Evaluation Strategy to Further Assessment of BACH Patient
Outcomes and Clinic Performance


Evaluation Goals and Specific Objectives

The evaluation strategy incorporates four goals and objectives that address the aim of developing within BACH a patient-centered performance measurement system (PC-PMS).  Performance measurement involves the extent that clinics composing BACH (1) foster patient engagement in the health care process, and (2) achieve positive health outcomes in the areas of general health, disease and symptom management, and functioning.  BACH’s strategy is to locate clinics within vulnerable communities, offer medical homes to patients who experience unmet health needs, and engage the host communities in health promotion.  The linkage of patient engagement (as a process domain) and outcome (as a product domain) is consistent with BACH’s focus on accountable and responsive care.The PC-PMS will make transparent (particularly to consumers and enrolled patients) the extent to which a specific clinic (and BACH as a whole) engages patients in the process of health care with the aim of helping patients to advance their general health, manage serious disease states, and improve their functioning in daily life.  The specific objectives emerge from these goals.

While there are other important dimensions of a PMS, the principal concern of the evaluation strategy is the development of metrics that support the assessment of the extent that the health of patients is central to BACH’s performance. Performance must also incorporate the extent to which clinics assist patients in managing their own health. Thus, the proposal broadens performance to include the extent to which BACH fosters an alliance between patients and their care providers.

Goal 1 addresses this nexus, and identifies the importance of assessing (1) the extent that patients are involved in the process of health care, and (2) the relationship of patient engagement to the realization of health outcomes.  It is this nexus that serves as the heart of the proposed patient-centered performance management system (PC-PMS), which will be piloted at 10 BACH clinics to test metrics, investigate survey methods for capturing engagement and outcome data, develop databases on the performance of pilot clinic sites, and explore reporting procedures capturing multiple indicators of patient engagement and health outcome.

Goal 2 and Goal 3 incorporate activities important to the process of piloting performance measurement procedures. Given the health literacy issues many of the BACH users face, an important step in strengthening the utility of the system will involve exploring multiple tactics for facilitating patients’ awareness of engagement and outcome indicators, understanding the quality of the care a clinic achieves, and ability to use the information to advance their own personal health care in partnership with their primary care provider.  Together these dissemination and utilization activities form Goal 3.

Goal 4 will examine methods for introducing engagement and outcome metrics into the process of clinic management and quality improvement.  Through capacity to measure multiple patient engagement and health outcome indicators, clinics can establish targets for their improvement of access, continuity of care, patient education and training, and outcome management.The proposed project is developmental and evaluative in its methodological orientation: it seeks to create a performance measurement system grounded in the patient care experience, and to integrate this system into patient education, self-care and health promotion programming, and quality improvement of health care provision. The four project goals reflect a basic tenet of the project:  that quality of care is a product of a partnership formed between a patient and a provider both of whom focus on engagement in the process of care and a broadened framework of health outcome. Patient-centered performance, then, involves the intentional engagement of patients in the process of care and achievement of several different but complementary health outcomes that are manifest in improved patient functioning.         

Specific Evaluation Hypotheses, Conceptual Framework, and Method

The principal hypotheses of this project are: that (1) patients who report high engagement in the process of personal health care will report strong positive outcome levels in the areas of general health, management of their disease state,symptoms, and functioning in daily life; and (2) clinics that achieve high levels of patient engagement in health care delivery and positive health outcomes will achieve high levels of patient satisfaction.

In this project, patient engagement will be assessed as a multi-dimensional construct incorporating measures of (1) patient access to care, (2) involvement in the care process, (3) the responsiveness of the provider to perceived health concerns, (4) quality of the patient-provider alliance, and (5) patient self care activity and adherence to the plan of care. The founding of BACH clinics in an ethos of health promotion justifies a broader view of health outcomes, conceptualized as involving (1) the promotion of general health, (2) the management of serious disease and symptoms, and (3) the realization of better functioning in daily life. Health is seen as a broad construct that involves the adaptability of the person (who faces a degraded environment, considerable stress, and reduced supplies, such as nutrition) to the exigencies faced in daily life.  Despite the health status of a particular patient, it is the augmentation of patient adaptability that a clinic avows as a central value, and is likely expressed as improved functioning in daily life.  The comprehensiveness of the scope of clinic services strengthens BACH’s capacity to respond to the medical, nutritional, social service, and community living needs of patients, which justifies this broadened concept of health as a central value of performance measurement.

Evaluability capacity building projects undertaken by BACH identified a taxonomy of clinic types among the 21 sites in operation, including clinics in educational sites (schools, head starts), neighborhoods, public housing, and store front locations.  While all sites have common properties they vary by location and purpose. Specific clinics will be selected from each type BACH clinic for the purposes of PC-PMS development.  Adult patient clusters will be established within each site for three principal disease management programs involving diabetes, arthritis, and high blood pressure.  Stratification of patients within these clusters (by race, gender, age) will produce index cases for initial development of the PC-PMS data collection tools, refinement of these tools, and monitoring of quality care and outcome over time. This design will facilitate the project’s response to four research questions: (1) What extent are patients engaged in the process of health care?; (2) What outcomes do patients experience in the areas of general health, disease-specific management and symptoms, and functioning in daily life?; (3) What extent do engagement indicators explain variation in ratings of health?; and (4) What extent do engagement indicators and health outcome indicators predict patient satisfaction ratings? 

Evaluation Plan

The methodological approach of this project will involve the creation and refinement of eleven deliverables. The achievement of each goal fosters progress toward the implementation analysis of the PC-PMS in ten BACH clinics, and the augmentation of the Alliance’s capacity to incorporate the system into other established clinic sites as well as into the sites that are under development.

Principal outcomes of this proposal will be the ten case studies and the manual capturing the developmental knowledge base of the PC-PMS and knowledge derived from the evaluation of the system.  An important related outcome lies in the assistance the project will offer in helping the BACH system to incorporate the PC-PMS operationally, an outcome of the final deliverable.