The newest feature on the Playbook is an interactive map of complex care programs across the United States. In the following Q&A, Allison Hamblin, MSPH, Senior Vice President at the Center for Health Care Strategies, explains how she and her team populated the map.
How did you identify the programs included on the map?
As a starting point we used three data sources. The first was a 2016 CHCS fact sheet on complex care programs across the country, especially those serving low income patients, including people covered by Medicaid and the uninsured. We also used the originally released version of the Playbook quick reference guide for evidence-based care coordination programs, which had a greater representation of programs serving older adults. Our last source was Healthcare Value Hub’s inventory of programs serving high-need, high-cost patients by state. Our team, in collaboration with IHI and the six foundation collaborative, sent out a survey to each of the programs across these sources, a total of 112 programs, and received about a 50 percent response rate.
Of the programs that responded, how did you decide which to include on the map?
We applied a set of inclusion criteria to determine which programs would appear on the map. First, we decided to focus on programs serving adults, with an emphasis on individuals who are publicly insured or uninsured.
All the programs included were assessed for the essential elements of person-centered care as defined by the American Geriatric Society (AGS). Of the eight elements, we identified four that programs had to have to be included on the map: individualized care plans, ongoing review of the person’s goals, care by an inter-professional team, and active care coordination.
With these criteria, we ended up with 49 programs that represent over 1,500 replicated sites.
What information did you seek from each program to share on the map?
We used the survey to identify whether they incorporate each of the AGS elements, including the following elements in addition to those named above: continual data sharing, one lead point of contact for the patient, health education, and a continuous quality improvement approach. We also collected insurance status. In addition, we were interested in whether they address behavioral health and the social determinants of health, to what extent they had been replicated in multiple sites, and whether or not there is a body of evidence supporting the program or intervention along with an assessment of the level of this evidence.
What should users do if they know of a program that meets the criteria but isn’t yet featured?
We are certain there are more programs out there that warrant inclusion on the map, and we hope that this initial launch helps identify those that are missing from the initial list. Together with our partners in this effort, our hope is that the map becomes a living resource to reflect the emergence and spread of effective complex care models across the country. To submit another program for consideration, please fill out the user-submitted content form on the Playbook.