Impact of Convenience Care on Pediatric ED Utilization:

The El Centro de Corazón Pilot Project

Outline

Project Background Intervention Evaluation Methods

Time Series Pre-test Post-test

Results Conclusions

Background: Overview

Project partners: Texas Children’s Health Plan (‘TCHP’), El Centro de Corazón (‘El Centro’) St. Luke’s Episcopal Charities and Rotary Club of Houston

Objective: To reduce ED utilization for ambulatory care sensitive conditions (ACSC) among TCHP beneficiaries who reside in east Houston.

Strategy: Provide expanded-hours primary care at a community clinic (El Centro/Eastwood Clinic) in east Houston. Pilot Project ran from Sept. 2006 – Feb. 2007

El Centro de Corazón Pilot Project

Background: Project Partners

Founded in 1996, TCHP was first group health plan exclusively for children.

Catchment area includes Harris County and 10 surrounding counties.

Provides Medicaid STAR and CHIP coverage for 170,000+ enrollees.

Primary care network includes 780+ pediatricians 1,316 specialists 52+ in-network hospitals (around greater Houston area)

Texas Children’s Health Plan

Background: Project Partners

October 2003 merged with Eastwood Health Clinic. December 2003 obtained FQHC status. TCHP network provider Provides primary, preventive, dental and mental

health services, lab and pharmacy services at 3 sites in east Houston: El Centro de Corazón Navigation El Centro/ Magnolia El Centro/ Eastwood**

El Centro de Corazón

**site of El Centro extended hours pilot project

Intervention

El Centro Extended-Hours Primary Care

Day of Week

Pre-Pilot StudyHours of Operation

Bus.Hrs.

Pilot Study Hours of Operation

Pilot StudyBus. Hrs.

Mon 8:30AM – 7PM 10.5 8AM – 8PM 12

Tues 8:30AM – 7PM 10.5 8AM – 8PM 12

Wed 1PM – 7PM 6 8AM – 8PM 12

Thurs 8:30AM – 7PM 10.5 8AM – 8PM 12

Fri 8:30AM – 5PM 8.5 8AM – 1PM 5

Sat Closed 0 Closed 0

Sun 9AM – 1PM 4 9AM – 1PM 4

Total # Business Hours 50 57

Intervention

Clinic and Office Personnel

Daytime (8AM – 5PM): 1 nurse practitioner, 1 P/T and 2 F/T medical assistants, 3 staff members in front office

Extended hours (5PM – 8PM) and Sundays: 1 physician assistant, 2 medical assistants 1 staff member in front office (2 on Sunday AM)

El Centro Extended-Hours Primary Care

Intervention

TCHP Marketing and Educational Outreach

Campaign ran Sept 2006 – Feb 2007 Outreach products printed in English and Spanish Sent to targeted TCHP enrollee households (HHs), not individuals

Sept 2006 Oct Nov Dec Jan 2007 Feb Mar Apr

Sent 391 new HHs Memo Boards

Sent 28,335 6x9 informative PostcardsSent 2,498 new HHs Magnet Mailers

Sent 6,459 Magnet Mailers

Sent 6,462 Memo Boards

Sent 7,4166x9 Postcards(Excess)

Sent 7,4966x9 Postcards(Excess)

Intervention

TCHP Marketing and Educational Outreach

MEMO BOARD

MAGNET MAILER

Intervention

TCHP Marketing and Educational Outreach

6x9 Postcard

Printed in English and Spanish

Contains reminders about getting health care for a sick child:1. Call physician2. Call TCHP Nurse Help Line 3. Go to Eastwood Clinic

Intervention

Between Sept 2006 – Feb 2007:

Distributed Rx Pads to 420 network PCP offices

Made 274 visits to community based organizations, churches, apt. complexes, school nurses in study area (177 locations)

Distributed 21,730 promotional flyers

Auto dialer campaign delivered 10,000+ promotional messages over 2 months (number of messages received is unknown)

TCHP Marketing and Educational Outreach

Evaluation Methods

Study GroupTCHP enrollees who reside in 11 ZIP codes surrounding El

Centro (approx. 18,000 children)

Comparison GroupsMatched Comparison group (approx. 7,600 children)

Enrollees who reside in 7 ZIP codes with similar race/ethnicity, poverty levels, education, and use of English in household

TCHP enrollee base excluding study group (approx. 140,000 children)

Study Population

Evaluation Methods

Comparison of Study Group and Matched Group Characteristics at the ZIP code level

Population Characteristics

El Centro Zip Codes

(N = 283,774)

Control Zip Codes

(N = 219,818) n % n % Latino or Hispanic Ethnicity of any race 178,308 62.8 142,899 65.0 White 106,843 37.7 126,834 57.7 African-American 70,178 24.7 22,043 10.0 Families below poverty level 15,663 5.5 10,132 4.6 High School grad or higher 76,134 26.8 65,861 30.0 Speak language other than English at home

149,331 52.6 116,944 53.2

*Data Source: http://factfinder.census.gov/home/saff/main.html?_lang=en *The Census Bureau allows survey respondents to report one or two races, therefore some individuals are double counted and the percentages for race will not equal 100%. Likewise, an individual of Latino or Hispanic ethnicity may report no race or identify with one or two races.

Evaluation MethodsTargeted EC Zip Codes, Matched Comparison Zip Codes and

Surrounding EDs and Community Clinic* Network

*Community health centers are local, non-profit, community-owned health care providers serving low income and medically underserved communities. (http://www.nachc.com/client/documents/America's_Health_Centers_updated_1.08.pdf)

Evaluation Methods

Population perspective Measured monthly rates for ED use/100

enrollees (ED for ACSC visits and Total ED visits).

Compared utilization trends for study group and 2 comparison groups.

Interrupted Time Series: Sept 2005 – Aug 2007

Evaluation Methods

Clinical perspective Defined pre-pilot and post-pilot periods:

6 months prior to and subsequent to pilot period

Identified users and non-users of El Centro’s after hours services.

Calculated user and non-user ED rates for pre-pilot, pilot and post-pilot time frames.

Pre – Post Test

Results

Figure 2: EC Study Group Utilization of El Centro de Corazon Office Visits March 2006 - August 2007 and Extended Hours Visits September 2006 - August 2007

0

20

40

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120

Mar-06 May-06 Jul-06 Sep-06 Nov-06 Jan-07 Mar-07 May-07 Jul-07

Office Visits Extended Hours Visits

Results

Figure 3: Monthly Rates for ACSC ED Visits per 100 enrollees for El Centro Study Group, Control Group and TCHP Group, September 2005 - August 2007

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0.5

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r 1

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EC Study Grp

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TCHP

Pilot Study

Monthly Rates for ACSC ED Visits per 100 enrollees for El Centro Study Group, Control Group and TCHP Group, September 2005 - August 2007

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TCHP

Pilot Study

ResultsFigure 4: Monthly Rates for Total ED Visits per 100 enrollees for El Centro Study Group, Control Group and TCHP Group, September 2005 - August 2007

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/mo

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EC Study Grp

Control

TCHP

Pilot Study

Figure 4: Monthly Rates for Total ED Visits per 100 enrollees for El Centro Study Group, Control Group and TCHP Group, September 2005 - August 2007

0

0.5

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EC Study Grp

Control

TCHP

Pilot Study

Results

Tab le 2 : S ix-Mo n th Utiliza tio n R a te s fo r AC SC ED Vis its p e r 1 0 0 e n ro lle e sd u r in g Pre -p ilo t, P ilo t a n d Po st-p ilo t p e r io d s fo r EC G ro u p , u se rs a n dn o n -u se rs, C o n tro l G ro u p a n d T C HP G ro u p

Pre -P ilo ta Pilo tb Po st-P ilo tc Pre - Po stR a te D iffe re n ce

EC G ro u p 0 .8 4 1 .1 3 0 .8 6 0 .0 2

u se rs d 1.59 1 .8 0 1.17 - 0 .42

n o n -u se rs e 0 .6 0 0 .7 8 0 .6 4 0 .0 4

C o n tro l 1 .0 1 1 .3 9 1 .0 6 0 .0 5

T C HP 0 .9 5 1 .3 8 1 .1 0 0 .1 5a Pre -p ilo t: Ma rch - Au g u st 2 0 0 6b Pilo t: Se p te mb e r 2 0 0 6 - F e b ru a ry 2 0 0 7c Po st-p ilo t: Ma rch - Au g u st 2 0 0 7d u se rs: T C HP e n ro lle e s in ta rg e t ZIP co d e s with a t le a st o n e a fte r-h o u rsv is it to E l C e n tro C lin ic .e n o n -u se rs: T C HP e n ro lle e s in ta rg e t ZIP co d e s with n o a fte r-h o u rs v is itsto E l C e n tro C lin ic .

Results

Tab le 3 : S ix-Mo n th Utiliza tio n R a te s fo r T o ta l ED Vis its p e r 1 00 en ro llee sd u r ing Pre -p ilo t, P ilo t a nd Post-p ilo t pe r iod s fo r EC G ro up , u se rs an dn on -use rs, C on tro l G rou p an d T C HP G ro u p

Pre -P ilo ta Pilo tb Po st-P ilo tc Pre - Po stR a te D iffe re nce

EC G ro up 2 .90 3 .16 2 .97 0 .07

use rs d 5.02 5 .50 2.53 - 2 .49

n on -u se rs e 2 .05 2 .13 2 .19 0 .14

C o n tro l 3 .40 3 .65 3 .25 - 0 .1 5

T C HP 3 .30 3 .78 3 .46 0 .16

a Pre -p ilo t: Ma rch - Aug ust 20 0 6b Pilo t: Se p temb e r 20 0 6 - F e b rua ry 2 00 7c Po st-p ilo t: Ma rch - Au g ust 2 0 07d u se rs: T C HP e n ro lle es in ta rge t ZIP co de s with a t le a st o ne a fte r-h ou rsv is it to E l C e n tro C lin ic .e n on -use rs: T C HP e n ro lle es in ta rge t ZIP co de s with no a fte r-h ou rs v is itsto E l C e n tro C lin ic .

Conclusions

At population level, pilot program did not successfully divert patients away from ED.

At clinical-user level, effect was seen among users of El Centro’s after hours services: 26% decrease in pre-post ED for ACSC utilization rate; 50% decrease in pre-post total ED utilization rate.

Study group’s utilization of El Centro’s services increased during study period. Post-pilot drop in after hours visits might suggest

continued outreach is needed.

Study Highlights

Conclusions

Paid claims data might contain measurement error due to: Timing of claim submission, clinical error and necessary

adjustments; Extended hours visits might be underestimated due to

level of coding accuracy at provider level.El Centro hours of operation printed on outreach

materials did not reflect the clinic’s actual hours. Effect of error on study group is unknown.

We were unable to conduct statistical test of significance on pilot program’s effect. We are currently working on a retrospective panel study to

address this issue.

Study Limitations

Acknowledgements

We would like to thank St. Luke’s Episcopal Charities and Rotary Club of Houston for their support of the El Centro After Hours Pilot Program, without which this project would not have been possible. Additionally, we thank Rose Calhoun and Xuan Tran with Texas Children’s Health Plan for their assistance during the early stages of the project.