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Development and Applications of an Outcomes Assessment Framework for Care Management Programs in Learning Health Systems

Authors:

Lin Wang ,

U.S. Census Bureau
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Kara Kuntz-Melcavage,

Johns Hopkins Medicine
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Christopher Forrest,

University of Pennsylvania
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Yanyan Lu,

Johns Hopkins Medicine
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Leslie Piet,

Johns Hopkins Medicine
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Kathy Evans,

Johns Hopkins Medicine
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Maria Uriyo Uriyo,

Johns Hopkins Medicine
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Melissa Sherry,

Johns Hopkins Medicine
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Regina Richardson,

Johns Hopkins Medicine
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Michelle Hawkins,

Johns Hopkins Medicine
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Donna Neale

Johns Hopkins Medicine
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Abstract

Purpose: To develop and apply an outcomes assessment framework (OAF) for care management programs in health care delivery settings.

Background: Care management (CM) refers to a regimen of organized activities that are designed to promote health in a population with particular chronic conditions or risk profiles, with focus on the triple aim for populations: improving the quality of care, advancing health outcomes, and lowering health care costs. CM has become an integral part of a care continuum for population-based health care management. To sustain a CM program, it is essential to assure and improve CM effectiveness through rigorous outcomes assessment. To this end, we constructed the OAF as the foundation of a systematic approach to CM outcomes assessment.

Innovations: To construct the OAF, we first systematically analyzed the operation process of a CM program; then, based on the operation analysis, we identified causal relationships between interventions and outcomes at various implementation stages of the program. This set of causal relationships established a roadmap for the rest of the outcomes assessment. Built upon knowledge from multiple disciplines, we (1) formalized a systematic approach to CM outcomes assessment, and (2) integrated proven analytics methodologies and industrial best practices into operation-oriented CM outcomes assessment.

Conclusion: This systematic approach to OAF for assessing the outcomes of CM programs offers an opportunity to advance evidence-based care management. In addition, formalized CM outcomes assessment methodologies will enable us to compare CM effectiveness across health delivery settings.

How to Cite: Wang L, Kuntz-Melcavage K, Forrest C, Lu Y, Piet L, Evans K, et al.. Development and Applications of an Outcomes Assessment Framework for Care Management Programs in Learning Health Systems. eGEMs (Generating Evidence & Methods to improve patient outcomes). 2015;3(1):9. DOI: http://doi.org/10.13063/2327-9214.1119
Published on 23 Apr 2015.
Peer Reviewed

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