Performance Improvement 2002. Health Resources and Services Administration



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

Evaluation Program

The Health Resources and Services Administration (HRSA) supports a wide array of very different programs and activities that promote access to needed health care for all, including primary health care centers, the National Health Service Corps, HIV/AIDS programs, maternal and child health activities, health professions training, rural health programs, organ donation and transplantation initiatives, and telehealth activities. To provide underpinning for these efforts, HRSA’s evaluation program is designed to enhance strategic planning, strengthen budget and legislative development, and improve program performance.

HRSA also supports activities to enhance the quality of evaluation agency-wide, such as funding short courses in evaluation for staff and expanding agency staff’s access to technical assistance on the conceptualization, design and implementation of evaluation activities. The broad dissemination of evaluation products and results is also an area of emphasis.

Completed Evaluations

Enabling Services and Perinatal Care: Final Report

A key strategy used by all Bureau of Primary Health Care grantees is ro provide enabling services which may include transportation, translation, case management, health education, nutrition counseling and outreach--are not typically reimbursed under managed care. The purpose of this study was to analyze the types and levels of enabling services provided by Community Migrant Health Centers (C/MHCs), how these services have changed over time, and whether enabling services improve outcomes and reduce costs. The study drew upon aggregate data from the BPHC Uniform Data System, the annual report submitted by all grantees. A total of 650 grantees filed reports in both 1996 and 1997. In 1997, enabling service personnel accounted for almost one-quarter of total direct care staff and sample grantees expended $211 million on these services (about 13% of total direct service cost). About 95% of grantees provided case management and health education services. At the other end of the spectrum, under 20% provided child care on-site or operated food banks and/or delivered meals. It was found that health center prenatal care users are twice as likely to be teenagers-- and twice as likely to be Hispanic -- than the comparable US prenatal population. About 72% of C/MHC grantees have specialized obstetrical staff; the average grantee with specialized staff has 1.3 OB-GYN/Certified Nurse Midwife full-time employees. The report concludes that the breadth of perinatal services, coupled with staffing that promotes continuity of care, contribute to appropriate and timely use of prenatal and after-delivery services by mothers and infants.
PIC ID: 7126; CONTACT: Fred Butler, 301-549-4281; PERFORMER: MDS Associates, Inc., Wheaton, MD

Professional Nurse Traineeship Grants: Who Gets Them and Where Do They Work After Graduation?

The Professional Nurse Traineeship Program (PNT) is one of the Health Resources and Services Administration (HRSA) programs intended to alleviate access to primary care provider problems in medically underserved communities. Nursing schools may apply for PNT funds to support the education of nurses in graduate programs of study. This report describes the findings from the first study of the PNT program. The study focuses on whether the PNT Program met the GPRA goal of placement of 40 percent of graduates in medically underserved communities. The overall findings: (1) The study showed that the PNT program appears to be meeting the standard specified for the Government Performance Reporting Act--40 percent placement of nurse graduates in medically underserved communities. In fact, 45 percent of the graduates worked in a medically underserved community at the job at which they had spent the most time since graduating. (2) The study did not show that schools receiving the preference had higher placement rates of their graduates in underserved communities than did the other schools.
PIC ID: 7130; CONTACT: Madeleine Turkeltaub, 301-443-6193; PERFORMER: Mathematica Policy Research, Inc., Washington, DC

America's Health Care Safety Net

This study examined the impact of Medicaid managed care and other changes in health care coverage on the integrity and viability of safety-net providers operating in primary care settings, including those funded by the Health Resources and Services Administration, including Community and Migrant Health Centers, Maternal and Child Health programs, Ryan White Comprehensive AIDS Resources Emergency (CARE) Act programs. The Institute of Medicine selected 14 experts to serve on a committee to conduct the study. The committee found convincing evidence that even within the context of insurance reform, segments of America's most disadvantaged populations will continue to rely on traditional safety net providers for their health care services, primarily because many of these providers are uniquely organized and oriented to the special needs of low-icome and uninsured populations. The IOM committee defines the “health care safety net” as follows: “Those providers that organize and deliver a significant level of health care and other related services to uninsured, Medicaid, and other vulnerable patients.”
PIC ID: 6815; CONTACT: Alexander Ross, 301-443-1512; PERFORMER: National Academy of Sciences, Institute of Medicine, Washington, DC

In-Progress Evaluations

Assessment of Domestic Violence Interventions and Staff Training Protocols in Community-Based Primary 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.
PIC ID: 7284; EXPECTED COMPLETION: FY 2002; CONTACT: Kathleen Shannon, 301-594-3621; PERFORMER: North American Management Company, Alexandria, VA

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.
PIC ID: 6784; EXPECTED COMPLETION: FY 2003; CONTACT: Rhonda Hughes, 301-594-4280; PERFORMER: Ann Zuvekas, Consultant, Annandale, VA

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

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.
PIC ID: 6364; EXPECTED COMPLETION: FY 2002; CONTACT: Barbara Wells, 301-594-4463; PERFORMER: MDS Associates, Inc., Wheaton, MD

Health Status Outcome Measures for the Bureau of Primary Health Care: Examination of Episodes of Care for Diabetes, Hypertension, Asthma

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.
PIC ID: 7127; EXPECTED COMPLETION: FY 2002; CONTACT: Barbara Wells, 301-594-4463; PERFORMER: MDS Associates, Inc., Wheaton, MD

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.
PIC ID: 6802; EXPECTED COMPLETION: FY 2002; CONTACT: Barbara Wells, 301-594-4463; PERFORMER: The Lewin Group, Fairfax, VA

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 (SCHIP) 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.
PIC ID: 6039; EXPECTED COMPLETION: FY 2002; CONTACT: Felicia L. Collins, 301-594-3732; PERFORMER: Northwestern University, Center for Health Services Policy, Evanston IL

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 (SCHIP) 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 of 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 SCHIP has affected the insurance coverage of children served by CHCs and MCH programs.
PIC ID: 7125; EXPECTED COMPLETION: FY 2002; CONTACT: Jean Yoon, 301-594-6460; PERFORMER: George Washington University, Washington, DC

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 health 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 meets 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. PIC ID: 6811; EXPECTED COMPLETION: FY 2002; CONTACT: Jerrilynn Regan, 301-594-4283; PERFORMER: Research Triangle Institute, Research Triangle Park, NC

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.
PIC ID: 7267; EXPECTED COMPLETION: FY 2002; CONTACT: Moses B. Pounds, 301-443-2894; PERFORMER: Johns Hopkins University School of Medicine, Baltimore, MD

Impact of Increased Dental Medicaid Reimbursement Rates

The purpose of this study is to evaluate the impact of increased Medicaid dental fees on children’s utilization of dental services and access to dental care in South Carolina. The study will also include an analysis of the supply of dentists that accept Medicaid and the geographic distribution before and after the fee increase. In addition, it will assess changes in the utilization patterns of preventive and restorative care, and will examine the feasibility of developing performance measures that could be tracked using Medicaid data. The study will involve analysis of Medicaid and other extant databases, and secondary analysis of a survey by the South Carolina Dental Association.
PIC ID: 7196; EXPECTED COMPLETION: FY 2002; CONTACT: Raul A. Romaguera, 404-562-4180; PERFORMER: Medical University of South Carolina, Charleston, SC

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.
PIC ID: 7215; EXPECTED COMPLETION: FY 2002; CONTACT: Faye Malitz, 301-443-3259; PERFORMER: The Learning Group Corporation, Rockville MD

Assessment of HRSA’s Distance Learning Program

This project is the initial phase of a longer-term effort to evaluate the effectiveness of HRSA’s many efforts to disseminate information and provide education and training through various distance learning techniques. To inform this eventual assessment, this project will: (1) provide a review of relevant literature on the relative effectiveness of different distance learning approaches; (2) catalogue HRSA’s dissemination and distance learning programmatic efforts to determine the methods and purposes for which they are used; (3) examine the data currently being collected on these efforts and the utility of those data; (4) determine additional data and analytical needs; and (5) recommend designs for an evaluative study.
PIC ID: 7114; EXPECTED COMPLETION: FY 2002; CONTACT: Jacob Tenenbaum, 301-443-9011; PERFORMER: The Lewin Group, Falls Church, VA

Hospital Organ Donation Best Practices: Study Design

The purpose of this project is to develop an approach to investigate factors associated with variations in hospital organ and tissue donation rates. Such factors include but are not limited to family request practices and hospital referral patterns for reporting deaths and imminent deaths to Organ Procurement Organizations (OPO). The goal is to be able to identify hospital and OPO practices that are associated with higher donor referral, consent, and recovery. Contingent upon the success of this design phase, a study will be implemented and information on best practices will be shared with the hospital and transplant communities to stimulate improvement in donation practices.
PIC ID: 7288; EXPECTED COMPLETION: FY 2002; CONTACT: Mary Ganikos, 301-443-7577; PERFORMER: The Lewin Group, Falls Church, VA

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.
PIC ID: 7250; EXPECTED COMPLETION: FY 2002; CONTACT: Lynette Araki, 301-443-6204; PERFORMER: Westat, Inc., Rockville, MD

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.
PIC ID: 7241; EXPECTED COMPLETION: FY 2002; CONTACT: Michael Millman, 301-443-0368; PERFORMER: Chicago Center for Health Systems Development, Chicago, IL

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 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.
PIC ID: 7240; EXPECTED COMPLETION: FY 2002; CONTACT: Alexander Ross, 301-443-1512; PERFORMER: Mathematica Policy Research, Inc., Washington, DC