Federal support through grant funds and the Medicaid and Medicare programs. In 1994, the Bureau of Primary Health Care funded an in-person survey of CHC users modeled on the National Health Interview Survey (NHIS). The survey found that CHC users are disproportionately at risk for hypertension, and therefore at serious risk for coronary heart disease, stroke and premature death. The purpose of this project is twofold: (1) to compare the prevalence of hypertension among adult CHC users with other low-income, vulnerable U.S. adults who may similarly face barriers to health care; and (2) to assess whether CHC care of hypertensive patients meets nationally accepted standards.

Results of a Multisite Study of Mandatory Medicaid Managed Care Enrollment Systems: Implications for Policy and Practice

Under most Medicaid managed care programs, beneficiaries who do not select a plan are automatically assigned to one. This study describes the effects of enrollment and autoenrollment (automatic assignment) policies and practices under mandatory Medicaid managed care on federally qualified health centers (FQHCs), FQHC networks and plans, and their patients. The research indicated that while states had similar enrollment practices, their approach to outreach and education regarding enrolling in managed care differed; the lack of information available to beneficiaries on providers and plan networks was seriously compromising or foreclosing their choices; the rate of autoenrollment was not necessarily a useful means of assessing the effects of Medicaid policies; managed care plans were more concerned about the overall decline in Medicaid cases and financial losses due to the instability of the pool of eligible beneficiaries than in autoenrollment policies; while enrollment was important to FQHCs, they were more concerned about financing and reimbursement; beneficiaries felt the ability to choose and stay with a particular provider was their most important concern, despite the emphasis on choosing a plan during enrollment; and although information provided to beneficiaries was limited, they valued material from such familiar sources as their regular provider. Most important of all, the research revealed that pressure from the rapid implementation of enrollment and autoenrollment policies was creating a lack of accurate information on provider networks both before and during enrollment. The report recommends States make advance preparations for mandatory enrollment periods to ensure that more comprehensive information is available to beneficiaries.

PERFORMER: George Washington University, Center for Health Policy Research
Washington, DC

Cross-Cutting

A Pilot Study to Identify Infrastructure Building Across HRSA Programs

The Health Resources and Services Administration (HRSA) provides a healthcare infrastructure or safety net for certain vulnerable and underserved populations through such programs as Ryan White Pediatric AIDS and Healthy Start, a program to reduce deaths among babies in areas with high rates of infant mortality. This study examined various communities to describe how HRSA programs contribute to its goals and how its funding affects the development of a community's healthcare safety net. The research indicated that while HRSA funds only a small portion of the total support of an organization, regardless of the amount, the money is being used to leverage additional funding. Without HRSA funding, some essential services would be significantly reduced or cease to exist altogether. These and other findings as well as recommendations for collecting information for future assessment and planning purposes were included in the study.

Demonstration and Evaluation of Diverse Methods of Technical Assistance Provision to HBCUs

The purpose of this study was to determine the better of two approaches for providing technical assistance to Historically Black Colleges and Universities (HBCUs) to increase their participation in Health Resources and Services Administration (HRSA) projects. Because HBCUs have had a long tradition of providing social services to minority and low-income communities, they are particularly well-suited for participating in HRSA's programs aimed toward ensuring access to adequate healthcare for minorities and disadvantaged groups. The two approaches evaluated for delivering technical assistance were to conduct workshops: (1) in a regional setting, involving 20 HBCUs, and (2) on-site at campuses of 5 HBCUs. The study determined that the former was the better of these approaches. This and other findings and recommendations were included in the study.

PERFORMER: Institute for College Research Development and Support
Silver Spring MD

The purpose of this study, which is jointly sponsored by the Health Resources and Services Administration (HRSA) and the Health Care Financing Administration (HCFA) and managed by HCFA, is to develop: (1) a design for evaluating a demonstration financed by the HCFA in 1997 in selected New York State teaching hospitals, and (2) recommendations for evaluating Phase II of the demonstration, along with related provisions of the Balanced Budget Act (BBA). The 42 hospitals in the current demonstration volunteered to reduce the number of resident physicians in training by 20 percent or more over a five year period, while maintaining or increasing the proportion in their primary care program. In return, the HCFA provides transition payments of $400 million over six years. The hospitals repay the payments if they fail to meet their reduction targets. The BBA provides similar options for hospitals in other States and modifies the transitional payment policies by eliminating payment for the first five percent reduction in the full-time equivalent residents. Evaluation objectives include: (1) performance in meeting targets for reductions, (2) impact on access and efficiency, and (3) potential spillover effects on non-participating hospitals.

HIV/AIDS Services

Development of Estimates of Unduplicated Annual Administrative Report Client Counts Based Upon Client-Level Demonstration Projects

This report provides estimates for the degree of duplication in the Annual Administrative Report (AAR) database in the number of clients receiving Title I and Title II Ryan White Comprehensive AIDS Resources Emergency Care Act (CARE) services. The goal of the research was to develop and test statistical models for predicting unduplicated counts of clients receiving the services using the information contained in the Annual Administrative Report (AAR) and to determine the degree that the aggregate AAR data overestimates the number of clients served with Ryan White funds. These estimates were needed for evaluation and information purposes, including the Government Performance and Results Act (GPRA). Estimates were needed for the number of clients by state and for the nation. The overestimate was calculated at 37 percent, thus reducing the total of AAR clients reported in 1996 to 502,064. Thus, the Ryan White program managed to serve a little over half (55.5 percent) of the 950,000 people who had HIV in the United States in 1996. The regression analysis model developed in the study was a significant improvement over other methods.

Maternal and Child Health

Infant Mortality Prevention in American Indian Communities: Northern Plains Healthy Start

This report is part of a national cross-site evaluation of the 15 funded demonstration projects funded by HRSA on the Healthy Start program regarding infant mortality. Because the Northern Plains project exhibits features unique to rural Indian communities, such as a higher incidence of post-neonatal mortality, and because it is so large and complex, the evaluation team conducted a special study of Northern Plains Healthy Start (NPHS). As with the broader national study, the NPHS evaluation draws on multiple data sources, analyzing data from site visits, focus groups, the project's client data system, a post-partum survey, and vital statistics. The data from the report do not demonstrate a significant impact on infant mortality from the NPHS program. However, there were significant project effects on the adequacy of prenatal care and the incidence of adolescent pregnancy.

State Children's Health Insurance Program

An Analysis of Implementation Issues Relating to CHIP Cost-Sharing Provisions for Certain Targeted Low Income Children

Title XXI of the Social Security Act permits State Children's Health Insurance Programs (CHIP) to impose cost sharing on beneficiaries, when the program is not an expansion of the State's Medicaid program. (Under Medicaid, cost-sharing for services to children is prohibited.) This project analyzes cost-sharing models that can be used by States to track cumulative out-of-pocket expenditures for State CHIP activities and employer-based health insurance plans that participate in CHIP; and reviews findings from studies that examine the relationships among health insurance premiums, cost-sharing arrangements, and enrollment and utilization by low income families. Findings will inform guidance for States in designing cost-sharing provisions for the CHIP plans.

In-Process Evaluations

Community Health Centers

Assessment of Domestic Violence Interventions and Staff Training Protocols in Community-Based Primary Care Health Care Settings
Determinants of Change in Health Center Revenues, Service Capacity, and Payor Mix at the Marketplace Level
Evaluation of the Effectiveness and Impact of Community and Migrant Health Centers: Implementation Phase
Evaluation of the Relationship Between Enabling Services and Patient Access and Outcomes
Health Care Status Outcome Measures for the Bureau of Primary Health Care: The Assessment of Ambulatory Care Sensitive Conditions Through State Medicaid Research Files
Health Status Outcome Measures for the Bureau of Primary Health Care: Examination of Episodes of Care for Diabetes, Hypertension, Asthma and Other Ambulatory Care Sensitive Conditions
Health Status Outcomes for the Bureau of Primary Health Care: A Pilot Study Assessing Physiologic Measures Through Medical Record Review
Impact of Publicly Funded Insurance Programs on Pediatric Safety -Net Providers
Year 2000 Community Health Center and National Health Service Corps User/Visit Survey

Cross-Cutting

Analysis of Client-Level Data from the National Survey of Homeless Assistance Providers and Clients
Development of an Inventory of Health Indicators Comparing Large U.S. Cities
Health Needs of Gay, Lesbian, Bisexual, and Transgender Communities
Historically Black Medical Colleges' Participation in HRSA-Supported Health Professions Training Programs
State-Level Assessment of Current Access and Utilization of Dental Services and Dental Services Infrastructure

Expanding Access to Care

Safety-Net Provider Capacity for Care to Low-Income Uninsured Patients

Health Professions

Employment Sites of Nursing Graduates Supported by the Professional Nurse Traineeship Program
Nurse Staffing and Quality of Care in Hospitals

HIV/AIDS Services

Comparison of Services Received and Health Outcomes for Persons Funded by the CARE Act and by Other Sources
HIV Service Utilization and Health Outcomes for PLWH with Comorbidities in RWCA-Funded Programs
HIV/AIDS Cost Analysis and Development of Capitation Rate Methodology
Impact of RWCA Title I Funding on HIV Services Utilization and Health Outcomes in Las Vegas, Nevada and Norfolk, Virginia
Population- and Data-Based Assessment of Unmet HIV Service Needs

Managed Care

Managed Care and the Safety Net-Providers

Maternal and Child Health

National Evaluation of the Healthy Start Program
The Impact of the State Children's Health Insurance Program on Selected Community Health Centers and Maternal and Child Health Programs

National Health Service Corps

Effectiveness of the National Health Service Corps

State Children's Health Insurance Program

Cost Implications of Providing 12 Months' Continuous Coverage for Children Under Public Health Insurance Mechanisms

Community Health Centers

Assessment of Domestic Violence Interventions and Staff Training Protocols in Community-Based Primary Care Health Care Settings

The purposes of this study are to examine a) the characteristics/components of the domestic violence protocols used in HRSA-funded community-based primary health care centers; b) the effect that these protocols have on the reporting of violence, clinical diagnoses, and referrals to local community services among female clients; and c) how other BPHC-funded programs can develop domestic violence interventions in their organizations and communities. Health providers often treat abused women without recognizing or addressing the underlying causes of their health condition. A 1995 survey of 10 BPHC-funded primary health care sites found that only half had a formal tool for assessing domestic violence. This study will analyze time series data to compare the effects of incorporating a protocol on domestic violence. Statistical analysis will control for sociodemographic characteristics and other known confounders. In-depth telephone interviews will be conducted with health care center staff (protocol developers, trainers, and key program coordinators). Documentation, screening, and reporting procedures will be reviewed. Training and referral strategies will be analyzed. Nine sites will be selected for study based on a comprehensive literature review of domestic violence interventions during the past five years. A Steering Committee for Family and Intimate Partner Prevention Violence, comprised of HRSA staff, will provide advice on methods.

Determinants of Change in Health Center Revenues, Service Capacity, and Payor Mix at the Marketplace Level

The purpose of this study is to examine the impact of changes in environmental and management factors in the health care system on the revenues, service capacity, and payor mix of Community Health Centers (CHCs). A previous study found that nationally, Medicaid users have decreased, uninsured users have increased, and Medicaid revenues per user have decreased somewhat. This study will explore CHC-specific data in selected areas of the country. Independent variables to be studied include the percentage of Medicaid recipients in managed care and the overall managed care penetration; the percentage and growth of uninsured; the number and nature of HMOs providing Medicaid services; the safety net provider capacity; Medicaid enrollment; patient access/satisfaction; participation in integrated delivery systems and networks; extent of CHC participation in managed care and; CHC performance (based on nine measures used in BPHC's health center reinvestment process). Data will be drawn from the 12 areas in the RWJ Community tracking study, complemented by BPHC Market Place Analysis information for 4-5 areas. Relevant State Insurance Department and State Hospital Association data, and the Dartmouth Atlas will be reviewed. Data for CHCs will be drawn from BPHC's Uniform Data System.

Evaluation of the Effectiveness and Impact of Community and Migrant Health Centers: Implementation Phase

This comprehensive evaluation of the effectiveness and impact of Community Health Centers (CHCs), begun in 1994, has two components. The content of care component will assess CHC clinical performance and suggest indicators of targets of opportunity for improving patient health status. The Medicaid analysis portion of the study is using Medicaid claims data from seven States (one with Medicaid managed care) to examine three questions: (1) Is there a difference in case mix between Medicaid beneficiaries using CHCs and beneficiaries using other providers of primary care? (2) Are there differences in utilization and expenditures between CHC users and non-users, and what is the effect of adjusting for case mix on these differences? (3) How do CHC characteristics contribute to differences in use and expenditures among CHC users? The findings from this study will identify opportunities and challenges for health centers in both fee-for-service and managed care settings. (See PIC ID 4918)

Evaluation of the Relationship Between Enabling Services and Patient Access and Outcomes

Community and Migrant Health Centers (C/MHCs) provide extensive enabling services to facilitate access to care for vulnerable populations. These services--which include transportation, translation, case management, health education, nutrition counseling and outreach-- are not typically reimbursed under managed care. The purpose of this study is to analyze the types and levels of enabling services provided by C/MHCs, how these services have changed over time, and whether enabling services improve outcomes and reduce costs. Study findings will be used to inform national program expectations and to guide C/MHCs in structuring their enabling services to maximize access to primary care and preventive services.

Health Care Status Outcome Measures for the Bureau of Primary Health Care: The Assessment of Ambulatory Care Sensitive Conditions Through State Medicaid Research Files

This project will compare the relative risk of inpatient hospitalizations for Community Health Center (CHC) users with non- CHC users for ambulatory care sensitive conditions. Ambulatory care sensitive conditions are those considered preventable, treatable, or controllable in an outpatient setting. The project will design and test a methodology using selected areas in selected states from the newly available State Medicaid Research Files (SMRF). Major research questions for the study include: (1) the best methodological design to assess relative risk of inpatient hospitalizations for selected ambulatory conditions; (2) the relative risk of inpatient hospitalizations.

Health Status Outcome Measures for the Bureau of Primary Health Care: Examination of Episodes of Care for Diabetes, Hypertension, Asthma and Other Ambulatory Care Sensitive Conditions

A consensus conference in December, 1995 recommended the use of Medicaid data to examine changes in utilization patterns for Community Health Center (CHC) patients diagnosed with ambulatory care sensitive conditions (ACSCs). These are conditions which frequently can be managed with timely and effective treatment in outpatient settings, thus preventing the need for hospitalization. The purpose of this study is to compare episodes of ambulatory care for CHC users to those of non- CHC users when both have been hospitalized with a primary diagnosis of diabetes, hypertension, asthma, or other ACSCs, as well as when neither has been hospitalized. A previous study (See PIC ID 6001) showed that Medicaid beneficiaries who received most of their care from CHCs had lower hospitalization rates for ACSCs than did non-CHC users. Findings of the current study will improve understanding as to why CHC users experience lower hospitalization rates for ACSCs, and may have different patterns of ambulatory care use. Findings should also identify the major strengths and limitations of the State Medicaid Research Files for examining episodes of care for a comparison of CHC users and non-CHC users.

Health Status Outcomes for the Bureau of Primary Health Care: A Pilot Study Assessing Physiologic Measures Through Medical Record Review

Through a review of medical records, this study will assess changes in health status among a sample of adult patients of Community Health Centers (CHCs). The conditions selected for evaluation are hypertension and diabetes mellitus. The review will address: (1) the definition of a CHC "user"; (2) confirmation of a diagnosis; (3) patient stratification by severity and/or onset of the condition; (4) expected attrition rates; (5) inclusion of insurance/payer status as a control variable; (6) the time frame in which the two conditions will be measured; (7) protocol for sampling medical records; (8) development of an index of co-morbidities; (9) preparation of a taxonomy of CHC site characteristics; and (10) the appropriate instrument for extracting pertinent data. This project continues the HRSA's systematic effort to identify health status outcomes that may be used to measure the effectiveness of primary care programs.

Impact of Publicly Funded Insurance Programs on Pediatric Safety -Net Providers

The purposes of this study are to a) describe the relationship between characteristics of publicly- funded programs and the survival/financial viability of pediatric safety-net providers; b) determine the differential effects of Medicaid Managed Care (MMC) and the implementation of the State Children's Health Insurance Program (S-CHIP) for pediatric safety-net hospitals relative to pediatric Federally Qualified Health Centers (FQHCs); c) investigate institutional and organizational factors among pediatric safety-net providers; and d) examine the success and failures that these providers have experienced in confronting changes in their community. Improved understanding of the impact of major policy changes on the viability of community pediatric safety-net health care providers can facilitate program strategies to lessen adverse consequences for vulnerable children. Case studies and interviews will be conducted to examine changes in the financial status of these institutions. A logistic regression model will be used to estimate the impact of hospital, market, and policy factors on closure of safety-net providers. Hospital cost, revenue, and profit equations will be estimated using a fixed effects regression model.

PERFORMER: Northwestern University, Institute for Health Services Research and Policy Studies
Evanston IL

Year 2000 Community Health Center and National Health Service Corps User/Visit Survey

The purpose of this study is to conduct: 1) a personal interview survey of users of Community Health Center/Maternal and Child Bureau sites; 2) a separate record-based study of visits to these sites; and 3) a pilot test of the feasibility of a prospective sampling strategy for use in the Community Health Center and National Health Service Corps User/Visit Survey. The user and visit survey will provide in-depth information about the socio-demographic characteristics of users, their risk behaviors and health status, the reasons they seek care, most frequent diagnoses, satisfaction with care, monitoring of chronic conditions, and the services used in a medical encounter. Attention will be paid to whether the sites provide care that meet or exceeds the Healthy People 2000 and 2010 national objectives. A sample of 50-60 grantee health centers and 15 non-grantee, freestanding sites will be selected, and a sample of 40-50 clients per center/site from medical records. Sampling from the 48 contiguous States will involve urban /rural and the West, Midwest, Northeast, and South Census regions. Questions will be taken from the National Health Interview Survey to allow comparisons with the national population. A retrospective sample of visits will be drawn to obtain a profile of the kinds of conditions treated and services provided.

Cross-Cutting

Analysis of Client-Level Data from the National Survey of Homeless Assistance Providers and Clients

The purpose of this study is to analyze the characteristics and health service use patterns of homeless people with special needs, and how the homeless population with alcohol, drug, and mental health problems compares to the general population. Issues to be addressed include: a) comparison of the rates of alcohol, drug, and mental health problems, and related treatment patterns with the general or low-income population; b) development of severity indexes on domains such as health, mental health, substance abuse, employability, and receipt of benefits; c) variation of service utilization patterns and their association with other significant variables (e.g., effect of Medicaid or other type of insurance on type and frequency of treatment); d) the relationship between severity indexes, service use patterns, and the history or nature of homelessness (e.g., relationship between treatment history and homelessness); and e) the factors associated with reported service needs and problems (e.g., reports of difficulty accessing primary/dental care). Core data (available in August 1999) will be drawn from the National Survey of Homeless Assistance Providers and Clients (NSHAPC), the first national-level and comprehensive survey of homeless clients since 1987. The NSHAPC has data on providers in 76 U.S. geographic regions, 52 urban and 24 small/rural cities, and a nationally representative sample of clients served by these providers. It was conducted by the Census Bureau on behalf of 12 Federal sponsoring agencies.

Development of an Inventory of Health Indicators Comparing Large U.S. Cities

The purpose of this study is to develop a fourth edition of Big Cities Inventory, an inventory comparing mortality, natality, and morbidity data for the nation's large cities. Local health departments require comparative data to determine the relative progress in their population's health. Although county data are available, large city health departments often cannot distinguish their own performance from surrounding counties that may have very different socio-demographic and resource characteristics. Data needs will be identified in consultation with members of the National Association of County and City Health Officials (NACCHO), who are from big cities, and the previous three editions of the Big Cities Inventory (Chicago Department of Public Health). Issues and barriers encountered in collecting and analyzing comparable data from national and local data sources will be documented. A plan for automating future editions of the Big Cities Inventory will be prepared, including approaches for using Web-based technology to disseminate the report.

Health Needs of Gay, Lesbian, Bisexual, and Transgender Communities

The purpose of this study is to develop a white paper that articulates and defines barriers to access to quality preventive and primary care health services for Gay, Lesbian, Bisexual, and Transgender (GLBT) populations. The information paper will provide a comprehensive review of the existing literature on health care and sexual orientation and will consist of two parts. The first part will be a rationale for studying health and sexual orientation by focusing on the epidemiological evidence of differential disease occurrence in GLBT populations, the hypothesized risk and protective factors related to these differences, and possible differences in response and access to therapies. The second part will explore methods to study the health of GLBT populations, including reviewing existing data sources, obtaining probability samples, measuring the dimensions of sexual orientation appropriate to particular health questions, and asking questions in sensitive and answerable ways.

Historically Black Medical Colleges' Participation in HRSA-Supported Health Professions Training Programs

The purpose of this study is to conduct a comprehensive assessment of the level of participation of Historically Black Medical Colleges (HBMCs) in HRSA-supported health professions training programs. These institutions are Meharry Medical College, Morehouse School of Medicine, Howard University, and Charles R. Drew University of Medicine and Science. Since 1995, HBMCs have received HRSA funding in several areas, mainly through health professions programs. However, HBMC funding declined during FY 1995-FY 1997, although appropriations for health professions training did not decline. HBMC Annual Performance Reports and documents relating to the HRSA peer review process will be reviewed. Interviews will be conducted with HRSA officials to gain perspective on grant processes and the role of HBMCs in HRSA programs, and to determine the type of technical assistance provided to applicants under the 16 programs for which HBMCs are eligible. HBMC staff also will be interviewed. The findings of this study will assist in determining whether changes in policies or processes are needed to increase the participation of HBMCs in HRSA-supported health professions training programs.

State-Level Assessment of Current Access and Utilization of Dental Services and Dental Services Infrastructure

The purpose of this study is to establish and assess baseline data concerning the public health infrastructure and dental services utilization in the West Central Region VIII. In many States, there is limited capacity to collect and analyze data to evaluate oral health programs with respect to access to dental services for the underserved and disparities in oral health. This project will involve three States (North Dakota, South Dakota, and Colorado) in the collection of oral health data and Geographic Information System (GIS) Mapping. Analysis will focus on the location of HRSA-funded and non-HRSA oral health programs; a related dental workforce of dentists and dental hygienists by county; the current use of dental services by age and county; the types of dental services provided by State, regional, and local-based public systems of care; the proportion of Medicaid, private, or other dental insurance coverage by county; and State demographic characteristics. Products will include a directory of existing HRSA-funded dental programs, mapping of utilization by area, and baseline data used to evaluate progress in HRSA's Oral Health Initiative.

Expanding Access to Care

Safety-Net Provider Capacity for Care to Low-Income Uninsured Patients

The purpose of this study is to evaluate the capacity of health departments, public hospitals, and other community-based, safety-net providers to serve the low-income uninsured. Evidence indicates that these safety-net providers are under increased financial pressure due to Medicaid managed care, reduced State funds for the direct delivery of health care services, and a continued rise in the number of uninsured and under-insured. The capacity of safety-net providers is to be measured in terms of change in revenues to serve the low-income uninsured (e.g., change in operating margins or limits on cash reserves), number and type of patient encounters, and the proportion of services provided. Secondary data analysis and site visits will be conducted in twenty communities, with both urban and rural locations. Secondary data will be drawn from AHA's and National Association of Public Hospitals' surveys, NACCHO's survey of local health departments, HRSA's data on community and migrant health centers, CDC's proposed tracking of health departments, and RWJ's Community Tracking Study of community-based providers. Time series analysis will include three years of the most recent available data. Site visits will collect information on State and local government policies that influence the safety net and the role of local provider organizations in the viability of the safety net. Focus groups and interviews with providers and local public health officials will be held in each of the sampled communities. With emphasis on HRSA-supported programs, this study will help policy makers to identify the impact of shifts in health care financing on services provided to low-income uninsured patients. Resources within HRSA's service delivery program can be reallocated to ensure that those most needing care are served.

Health Professions

Employment Sites of Nursing Graduates Supported by the Professional Nurse Traineeship Program

Professional Nurse Traineeship (PNT) grants are awarded to eligible institutions for the support of students in advanced nursing education. Traineeships are then awarded by the institutions to individuals enrolled in masters and doctoral programs to prepare for practice as advanced practice nurses. These funds are distributed to institutions based on a formula that incorporates three statutory funding factors. The factor to be studied is the statutory general funding preference which is given to institutions that demonstrate either: (1) a high rate of placing graduates in medically underserved communities (MUCs), or (2) a significant increase in the rate of placing graduates in such settings. Comparisons of employment sites of graduates in school receiving the preference with those of graduates in schools not receiving the preference will indicate the significance of a funding preference in promoting program objectives of increasing access to care in underserved communities. The data collected through this survey will help to formulate programmatic and policy recommendations designed to strengthen and increase the effectiveness of the PNT program.

Nurse Staffing and Quality of Care in Hospitals

The purpose of this study is to identify patient outcome measures that are sensitive to variations in nurse staffing in acute care hospital settings. Changes in the health care system have raised questions about the quality of patient care. Recent reviews by the Institute of Medicine recommended research on the relationship between quality of inpatient care and level and mix of nurse staffing. Also, the Health Care Financing Administration has drafted proposed Conditions of Participation for Hospitals that must be met if hospitals are to participate in Medicare/Medicaid programs. This study will address these concerns in Phase I by identifying and assessing current studies/methods that are focused on patient outcomes that are sensitive to nurse staffing. Existing and pending data bases useful for conducting research on the sensitivity of patient outcomes to variations in nurse staffing will be identified as will alternative study designs that can provide nationally generalizable information. Phase II will involve acquiring data bases and conducting both descriptive and multivariate analysis of the relationship between nurse staffing and patient outcomes.

HIV/AIDS Services

Comparison of Services Received and Health Outcomes for Persons Funded by the CARE Act and by Other Sources

The purpose of this study is to compare demographic characteristics, services needed and provided, and health outcomes between persons receiving CARE Act-funded services and the general treatment population. Increasing demands for accountability, shifts in the populations affected by the HIV epidemic, and the development of effective combination therapies have been associated with increases in the number of people living with HIV who will need care for longer periods of time. While a great deal is known about the types of services and providers supported under the CARE Act, the demographic characteristics of, and services used by, patients are less clear because of a lack of client-level reporting mechanisms. The findings of this study will help to develop an empirical basis for program accountability and performance measurement.

HIV Service Utilization and Health Outcomes for PLWH with Comorbidities in RWCA-Funded Programs

The purpose of this study is to evaluate (a) the additional demands placed on the health care system by individuals living with HIV infection who have comorbid conditions and (b) the benefits and costs of integrating and coordinating treatment for these conditions. Two separate projects are underway. The Johns Hopkins University will describe and quantify the delivery of comorbidity services, compare this delivery with established guidelines and standards, and analyze the outcomes of the HIV infection and selected comorbidities (substance abuse, psychiatric illness, and hepatitis C). The Washington University School of Medicine will study comorbidities of adult and adolescent women with HIV. Conditions include chemical dependency, mental illness, TB, STD, cervical dysplasia and cancer, diabetes, hypertension, renal failure, and hepatitis B and C. Homelessness and encounters with the criminal justice system will also be explored. The project will analyze how many clients are receiving services for comorbid conditions and HIV, the standard of medical care for those with these conditions, and changes in this standard during 1996-1998. At least one publishable article is to discuss how grantees and planning bodies can use study findings to optimize the delivery of services under the Ryan White CARE Act.

PERFORMER: Johns Hopkins University School of Medicine
Baltimore, MD and Washington University School of Medicine, St. Louis, MO

HIV/AIDS Cost Analysis and Development of Capitation Rate Methodology

The purposes of this study are to a) determine how utilization of services for people living with HIV (PLWH) is associated with comorbidities (especially substance abuse and mental illness); b) develop a method(s) for determining capitation rates for HIV/AIDS populations under Medicaid managed care systems (MCOs) that take comorbidities into account; and c) evaluate the impact of protease inhibitor combination therapy on care costs. Most capitation rates paid for people with HIV-- that has not yet developed into AIDS-- are substantially lower than the cost of care. High enrollments of PLWH place MCOs at financial risk. Preliminary studies in Maryland suggest that there is nearly as much variability in the costs of HIV care as there is in the costs of AIDS care; a key factor may be comorbidities that have a major impact on the cost of HIV care. This study will analyze Maryland State Medicaid data from FY 1997 to determine the extent to which comorbidities are associated with variations in demand for services. Evaluation will be made of rate setting methodologies that take into account comorbidities in determining per member, per month costs of treatment. Maryland's Medicaid reimbursement for protease inhibitors above capitation rates also will be assessed. The study will illuminate the possible need to factor comorbidities into capitation rate-setting methods and the adoption of special HIV as well as AIDS capitation rates for MCOs.

PERFORMER: Univ. of Maryland, Ctr. for Health Prog. Dev. Management
Baltimore, MD

Impact of RWCA Title I Funding on HIV Services Utilization and Health Outcomes in Las Vegas, Nevada and Norfolk, Virginia

The purpose of this collaborative project with CDC is to examine the impact of Ryan White CARE Act Title I funding on HIV service use and outcomes in newly eligible metropolitan areas (EMAs). Title I grants are expected to increase each EMA's financial base for planning, developing, and expanding HIV-related health and support services. This project will determine how these funds affect the availability, accessibility, quality, continuity, and integration of care, and HIV-related morbidity (e.g., the incidence of opportunistic infection) and mortality among underserved and vulnerable populations with HIV/AIDS. A cross-sectional pre- and post-analysis of the effects of Title I funding will be conducted in two new EMAs-- Las Vegas, Nevada and Norfolk- Newport News, Virginia. The analysis will provide additional information about the nature and magnitude of the impact of Ryan White program funding on health care services and outcomes for persons with HIV/AIDS.

Population- and Data-Based Assessment of Unmet HIV Service Needs

The purpose of this 2-year study is to provide methods for Ryan White CARE Act planning bodies to assess unmet needs for HIV health and support services. Products are to include a qualitative and quantitative assessment of unmet needs for a particular catchment area covered by one or more CARE Act-supported programs in 1999. A complete description of a generalizable and suitable methodology for CARE Act programs to conduct these assessments is also to be provided. The catchment area analysis is expected to include an estimation of overall service needs and the degree to which existing private and public health insurance streams provide health and social services that meet these needs. Estimates are to be compared with catchment area service capacity and client perceptions of unmet need and barriers to care, which can include financial constraints, logistical problems, insufficient availability of services, and lack of provider experience.

Managed Care

Managed Care and the Safety Net Providers

This study will examine the impact of Medicaid managed care and other changes in health care coverage on the future integrity and viability of safety net providers operating in primary care settings, including those funded by the Health Resources and Services Administration (HRSA), including Community and Migrant Health Centers, Maternal and Child Health programs, Ryan White Comprehensive AIDS Resources Emergency (CARE) Act programs. Findings and recommendations will be disseminated nationally through a variety of mechanisms, including publication of the report and a series of public forums and workshops.

PERFORMER: National Academy of Sciences, Institute of Medicine
Washington, DC

Maternal and Child Health

National Evaluation of the Healthy Start Program

The Healthy Start program was launched in 1991 by the Health Resources and Services Administration (HRSA) of the U.S. Public Health Service to demonstrate innovative ways to reduce infant mortality in areas with some of the highest rates. The National Evaluation consists of a cross-site process study and an outcome study of the 15 original sites. The final report of the process evaluation, "The Implementation of Healthy Start: Lessons for the Future," was completed in FY 1998 (See PIC ID 5610.1). The outcome evaluation is assessing infant mortality and birth outcomes, including improvements in the adequacy of prenatal care, and the incidence of low and very low birth weight and pre-term deliveries compared to matched comparison communities. The final report will also include findings from a Survey of Postpartum Women, and from special reports on Fetal and Infant Mortality Reviews, Health Education, and Case Management. Study results will be used to improve the Healthy Start projects funded subsequently, and will be shared with the public health community for application in other settings.

The Impact of the State Children's Health Insurance Program on Selected Community Health Centers and Maternal and Child Health Programs

This study is assessing: (1) the effect of the State Children's Health Insurance Program (CHIP) on the insurance status of children served by selected Community Health Centers (CHCs) and Maternal and Child Health (MCH) programs, and (2) the impact on the extent to which these children enter or remain in care at selected CHC and MCH sites. Issues to be addressed include: (1) the insurance history of children who have used or are new to the site; (2) the continuous nature and time span of the coverage; (3) insurance characteristics of, and source care for, children who are no longer users; and (4) the characteristics of sites relative to their ability to enroll and/or retain newly insured children. Previous analysis of CHC encounter files documented significant volatility in coverage, with patients going on and off coverage as many as five times in a given year. Study findings will provide a framework for future investigation, develop a transferable methodology for use by States and sites, and help to assess the extent to which CHIP has affected the insurance coverage of children served by CHCs and MCH programs.

National Health Service Corps

Effectiveness of the National Health Service Corps

The purpose of this project is to study the effectiveness of the National Health Service Corps (NHSC), including examination of the various mechanisms for training and recruiting providers, placing them in underserved areas, and retaining them in primary care and related professions. Prior studies have tended to define NHSC "effectiveness" narrowly, e.g., using retention at a particular site as a measure. Current and alumni clinicians and administrators of sites staffed with NHSC clinicians are providing information for the study. Study findings will be used in policy development and program management, and in developing the proposal for new authorizing legislation, needed as of October, 2000.

State Children's Health Insurance Program

Cost Implications of Providing 12 Months' Continuous Coverage for Children Under Public Health Insurance Mechanisms

The purpose of this study is to assess the effect of extending 12 months of continuous eligibility for Medicaid or CHIP on the administrative and service costs of caring for children. The Balanced Budget Act of 1997 authorized each State: 1) to provide twelve months of continuous Medicaid eligibility for children and 2) to increase the Medicaid match for continuous eligibility under CHIP. However, some States may consider this too expensive to implement versus a two to six-month Medicaid eligibility. Site visits will be made to four States and Medicaid administrative data will be analyzed. Monthly enrollment data and annual expenditure information from 1995 State Medicaid Research Files (SMRF) person summary files, supplemented with site visit information, will be used to estimate the costs of an additional month of coverage. Service cost estimates will be drawn from both fee-for-service and managed care sectors. Estimates of administrative savings will be based on interviews with State personnel and any reduction in the number of re-determinations of eligibility conducted by States (presumptive eligibility). Institutionalized children and children enrolled in the Supplemental Security Income program will not be included in the analysis.

	Office of the Assistant Secretary for Planning and Evaluation

	Policy Information Center

Office of the Assistant Secretary for Planning and Evaluation

Policy Information Center

Chapter III

Compendium of HHS Agency FY 1999

Evaluations Completed and In Progress

HEALTH RESOURCES AND SERVICES ADMINISTRATION

Fiscal Year 1999 Evaluation Reports

In-Process Evaluations