Delaware Community Health Access Program (CHAP): Evaluation of Referrals and

Health Outcomes

James M. Gill, MD, MPH

Christiana Care Health Services

August 21st, 2003

IntroductionIntroduction

CHAP objectives– Provide a medical home for uninsured

Delawareans, so as to improve access, quality and outcomes

– Increase primary and preventive care– Reduce hospital emergency department (ED)

visits and hospital stays– Improve health status and patient satisfaction

Methods: Part 1Methods: Part 1

Study Design– Compared changes in health care utilization

and other outcomes before CHAP enrollment and six months after enrollment

– 795 qualified enrollees

Time Period– June 2001 through January 2003

DemographicsDemographics

CHAP enrollees tend to be– Young adults (18 - 39 years of age)– Female– New Castle County– Hispanic– Non-citizens

Preventive CarePreventive Care

39.6

58.8

42.8

56.3

48.2

68.6

60.0

89.1

0

10

20

30

40

50

60

70

80

90

Percen

t Up

To

Date

Cholesterol Mammogram Breast Exam Pap Smear

Baseline

Follow up

Past 5 year, ages 35+ (N=252)

Past 2 yearsages 40+(N=123)

Past 2 yearsages 18+(N=123)

Past 3 yearsages 18+(N=484

Preventive CarePreventive Care

21.1

27.7

18.6

25.0

14.2

21.2

13.318.3

0

10

20

30

40

50

60

70

80

90

Pe

rce

nt U

p T

o D

ate

Flu Shot Pneumo Vax Sig/colonoscopy Blood Stool

Baseline

Follow up

Past yearages 50+ or <50 with diabetes or asthma (N=138)

Everages 65+ or

<with diabetes(N=45)

Past 5 yearsages 50+(N=104)

Past yearages 50+(N=104)

Emergency Department and Hospital Visits Emergency Department and Hospital Visits

9.9

3.8 2.7 2.8

0

10

20

30

40

50

60

Percen

t

ED Visits Hospital Admits

Baseline

Follow UP

Satisfaction with CareSatisfaction with Care

Before CHAP Enrollment

90.8

9.2

After CHAP Enrollment

54.3

45.7

ExcellentExcellent

Methods: Part 2Methods: Part 2

Study Design– Examined referral patterns, including sources of

referrals to health homes– Identified percent seen at health homes after

enrollment– Investigated percentage already patients prior to

CHAP Time Period

– Beginning June 2001 and ending November 2002

Referred To

1.2 7.3 5.0

29.4

15

42.1

Health Home ReferralsHealth Home Referrals(N=2525)(N=2525)

Referred From

20.5

5.7

3.1

24.0

6.1

40.5

ED/Hospitals

Delmarva

HJMC

LaRed

Westside

VIPII

Percent of Referrals Leading Percent of Referrals Leading to Health Home Visitsto Health Home Visits

52.1

24.0

56.2

38.5

0102030

40506070

8090

Percen

t

Total EmergencyDept

HealthHomes

EDS/VIP

N=2116N=262 N=1841

N=13

Percent of Enrollees Who Were Patients Prior to Enrollment

50.0

27.4 28.634.5

66.9

0

10

20

30

40

50

60

70

80

90

Percen

t

Total Delmarva HJMC LaRed Westside

(N=185) (N=126) (N=742) (N=1063)(N=2116)

Time Between First Pre-CHAP Time Between First Pre-CHAP Visit and CHAP EnrollmentVisit and CHAP Enrollment

0

10

20

30

40

50

60

70

80

90

Pe

rcen

t

Total Delmarva HJMC LaRed Westside

< 2 Weeks

> 2 Weeks

(N=1057) (N=54) (N=36) (N=256) (N=711)

SummarySummaryReferrals and EnrollmentReferrals and Enrollment

Over 2500 persons enrolled in CHAP in initial 16 months– Another 400-500 enrolled in Medicaid

Largest providers LaRed and Westside Followed by VIP 2

Most captured at health homes themselves; only 21 percent at ED’s

50-60 percent of those referred to health home make visit

30-40 percent referred to health home were already patients there

SummarySummaryChanges in Health Care UtilizationChanges in Health Care Utilization

Substantial increases in some preventive care (Pap’s, mammograms, cholesterol)

Small impact on CRC screening and adult immunizations

Significant reductions in ED visits, but not hospitalizations

Dramatic improvements in satisfaction with care

CaveatsCaveats Short time frame: establishing medical

home takes longer to accrue benefits Not able to capture all benefits; may have

less unnecessary care and fewer medication errors by shifting care from ED to primary care

Medical home is essential but not sufficient for optimal care

CRC screening may require additional interventions (e.g., education, payment)

Future DirectionsFuture Directions New CHAP data collection tool

– Impact on efficiency and cost Continue to monitor Colorectal Cancer

Screening, PAPs and Mammograms Evaluate CHAP as part of overall uninsured

in DE– Colorectal Cancer Screening– Women’s Health

Demographics (N=795)

Number Percent Number Percent

AgeUnder 1818-3940-6465+

85523172

14

10.765.921.7

1.8

Income0-100% Poverty100-125125-150150-175175-200

402183120

5732

50.623.015.1

7.24.0

GenderMaleFemale

CitizenshipUS CitizenNon Citizen

227568

144651

28.671.4

18.181.9

CountyNew CastleKentSussex

55656

183

69.97.0

23.0

Race/EthnicityWhiteBlackAsian/Pacific IslanderHispanicOther

7075

8620

13

8.99.51.0

78.91.7

Health HomeClaymontDelmarvaHJMCLa RedVIP IIWestside

183715

17170

484

2.34.71.9

21.58.8

60.9