This is very confusing???   Below in italics is the text from the audit.  Here are questions:

  • The contract was 984 Hypertension (HTN) referrals.  The number through June is 10?
  • The contract was for 6 Chronic Disease Self-Management Programs.   The number through June is 1?
  • Are we reading this correct?
  • Hopefully City Councilors will clarify this tomorrow night.

 

Actual services to PWTF patients, those identified in a census tract, began toward the end of the grant phase. Data
reports for Tier 1 interventions became available in August 2015 for data reported through May 2015. Tier 1
interventions are those for which there is straight‐forward access to data, a strong evidence base for clinical
impact, and a high likelihood of a positive return on investment (ROI). Tier 1 interventions for Hypertension (HTN)
included evidence based HTN screening (clinical reporting) and community based organization (CBO) offered
courses on Chronic Disease Self‐Management Programs (CDSMP). Senior Falls included a Clinical Risk Assessment
and a home safety assessment by the CBO. Pediatric asthma included care management for high risk asthma
patients (clinical), and a home based assessment for asthma triggers. Through May 2015 there were 2 referrals
for Senior Falls, 32 for Pediatric Asthma and none for HTN. Numbers increased in June 2015 based on partner
provided performance reports to 10 HTN referrals, 1 CDSMP pilot, 74 Pediatric Asthma home visits and 10 Senior
Falls home assessments.

Some partner subcontracts had requirements for specific outcomes including clinical referrals to CBOs and
required number of CDSMP courses to be provided by the CBO. In some instances the outcomes were not met.
For example, one clinical contract was expected in the first year to offer referrals to the CBO for services for 984
uncontrolled HTN patients and achieve 50% voluntary participation while the CBO contract was to offer 6 CDSMP
courses over the same period. As of June 2015, there were very few referrals to the CBO for the self‐managed
program, although the pilot CDSMP was implemented in that month. State field agents cited referrals as
increasing in July for the HTN intervention with 10 referrals and a CDSMP course conducted. The agreement with
the CBO required 6 CDMSP courses by the end of the contract period, August 31, 2015. The course generally
requires 10 participants and there was a lack of sign‐ups. Quality improvement plans in the current quarter for
HTN seek to increase the number of the results through CHWs at both the CBO and clinic. Similar results occurred
for the Senior Falls program for group classes in Tai Chi for Healthy Living and Matter of Balance. It was noted by
state agents that there is great difficulty in getting the appropriate number of referred patients to sign up for
group courses in both Senior Falls and HTN. Pediatric Asthma had better results with over 70 referrals by the end
of the year. In cases where CBOs had not received referrals, training and outreach activities occurred including
reverse referrals to clinics.