Post Office Box 66769
Houston, Texas 77266
Contact: Marion Scott
Phone: (713) 746-6513
Key words: continuity of care; systems
integration; client satisfaction
The purpose of this study was
to examine the continuity of care and
systems integration as well as client
satisfaction within Harris County Hospital
Districts (HCHD) Health Care for the Homeless
Program (HCHP).
METHODS & PRELIMINARY RESULTS
Purified Protein Derivative (+) Follow-up:
Problem Statement It is easy to predict
that tuberculosis disproportionately affects
the homeless. The prevalence of multiple
risk factors predispose the homeless population
to tuberculosis. The HCHP has chosen education,
screening, and increased follow-up of
Purified Protein Derivative (PPD) + patients
as strategy to impact tuberculosis. The
health care system for Houston/Harris
County is set-up to allow HCHD, HCHP staff
to place and read PPD_s. However, PPD+
patients are referred to non-HCHD clinics
(city clinics) for CXR follow-up and chemoprophylaxis
therapy as indicated. Often HCHP has only
the hope of seeing the patient again to
determine the status of the referrals.
Objective Increase coordination and information
dissemination of HCHP referrals for PPD+
patients with city clinics. Description
of Outcome(s) Measure(s) Systems-level
outcome (continuity of care). One hundred
percent of referrals from city clinics
will be returned to the HCHP to identify
patients who kept appointments and the
recommended treatment regimen for them.
Description of Outcomes Research Project
Process objective to be used to enhance
the programs ability to determine health
outcomes in the future. The City Clinics
agreed to provide epidemiology reports
which provided clinic dispositions on
all patients keeping appointments. A computerized
database was formulated to key enter the
information received. This information
was then analyzed to identify: (1) individuals
who did not keep appointments and (2)
a typology of individuals keeping appointments.
Of the 2,737 patients tested for TB January
1 through November 30, 1997, 254 were
identified as PPD (+). Frequencies and
percentages were used to identify the
following: 1) race; 2) gender; 3) date
of birth (DOB); 4) shelter site where
PPD was placed; 5) date PPD was read;
6) PPD results; 7) appointment date; 8)
appointment site; 9) CXR results; 10)
TB diagnosis; 11) chemoprophylaxis; 12)
supervised medication status (Directly
Observed Therapy/DOT); and 13) follow-up
exam date. Also, data was collected to
reveal marital status, education level,
employment status, length of homelessness,
length of time in Houston, and benefit
status. Patient Satisfaction: Problem
Statement Patient satisfaction relates
directly to the acceptability dimension
of quality health care. Every center/clinic
attempts to provide patient care in such
a way that is acceptable to the patients
because of the marketing impact that satisfied
and/or dissatisfied patients can have
on a center/clinic. Even more significant,
is the impact on the patients health that
can occur as a result of the patients
satisfaction with the health care process
and its results. That is, satisfied patients
simply do a better job of getting well.
Objective To monitor patient perceptions
of service measures to insure their acceptability,
accessibility, and appropriateness. Description
of Outcome(s) Measure Client-level outcome.
Ninety-five percent of patient scores
on patient satisfaction surveys will evidence
services delivered as accessible and acceptable.
The HCHP began looking at patient satisfaction
in 1990. Team members structured survey
questions at that time, however no reliability
or validity had been established on the
survey questions. The instrument used
in the project was revised to include
reliable and valid questions from the
Rand Medical Outcomes Study (1993). With
the assistance of a research advisor,
the HCHP replicated the Rand instrument
to look at patient satisfaction in assessing
the quality of health care services rendered.
Data was obtained from patients visiting
HCHP clinics. Completed questionnaires
were obtained from 10 percent of the eligible
population. Of the 270 patient satisfaction
surveys completed January 1 through November
30, 1997, frequencies and percentages
were used to analyze and interpret the
data collected. The instrument used to
collect patient satisfaction used a combination
of questions, some of which were individualized
to our population by project staff. Questions
1 through 12 were used to provide demographic
information; questions 13 through 22 were
provided by a research advisor and had
been previously tested for reliability
and validity. Patients were selected at
random to complete the surveys and no
demographic data was available on non-responders.
Preliminary data analysis revealed (most
frequently occurring data) the following:
total number of respondents-279; males-
105 (38 percent); females-165 (62 percent);
primary language English-224 (85 percent);
age 41-57 (21 percent); age 31-55 (20
percent); race White-56 (21 percent);
Hispanic-52 (19 percent); Black-162 (60
percent); and marital status-single 145
(54 percent).
Computerization of Data Management:
Problem Statement Since 1990, the HCHP
has monitored the quality and appropriateness
of services it delivers. The systems developed
rely on manual aggregation and analysis
of data, which requires a great deal of
time. In addition, as the program looks
more at service delivery, utilization,
trending, and evaluation data, the data
base grows larger and increasingly difficult
to manage using manual analysis and presentation
techniques. The HCHP, in 1996 through
HCHD organizational restructuring, also
became a part of the HCHD Community Health
Program (CHP). The HCHP quality management
program has had no reporting channel to
the CHP Multi-Disciplinary Performance
Improvement Committee, heretofore. The
HCHP activities impact service utilization
of CHP clinics and expand its efforts
to provide outreach to the homeless patients
in the communities. Many of these homeless
patients, do not present to these clinics
until their health needs require increased
urgent care which is more costly. It is
thus, only fitting for HCHP to report
its quality management activities to continue
to validate its impact. As the HCHP grows
older and its data base continues to grow
even larger, the efficiency with which
data is aggregated, analyzed, and evaluated
will certainly affect the evaluation of
program outcomes. Objectives To expand
the capacity of the HCH Total Quality
Management (TQM) program to aggregate
data for analysis and evaluation of outcome
measures by September 1997. Description
of Outcome(s) Measure(s) Systems-level
outcome (systems integration): The HCHP
quality management data will be 100 percent
computerized by September 1997. Description
of Outcomes Research Project This measure
is best described as a process objective
to be used for program monitoring and
evaluations. It is intended to improve
the level of program functioning by enhancing
the programs ability to evaluate its impact
on health outcomes for homeless individuals.
With the funds received from the outcomes
study project, computers and software
were purchased. Consultation regarding
the program design and key entry of past
and current data collected was begun.
The HCHD, HCHP has selected indicators
to monitor the quality and appropriateness
of care since 1990. Data analysis, heretofore,
had been a manual process which had become
tedious as the number of shelter sites
grew along with the volume of data gathered.
With the computerization of most manual
systems, the ability to analyze data is
less time consuming. In addition, the
HCHP received technical assistance to
perform a feasibility study to identify
barriers to, and the economics of placing
information systems integrated into the
HCHD MIS in shelter sites (sites are not
HCHD facilities). Two shelter sites now
have direct MIS integration.
Purified Protein Derivative (+) Follow-up
The problem addressed by this study looked
at the coordination of services between
HCHP and City Clinics. The existing system
was assessed to determine how patient/agency
needs could be met to improve continuity.
A sample of 254 PPD (+) patients was used.
Descriptive statistics and demographic
information was collected on all patients.
A data base was formulated to aggregate
and trend the data. Data collected was
reviewed for
compliance with appointment follow-up,
TB diagnosis status, and characteristics
of the patients keeping appointments.
Patient Satisfaction
The problem addressed by this study looked
at patient perceptions of services rendered
in HCHP clinics. Literature was reviewed
regarding patient satisfaction and technical
assistance was received from a research
advisor. Ten survey questions were taken
from the Rand PSA III survey. The instrument
used both positive and negatively-worded
items. Participants were asked to indicate
how they felt about the health care services
received in HCHP clinics, with no reference
to a specific visit or time frame.
Computerization of Data Management
The problem addressed by this study was
the expansion of the HCHPs capacity to
aggregate and analyze quality management
data from a manual to a computerized data
base. The purchase of computers and software,
consultation for program format and key
entry of data collected proved to be an
investment well
worth the effort.
Funding from these projects
to improve systems-level and patient-level
outcomes proved to be beneficial for improving
the quality and appropriateness of health
care provided by the HCHP. The major findings
of these projects were the following:
1) systems can collaborate and coordinate
to provide a continuum of health care
services; 2) numerous factors affect patient
satisfaction as experienced by homeless
patients; and 3) computerization of data
provides for timely aggregation and analysis
of data that can be used to monitor quality
and appropriateness of the health care
services rendered.
