Toward a Population Health Delivery System: First Steps in Performance Measurement

James Studnicki, Frank V. Murphy, Donna Malvey, Robert A. Costello, Stephen L. Luther, and Dennis C. Werner In spite of the technological sophistication and clinical excellence of the U.S. health care industry and annual health expenditures in excess of a trillion dollars, the overall health status of the American population is comparatively poor. The BCHS in west central Florida sought to improve the health status of the communities that it serves. Known by the acronym CHAPIR, an information-driven health status decision support system was developed, pilot tested, and is now fully implemented throughout the BCHS. The methodological approach, quantitative indicators, report format components, and management implications of the system are described.
Health Care Manage Rev, 2002, 27(1), 7695 2002 Aspen Publishers, Inc.

Managing health care organizations has never been more challenging. The continued growth of managed care, recent changes in Medicare reimbursement, and increased public access to detailed financial and clinical information are making it more difficult for health care executives to meet performance expectations related to the quality of service, market share, and profitability. An even more difficult challenge, however, may lie ahead for this countrys health care leadership: to demonstrate that the health status of communities and populations can be improved. Although the U.S. spends a larger percentage of its wealth for health expenditures and has, without question, the most technologically advanced medical care system in the world, our health status as a nation is persistently subpar, even when compared to some less economically developed nations. This gap between our wealth and our health, long a subject of some debate among researchers, is now being more widely acknowledged by politicians and the public at large. Increasingly, managers of our health care institutions and agencies will be expected to close this gap. Improving the health status of populations represents a new management challenge to a health care

Key words: community health status assessment, defined populations, integrated delivery systems, multihospital systems James Studnicki, Sc.D., is Professor of Health Policy and Management and Director, Center for Health Outcomes Research, University of South Florida, Health Sciences Center, Tampa and St. Petersburg, Florida. Frank V. Murphy, M.H.A., is President and CEO, BayCare Health System, Clearwater, Florida. Donna Malvey, Ph.D., is Assistant Professor, Health Policy and Management, University of South Florida, College of Public Health, Tampa and St. Petersburg, Florida. Robert A. Costello, M.B.A., is Director of Quality Planning, BayCare Health System, Clearwater, Florida. Stephen L. Luther, Ph.D., is Research Assistant Professor, Center for Health Outcomes Research, University of South Florida, Tampa and St. Petersburg, Florida. Dennis C. Werner, M.H.A., is Senior Research Coordinator, Center for Health Outcomes Research, University of South Florida, Health Sciences Center, Tampa and St. Petersburg, Florida.
This work was supported in part by grants from the U.S. Department of Commerce (Telecommunications and Information Infrastructure Assistance Program) and the BayCare Health System.

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system primarily oriented toward providing insurance coverage and medical and hospital services to sick people. Our organizational structures, priorities, values, and financial incentives are seemingly incongruent with an emphasis on the health of populations and on coordinated and focused efforts to identify health risks and prevent illness. Especially for private sector organizations in the U.S., these management objectives are unfamiliar territory. This article reviews the experience of a hospital-based integrated delivery system (IDS) taking its first steps toward managing the health status of defined communities. THE AMERICAN DILEMMA This fundamental, peculiarly American dilemma has been so well documented over such a long period of time and with such profound implications for our society, it is surprising that it is not widely acknowledged as a national disgrace: While our health care system consumes the massive amount of resources represented by the more than one trillion plus dollars expended annually, the health status of our nation as characterized by multiple measures is alarmingly low. At least a dozen nations with a population greater than one million persons have lower infant mortality rates.1 Immunization rates for measles by age 12 are higher in nearly 60 countries, including many that would be considered economically underdeveloped or distressed.2 Nearly 20 nations have male and female life expectancy at birth longer than the U.S. The World Bank has cited the United States as the nation with the worst health outcomes in relation to expenditures.3 MULTIPLE DETERMINANTS OF HEALTH Since the medical care system consumes such a large percentage of total U.S. health expenditures, many investigators expressing a public health perspective have challenged the extent to which these investments have improved population health status,4,5 generally concluding that medical interventions have a relatively minor impact on population mortality. Explanatory models have emerged that differentiate the concepts of disease, health, and well being.6 Multiple factors identified as impacting disease, health, and function include the social environment, physical environment, and genetic endowment.7 For example, extensive research evidence exists that higher levels

of socioeconomic status are persistently associated with lower mortality and morbidity.8,9 Related factors such as employment, income, social support systems, marital status, and race have been found to have independent effects on mortality rates.1012 Environmental hazards and toxic agents have been determined to have measurable impacts on the health of populations in the form of occupational hazards, food and water contaminants, and components of commercial products. Personal behaviors such as smoking habits, diet, exercise, alcohol use, motor vehicle use, sexual activity, and violent and abusive behavior contribute significantly to health outcomes.13 Therefore, since there are multiple determinants of population health, it is unlikely that even a lavishly funded medical care system alone will deliver substantial improvements in health status. Traditional public health agencies have defined as core functions the assessment of the health of populations, policy formulation appropriate to the problems identified, and assurance that relevant environmental, behavioral, or medical care interventions are applied and sustained.14 However, most Americans have no experience with public health agencies, which are chronically handicapped by a paucity of resources, and in many areas, relegated to the role of the health care provider of last resort to especially vulnerable populations. Many health policy experts have come to believe that improvements in population health status are likely to come only from the type of organization described by Alfred Sommer, Dean of the Johns Hopkins School of Hygiene and Public Health as a complex, diverse, integrated, and dynamic enterprise, composed of many disciplines, whose primary goal is improving and protecting the health of the public.15 (p.657) No such organization presently exists in the U.S. NEW ORGANIZATIONAL MODELS, BARRIERS, AND INFORMATION Currently, our health care system, despite an increasing awareness of the importance of both clinical and population outcomes, is neither organized nor incentivized to address population health. Considerations of profitability and market share continue to dominate management decisions in private sector organizations.16 Public health agencies and organizations are largely focused upon designated populations of interest (e.g., poor mothers and children, patients with AIDS) supported by categorical funding. The challenge of being able to affect both medical and

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nonmedical determinants of health through some type of vertically integrated delivery system has been addressed by a few researchers. It has been suggested that hospital integrated delivery systems may have the potential to incrementally develop the vertically integrated services (e.g., screening, health education) necessary to address additional determinants of population health.17 Barriers to the evolution of hospitalbased integrated delivery systems into integrated population health delivery systems are formidable. Implementing appropriate financial incentives is probably the most essential task in the creation of the new paradigm. Shortell has described the health promotion accountability region (HPAR), a type of integrated delivery system, at the state or regional level whose reimbursement would be tied to improvements in population health status.18 More recently, Kindig has suggested a financial mechanism that rewards integrated delivery systems and health plans for improvements in an index of health adjusted life expectancy (HALE) but also proposes the establishment of a Health Outcomes Trust that would have responsibility for coordinating the medical care sector and other sectors (e.g., social services, education, environment, public health) in order to maintain and improve the health of the public.19 It should be noted that other European nations have already incorporated improvements in population health as a means to evaluate the performance of health care managers. As exciting as these theoretical concepts and innovative organizational schemes may be to some researchers and policy analysts, the first few necessary steps must be taken on the messy turf of the real world. In the most fundamental terms, there are two practical requirements necessary for any organization wishing to impact on community health status: purpose and performance measurement. First, an explicit recognition of improved population health status as an enterprise objective is a prerequisite for success. Second, there must be a valid performance measurement system, which makes the powerful connection among the health of the community, informationdriven decision support systems, and management decisions.20 BAYCARE HEALTH SYSTEM In the summer of 1997, the signing of a joint operating agreement involving some of the largest and most influential not-for-profit community hospitals in west central Florida formed the BayCare Health System

(BCHS). The hospitals forming BCHS collectively represent 2,756 beds, 3,400 medical staff members, and 10,989 employees. In fiscal 1999, BCHS hospitals accounted for approximately 88,000 admissions, 14,000 births, and 269,000 emergency department visits. The system is moving toward vertical integration of services and provides a wide range of nonacute services in addition to hospital care including screening and preventive services, primary care, and postacute services. The system is organized into a regional structure of three community health alliances (CHAs) that are named after the system hospitals located in each of the geographically defined population areas (see Figure 1). BayfrontSt. Anthonys Health Care is located in southernmost part of Pinellas County, in the city of St. Petersburg. (Note: As of December 31, 2000, Bayfront Medical Center is no longer a BCHS member.) Morton Plant Mease Health Care represents the areas of Pinellas County, including the city of Clearwater, and the western area of Pasco County. St. JosephsBaptist Health Care incorporates all of Hillsborough County, including the city of Tampa, and the eastern area of Pasco County. The total threecounty area is home to approximately 2.4 million residents. Each of the three CHAs represents considerable geographic, demographic, and socioeconomic heterogeneity. Pinellas County, for example, is the least rural county in all of Florida, but both Pasco and Hillsborough Counties have expansive rural areas. As is true of many Florida places, older and wealthier coastal communities lie adjacent to inland pockets of relative poverty. This diversity represents a formidable challenge to the BCHS management team in assessing the needs and health status of the communities residing inside their population areas, as well as evaluating the impact of the services being delivered. All three CHAs share the same mission of BCHS, to improve the health of all we serve through community-owned health care services that set the standard for high quality, compassionate care. Each CHA operationalizes its commitment to improving the communities health status through their Quality Planning Process, which

The hospitals forming BCHS collectively represent 2,756 beds, 3,400 medical staff members, and 10,989 employees.

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FIGURE 1
BAYCARE COMMUNITY HEALTH ALLIANCES POPULATION AREAS

BAYCARE HEALTH SYSTEM COMMUNITY HEALTH ALLIANCES POPULATION AREAS

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defines multiyear Strategic Directions and annual Action Steps and Quality Improvement Goals. Community health priority areas for these benchmarks are selected based on findings from research methodologies discussed in this article. Progress on accomplishments (i.e., Quality Reporting) is shared on a quarterly basis with each CHAs senior and middle management teams, Community Affairs Board Committee, and the health system Board. PROJECT OBJECTIVES The rationale for the creation of BCHS was formed in the competitive hospital service market of the 1990s, and there was undoubtedly some reaction to the growth of the proprietary Columbia/HCA system in the Tampa St. Petersburg area during that period. The goals of the new enterprise reflected the typical anticipated benefits of service integration: cost efficiencies and economies of scale derived from consolidation of duplicated administrative services; improvements in the quality of clinical care by standardizing on best practices inside the system; and enhanced attractiveness to managed care organizations by providing a network of coordinated hospital and physician services through a single signature contract.21 These objectives are consistent themes inside the developing literature on the organization and operation of hospital-based integrated delivery systems.22,23 However, from the very beginning, the BayCare leadership underscored the systems promise for improving the health of the community. A decision was made to develop an information-driven, community health status decision support system. With consultation assistance from the Center for Health Outcomes Research at the University of South Florida Health Sciences Center, the development of this system was initiated. Known by the acronym CHAPIR (Community Health Alliance Performance Impact Report), it was determined that the community health status monitoring system would need to meet the following specifications: Comprehensiveness. Following the recommendations of the Institute of Medicine (IOM) of the National Academy of Sciences, the CHAPIR would establish and maintain a broad strategic view of the health status of the community and the various factors that influence it.24 Operational Integratability. The indicators used to monitor health status of communities inside the CHAs must, at least to some extent, be related to

the programs and services planned or implemented by the CHAs. Feasibility and Continuity. Data elements utilized in the CHAPIR must be drawn from available extant public databases, or existing sources of internal information. Information requiring original, primary data collection such as surveys would be less desirable on the assumption of the decreased likelihood that these special efforts would be sustained over time. Community-Level Granularity. County- and CHAspecific information, while valuable for comparative purposes, is insufficient in identifying the health status variability of the communities inside the CHA service areas. Therefore, the CHAPIR system must aggregate data to the community level as defined by groups of postal zip codes. Parsimonious Presentation. Intended primarily for senior corporate managers, clinical leadership, and board members, the CHAPIR reports must capture and present the important and valid indicators and findings without resorting to lengthy narrative or complicated statistical treatment. Measurement and Monitoring of Results. The CHAPIR report must include interim process indicators to measure progress on recommendations, goals, and action plans initiated to address priority problem areas. Process indicators can be reported on a more frequent basis than ultimate outcome indicators such as morbidity and mortality, which are typically updated on an annual basis.

THE METHODOLOGICAL APPROACH An existing methodology for assessing the health status of communities, under development for nearly 8 years, served as the starting point for CHAPIR. Known as CATCH (Comprehensive Assessment for Tracking Community Health), the method draws 250 indicators from multiple sources and uses a comparative framework and weighted evaluation criteria to produce a rank-ordered community problem list. The indicators are organized into 10 categories: demographic characteristics; socioeconomic characteristics; maternal and child health indicators; infectious disease indicators; physical and environmental health indicators; health status indicators (mortality and morbidity); social and mental health indicators; sentinel

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events (immunizable diseases and avoidable hospitalizations); health resource availability indicators; and, behavioral risk factors.25 Comprehensive CATCH assessments have been completed in 13 Florida counties including all three of the counties composing the BCHSCHA areas. The CHAPIR reports draw much of their data from the same sources, but the format specifies a three-level indicator selection process: 1. Generic Health Status Indicators, which are intended to provide a baseline profile of the important dimensions of community health status. This indicator list will be identical for each of the three CHAs, allowing comparison between the CHAs with statewide, regional, and national norms. 2. CHA-Specific Health Status Indicators are intended to profile those diseases or conditions that can be identified as a priority area of concern for each CHA. The assignment of priority for any indicator may be the result of each CHAs internal strategic analysis, a previous county-level CATCH assessment, an evaluation of zip code level community cluster analyses, or some other source of information. 3. Programmatic Indicators are determined largely by the nature of service programs and monitoring systems that have been implemented by the CHA operating units. These indicators would tend to be more operational, focusing on program utilization or intermediate outcome targets rather than morbidity and mortality indicators. Although these indicators are drawn largely from existing sources of external and internal information, some may require a primary data collection effort such as a periodic telephone survey.

percentage of the total variation represented by all of the indicators. A principal components analysis (PCA) was selected as the statistical technique to derive the parsimonious model. The PCA is applied to a set of variables where there is interest in discovering which variables inside the set or the group of indicators form coherent subsets that are relatively independent of one another. Variables that are correlated with one another but are largely independent of other subsets are combined into the principal components. The major goal of the PCA is to reduce the number of variables down to a few factors. For example, the total number of variables in the original CATCH socioeconomic indicators category was reduced to two factors: poverty and education/employment. The 14 factors created by the PCA and the individual variables comprising each are found in Table 1. CHA-SPECIFIC HEALTH STATUS INDICATORS Since comprehensive assessments were completed in each of the three counties composing the BCHS service area, the priority problems or issues identified in those projects were an important source of information in determining CHA priorities. Table 2 is a summary of the major categories and indicators identifying health challenges in each county. Subsets of the indicators utilized in the comprehensive community assessments are available at the postal zip code level. This presents the opportunity to focus down on identified communities inside each of the CHAs that are composed of groups of zip codes. This capability considerably enhances the process of describing the characteristics and health status of population groups inside the boundaries of each CHA. In order to provide these new dimensions to the CHAPIR report, the following analytical steps were completed: Each of the three CHAs was subdivided into communities based upon groups of zip codes. This process generally attempts to define communities that are relatively homogeneous internally, but acknowledged by residents to be different from other communities. While there tends to be some disagreement over the assignment of some boundary zip codes to one community versus another, there is usually high agreement regarding the core cluster of zip codes. Often these communities correspond very closely to old neighborhood boundaries.

GENERIC HEALTH STATUS INDICATORS The first level of Generic Health Status Indicators was identified through a comprehensive review and statistical analysis of the unique CATCH database. These indicators are intended to represent major disease groups and/or leading causes of death, the relevant CATCH category indicators, and a smaller subset of CATCH indicators that would explain most of the statistical variation in mortality accounted for by all of the CATCH indicators. Researchers refer to the subset as the parsimonious model, that is, a smaller group of indicators, which accounts for a large

TABLE 1 PRINCIPAL COMPONENT ANALYSIS OF COMMUNITY HEALTH STATUS: RESULTING FACTORS

Factor Poverty Education/Employment Demography Rurality Community Violence Maternal and Child Health Avoidable Hospitalizations Resources Infection Morbidity Chronic Morbidity Site-specific Mortality (adult) Unintentional Injury Infant Deaths (white) Infant Deaths (non-white)
AAM - age adjusted mortality

Indicators % of families below federal poverty level, per capita income % of unemployed persons, % of high school dropouts % of population 15, % of population 65, % of populations non-white % of population living in rural areas simple assault rate, aggravated assault rate, domestic violence birth to mothers 15, birth to mothers 1517, birth to mothers 1819 congestive heart failure, pneumonia, asthma physicians/100k population, dentists/100k population, LPNs/100k population enteric diseases colorectal cancer morbidity, breast cancer morbidity lung cancer AAM, cardiovascular diseases AAM, pneumonia AAM, prostate cancer AAM, AIDS AAM unintentional injury AAM infant mortality (white), neonatal mortality (white) infant mortality (non-white), neonatal mortality (non-white)

TABLE 2 MAJOR HEALTH PRIORITIES RESULTING FROM THREE COUNTY LEVEL ASSESSMENTS
County Priority Area Hillsborough County Maternal and Child Health Community Violence and Safety Issues Preventable Cancers Other infant, neonatal and post neonatal mortality mortality due to perinatal conditions, birth defects domestic violence, simple and aggravated assaults, suicide, homicide and unintentional injuries breast, cervical, colorectal; smoking related stroke, COPD Pinellas County Maternal and Child Health Social Issues Lung/Respiratory Diseases infant and child mortality, birth defect mortality births to mothers 15, repeat births to teenagers smoking related cancers, lung and bronchus cancers, pneumonia and influenza, chronic obstructive lung diesease Years of Productive Life Lost (YPLL) Pasco County Maternal and Child Health low and very low birthweight babies, births to mothers 15, perinatal conditions neonatal, post neonatal and infant mortality pneumonia and influenza breast, cervical; melanoma, lung, and smoking related syphilis, gonorrhea, meningitis stroke Indicators

Other

Lung/Respiratory Diseases Preventable Cancers Infectious Diseases Other

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Figure 2 illustrates the nine communities created by postal zip code aggregation within the St. JosephsBaptist Health Care CHA. A comprehensive list of indicators from the CATCH database, available at the zip code level, was then aggregated into CHA, county, and community (i.e., zip code groups) mean values. Finally, eliminating those indicators that reflected volumes so low that many zip codes would have three or fewer observations in 1 year reduced the list. The remaining indicators would then represent a relatively large volume of cases, and would be suitable for validly identifying indicators which had relatively large differences between the CHA mean value and one or more of the community values.

BCHS has also implemented a framework for identifying basic quality improvement goals, which were developed by each of the three CHAs and organized into three categories: service, outcome, and cost.
is, they are typically focused on clinical or administrative process improvement. Generally, these indicators emphasize improvement in service to key customers, outcomes (clinical and nonclinical), and cost. These indicators may be oriented toward improvements in community health status and will be incorporated into the CHAPIR report. For example, one CHA had as an expressed outcome goal the reduction in latestage breast cancer. This goal could be related to mammography screening or breast self-examination education programs, and ultimately to reductions in breast cancer mortality. REPORT FORMAT COMPONENTS There are two major methods of data presentation incorporated into the CHAPIR report format: core indicator graphs and the total indicator table. The core indicator set is composed of each indicator selected for analysis in each CHA through the process of selection previously described utilizing three levels of indicators (i.e., generic, CHA-specific, and programmatic). For each indicator, a graph depicts the CHA value as a horizontal line and reference symbols placed above or below the line. A sample core indicator graph (Figure 3) illustrates morbidity due to psychoses in the St. JosephsBaptist Health Care CHA and 12 symbols representing, from left to right, values for: the Florida state average, the Hillsborough and Pasco County averages, and the mean values for each of nine zipcode-defined communities within the CHA. Therefore, communities with unfavorable patterns of morbidity and mortality are easily identifiable. The number of core indicator graphs will vary somewhat between CHAs, and 27 were selected for St. JosephsBaptist Health Care CHA. Other methods for presenting the core indicator data are available such as color-coded mapping. For a more comprehensive view, all indicators having zip code level data are also displayed in a summary Table 3. The table organizes the indicators

PROGRAMMATIC INDICATORS A major source of information that was used to identify CHA-specific priority issues and problems is the internal strategic analysis conducted by the CHAs and/or their various operating units. Presumably, a set of organizational objectives serves as the guide for allocating resources and development of programs. Many of these decisions will be based upon the growth of new clinical programs, the strengthening of existing ones and even, occasionally, the termination of others. In a few instances, those objectives are congruent with improvement in community health status outcomes. In an effort to include this type of strategic thinking in the CHA-specific indicators, meetings were scheduled with key staff and management at each of the three CHAs. A loosely structured questionnaire was developed that elicited information for three domains: the health care needs that have been identified inside each CHA and its communities; the services or programs implemented or planned to address these identified needs; and the measures or quantifiable indicators currently utilized or planned that could monitor the implementation of the programs and anticipated outcomes that would be impacted by these programs. The responses were organized in the same categories utilized by the CATCH methodology so as to improve the internal consistency of both the reporting and the presentation. BCHS has also implemented a framework for identifying basic quality improvement goals, which were developed by each of the three CHAs and organized into three categories: service, outcome, and cost. These measures tend to be operational in nature; that

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FIGURE 2
ST. JOSEPHSBAPTIST HEALTH CARE COMMUNITY HEALTH ALLIANCE PERFORMANCE IMPACT REPORT (CHAPIR)

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FIGURE 3
CORE INDICATOR GRAPH: MORBIDITY DUE TO PSYCHOSES WITHIN ST. JOSEPHSBAPTIST CHA

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TABLE 3 TOTAL INDICATOR TABLE: ST. JOSEPHSBAPTIST CHA

St. Joseph/ Hillsborough Pasco NE Pasco SE Pasco Baptist CHA County County Community Community 1,042,571 918,084 310,517 51,260 73,227 Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K

CHA Indicators Socio-Demographic Indicators Non-White Population Median Household Income Population Over 65 Population Under 15 Disease Specific Mortality Total Mortality Cardiovascular Disease Heart Disease Total Cancer Preventable Cancers Smoking Related Cancers Lung Cancer Stroke Chronic Obstructive Lung Disease Diabetes Mellitus Colorectal Cancer Pneumonia/Influenza Colon Cancer Prostate Cancer Breast Cancer Chronic Liver Disease & Cirrhosis AIDS

185,764 17.82% $34,405 151,197 14.50% 250,549 24.03%

175,040 19.07% $35,549 119,200 12.98% 223,213 24.31%

14,535 4.68% $25,654 104,015 33.50% 55,947 18.02%

7,812 15.24% $24,006 8,767 17.10% 13,792 26.91%

2,912 3.98% $27,337 23,230 31.72% 13,544 18.50%

9,190 881.47 3,548 340.31 2,709 259.84 2,261 216.87 1,288 123.54 885 84.89 712 68.29 612 58.70 491 47.10 282 27.05 238 22.83 225 21.58 201 19.28 158 31.06 158 29.60 112 10.74 110 10.55

7,803 849.92 3,045 331.67 2,326 253.35 1,954 212.83 1,093 119.05 749 81.58 595 64.81 543 59.14 412 44.88 239 26.03 204 22.22 162 17.65 174 18.95 141 31.46 139 29.58 100 10.89 99 10.78

4,915 1582.84 1,988 640.22 1,594 513.34 1,238 398.69 726 233.80 527 169.72 433 139.44 274 88.24 312 100.48 101 32.53 113 36.39 159 51.20 94 30.27 92 62.18 67 41.22 52 16.75 31 9.98

448 873.98 160 312.13 118 230.20 90 175.58 61 119.00 41 79.98 36 70.23 19 37.07 20 39.02 16 31.21 13 25.36 17 33.16 11 21.46 7 27.80 5 19.17 6 11.71 6 11.71

939 1282.31 343 468.41 265 361.89 217 296.34 134 182.99 95 129.73 81 110.61 50 68.28 59 80.57 27 36.87 21 28.68 46 62.82 16 21.85 10 28.24 14 37.02 6 8.19 5 6.83

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TABLE 3 (continued)

NW Tampa New Tampa S Tampa E Tampa S Hillsborough Brandon Plant City Community Community Community Community Community Community Community 95,134 230,650 119,965 192,328 85,973 138,594 55,440 Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K

11,212 11.79% $42,416 8,591 9.03% 22,768 23.93%

37,271 16.16% $38,110 21,029 9.12% 54,169 23.49%

26,179 21.82% $34,008 20,614 17.18% 24,146 20.13%

74,836 38.91% $25,428 25,771 13.40% 50,416 26.21%

7,214 8.39% $32,689 23,072 26.84% 18,067 21.02%

14,007 10.11% $44,527 12,373 8.93% 38,465 27.75%

4,321 7.79% $33,547 7,750 13.98% 15,182 27.38%

672 706.37 230 241.76 166 174.49 195 204.97 116 121.93 77 80.94 64 67.27 44 46.25 38 39.94 22 23.13 18 18.92 11 11.56 16 16.82 5 10.75 18 37.02 5 5.26 8 8.41

1,620 702.36 589 255.37 416 180.36 429 186.00 244 105.79 163 70.67 121 52.46 137 59.40 105 45.52 45 19.51 43 18.64 28 12.14 39 16.91 34 30.24 27 22.84 20 8.67 22 9.54

1,240 1033.63 523 435.96 412 343.43 281 234.23 153 127.54 104 86.69 80 66.69 82 68.35 62 51.68 32 26.67 25 20.84 35 29.18 18 15.00 21 36.42 20 32.10 18 15.00 15 12.50

1,785 928.10 711 369.68 561 291.69 401 208.50 235 122.19 167 86.83 137 71.23 111 57.71 77 40.04 72 37.44 44 22.88 33 17.16 37 19.24 36 38.80 23 23.11 39 20.28 40 20.80

1,020 1186.42 481 559.48 369 429.20 232 269.85 114 132.60 87 101.19 69 80.26 78 90.73 56 65.14 21 24.43 21 24.43 16 18.61 19 22.10 22 50.95 18 42.06 5 5.82 3 3.49

904 652.26 316 228.00 251 181.10 262 189.04 148 106.79 93 67.10 79 57.00 51 36.80 47 33.91 30 21.65 37 26.70 19 13.71 33 23.81 14 20.41 20 28.57 11 7.94 7 5.05

562 1013.71 195 351.73 151 272.37 154 277.78 83 149.71 58 104.62 45 81.17 40 72.15 27 48.70 17 30.66 16 28.86 20 36.08 12 21.65 9 33.31 13 45.74 2 3.61 4 7.22

TABLE 3 (continued)
St. Joseph/ Hillsborough Pasco NE Pasco SE Pasco Baptist CHA County County Community Community 1,042,571 918,084 310,517 51,260 73,227 Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K 37 3.55 Melanoma Cervical Cancer Tuberculosis Other Mortality Indicators Unintentional Injuries Suicide Homicide Drowning Poison Mortality Maternal/Child Health Indicators Had Prenatal Care 1st trimester Teen Births age 1819 Low Birthweight Teen Births age 1517 Repeat Births Had Prenatal Care 3rd trimester Very Low Birthweight Infant Mortality No Prenatal Care Neonatal Mortality Teen Births under age 15 Child Mortality Perinatal Conditions Birth Defects Post Neonatal Mortality Morbidity Indicators Psychoses AIDS 1,962 188.19 395 37.89 379 41.23 1,872 203.90 50 15.94 1,189 382.91 6 11.71 47 91.69 11 14.34 43 58.72 10,164 661.03 1,015 66.01 957 62.24 669 43.51 424 27.58 187 12.16 179 11.64 90 8.63 87 5.66 55 5.28 52 3.38 47 18.76 45 4.32 36 3.45 33 3.17 31 3.38 26 2.83 9 2.90 40 4.36 19 6.12 1 1.95 36 16.13 9 2.90 3 5.85 1 1.37 46 3.38 15 26.81 3 5.85 7 9.56 50 5.45 8 2.25 6 43.50 2 2.73 80 5.88 10 3.22 2 2.36 5 36.92 81 8.82 18 5.06 1 1.95 4 4.36 161 11.83 21 6.76 2 2.36 4 5.46 165 12.12 37 10.40 4 7.80 5 5.45 366 26.89 40 11.25 11 12.96 5 6.83 589 43.28 104 29.25 15 17.67 7 7.63 874 64.22 168 47.24 30 35.34 7 7.63 889 65.32 183 51.46 44 51.83 28 30.50 8,901 654.05 273 76.77 40 47.11 36 39.22 2,827 794.99 59 69.49 43 46.84 440 518.26 67 72.98 823 896.51 385 36.93 132 12.66 57 5.47 16 1.53 2 0.19 2 0.22 10 1.09 0 0.00 51 5.56 11 3.54 0 0.00 103 11.22 8 2.58 5 9.75 0 0.00 336 36.60 57 18.36 3 5.85 1 1.37 124 39.93 11 21.46 3 4.10 18 35.12 18 24.58 31 42.33 35 3.36 22 4.12 3 0.29 3 0.33 21 4.47 1 0.32 25 2.72 5 3.08 0 0.00 30 3.27 26 8.37 0 0.00 0 0.00 19 6.12 2 3.90 1 2.64 2 3.90 8 10.92 5 6.83

CHA Indicators Rectal Cancer

TABLE 3 (continued)
NW Tampa New Tampa S Tampa E Tampa S Hillsborough Brandon Plant City Community Community Community Community Community Community Community 95,134 230,650 119,965 192,328 85,973 138,594 55,440 Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K 2 2.10 1 1.05 2 4.11 0 0.00 21 22.07 11 11.56 4 4.20 2 2.10 0 0.00 1,247 852.36 77 52.63 80 54.68 32 21.87 21 14.35 6 4.10 17 11.62 10 10.51 5 3.42 7 7.36 2 1.37 3 13.18 5 5.26 3 3.15 3 3.15 179 188.16 29 29.96 80 34.47 459 199.00 77 63.77 11 4.77 411 342.60 145 75.13 12 5.20 5 4.17 729 379.04 11 12.21 9 3.90 4 3.33 10 5.20 5 5.82 20 14.07 11 20.31 5 4.17 6 3.12 0 0.00 80 57.72 20 35.17 8 2.30 5 20.71 21 10.92 0 0.00 2 1.44 9 16.23 14 6.07 2 1.30 13 25.79 0 0.00 1 0.72 0 0.00 15 4.32 7 5.84 25 8.26 0 0.00 0 0.00 0 0.00 25 10.84 6 3.91 20 10.40 4 3.36 4 10.40 0 0.00 38 10.94 12 10.00 43 14.21 0 0.00 4 1.96 0 0.00 44 12.67 20 13.05 30 15.60 3 2.52 1 0.72 1 1.14 81 23.33 24 15.66 66 21.82 0 0.00 7 3.42 1 1.80 124 35.71 32 20.87 71 23.47 2 1.68 3 2.16 1 1.14 225 64.80 74 48.27 188 62.15 6 5.03 16 7.82 1 1.80 225 64.80 112 73.06 295 97.52 14 11.74 9 4.40 2 2.28 2,798 805.88 102 66.54 343 113.39 21 17.62 25 12.22 5 5.69 0 0.00 1,343 876.06 383 126.61 25 20.97 36 17.60 5 5.69 4 1.73 1 0.83 2,380 786.78 26 21.81 85 41.54 7 7.97 12 5.20 2 1.67 0 0.00 163 136.74 69 33.72 4 4.56 22 9.54 7 5.84 1 0.52 1 1.16 932 455.52 7 7.97 62 26.88 19 15.84 22 11.44 0 0.00 0 0.00 38 43.28 0 0.00 35 29.18 20 10.40 1 1.16 1 0.72 0 0.00 7 5.92 1 0.83 90 46.80 12 13.96 2 1.44 0 0.00 7 3.03 1 1.61 1 0.52 42 48.85 11 7.94 3 5.41 4 1.73 4 3.33 4 4.02 0 0.00 54 38.96 8 14.43 7 5.84 3 1.56 1 2.34 0 0.00 32 57.72 7 3.64 4 4.65 2 2.86 1 1.80 2 2.33 2 1.44 4 14.07 4 2.89 4 7.22 4 7.22

TABLE 3 (continued)
St. Joseph/ Hillsborough Pasco NE Pasco SE Pasco Baptist CHA County County Community Community 1,042,571 918,084 310,517 51,260 73,227 Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K 233 22.35 Giardiasis Salmonellosis Shigellosis Chlamydia Gonorrhea Alcohol Dependency Campylobacteriosis Depressive Disorder Hepatitis A Alzheimers Disease Hepatitis B Drug Dependence Rubella, including congenital Syphilis, congenital Tuberculosis Pertussis Meningitis (meningococcal) Mumps Rabies from Animal Rabies, Human Bitten Measles Syphilis, infectious Any foodborne disease outbreak Any waterborne disease outbreak Avoidable Hospitalizations Congestive Heart Failure Pneumonia 2,704 259.36 2,536 243.24 2,096 228.30 2,246 244.64 1,449 466.64 2,239 721.06 185 360.91 197 384.32 255 348.23 261 356.43 203 19.47 187 17.94 177 16.98 172 16.50 109 10.45 105 10.07 92 8.82 66 6.33 62 5.95 55 5.28 44 4.22 40 3.84 18 1.73 14 1.29 14 1.29 14 1.34 9 0.86 4 0.38 1 0.10 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 2 0.64 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 3 0.33 2 0.64 0 0.00 0 0.00 9 0.98 1 0.32 1 1.95 0 0.00 14 1.52 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 1 1.37 0 0.00 27 8.70 0 0.00 0 0.00 0 0.00 27 8.70 6 11.71 0 0.00 40 4.36 34 10.95 6 11.71 8 10.24 42 4.57 5 1.61 4 7.80 8 10.24 43 4.68 5 1.61 0 0.00 14 19.12 53 5.77 53 17.07 0 0.00 0 0.00 62 6.75 10 3.22 4 7.80 2 2.73 74 8.06 10 3.22 8 15.61 8 10.92 98 10.67 29 9.34 1 1.95 1 1.37 0 0.00 34 10.95 7 13.66 3 4.10 0 0.00 116 37.36 5 9.75 11 15.02 177 19.28 186 59.90 50 97.54 2 2.73 164 17.86 0 0.00 104 202.89 59 80.57 168 18.30 25 8.05 0 0.00 68 92.86 207 22.55 54 17.39 8 15.61 0 0.00 53 17.07 13 25.36 15 20.48 19 37.07 22 30.04 7 9.56

CHA Indicators Lead Poisoning

TABLE 3 (continued)
NW Tampa New Tampa S Tampa E Tampa S Hillsborough Brandon Plant City Community Community Community Community Community Community Community 95,134 230,650 119,965 192,328 85,973 138,594 55,440 Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K 1 1.05 23 24.18 16 16.82 4 4.20 0 0.00 0 0.00 21 22.07 8 8.41 7 7.36 4 4.20 3 3.15 3 3.15 3 3.15 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 1 0.43 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 2 0.87 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 3 1.30 1 0.83 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 2 1.67 4 2.08 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 2 1.04 2 2.33 1 0.72 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 1 1.80 11 4.77 0 0.00 0 0.00 0 0.00 3 2.16 0 0.00 16 6.94 6 5.00 0 0.00 0 0.00 0 0.00 4 7.22 16 6.94 5 4.17 17 8.84 0 0.00 0 0.00 0 0.00 6 2.60 4 3.33 13 6.76 0 0.00 0 0.00 0 0.00 15 6.50 15 12.50 18 9.36 2 2.33 2 1.44 0 0.00 18 7.80 16 13.34 13 6.76 0 0.00 3 2.16 1 1.80 24 10.41 9 7.50 22 11.44 4 4.65 2 1.44 0 0.00 0 0.00 30 25.01 19 9.88 0 0.00 9 6.49 0 0.00 0 0.00 0 0.00 19 9.88 4 4.65 2 1.44 2 3.61 45 19.51 0 0.00 0 0.00 0 0.00 16 11.54 0 0.00 55 23.85 22 18.34 0 0.00 0 0.00 4 2.89 0 0.00 46 19.94 20 16.67 71 36.92 0 0.00 0 0.00 0 0.00 14 6.07 14 11.67 25 13.00 13 15.12 0 0.00 0 0.00 33 27.51 36 18.72 21 24.43 17 12.27 0 0.00 138 71.75 12 13.96 25 18.04 5 9.02 5 5.82 28 20.20 2 3.61 10 7.22 9 16.23 6 10.82

241 253.33 224 235.46

512 221.98 558 241.92

491 409.29 394 328.43

816 424.28 726 377.48

13 15.12 26 30.24

173 124.83 168 121.22

0 0.00 0 0.00

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HEALTH CARE MANAGEMENT REVIEW/WINTER 2002

TABLE 3 (continued)
St. Joseph/ Hillsborough Pasco NE Pasco SE Pasco Baptist CHA County County Community Community 1,042,571 918,084 310,517 51,260 73,227 Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K 1,427 136.87 Cellulitis Perf. or Bleeding Ulcer Diabetes Pyelonephritis Ruptured Appendix Malignant Hypertension Hypokalemia Gangrene Immunizable Conditions 757 72.61 453 43.45 298 28.58 282 27.05 194 18.61 130 12.47 35 3.36 15 1.44 7 0.67 4 0.44 12 1.31 3 0.97 29 3.16 3 0.97 1 1.95 92 10.02 32 10.31 2 3.90 2 2.73 164 17.86 87 28.02 2 3.90 1 1.37 235 25.60 75 24.15 11 21.46 4 5.46 256 27.88 111 35.75 12 23.41 27 36.87 388 42.26 122 39.29 20 39.02 18 24.58 634 69.06 254 81.80 18 35.12 27 36.87 1,260 137.24 374 120.44 21 40.97 24 32.77 547 176.16 54 105.35 44 60.09 90 175.58 69 94.23 77 105.15

CHA Indicators Asthma

into six color-coded groups or categories: sociodemographic, disease-specific mortality, other mortality, maternal and child health, morbidity, and avoidable hospitalizations. Within categories, the indicators are rank ordered on the basis of the volume of cases or observations, in the St. JosephsBaptist CHA, from the highest to the lowest. Additionally, those indicators where the community value is unfavorable or worse relative to the CHA average are shaded. This allows for easier pattern recognition horizontally for each indicator across all communities or, vertically for each community across all indicators.

DISCUSSION: MANAGING THE INTERVENTIONS The data produced by the CHAPIR system have been formally integrated into BCHS management process and structure. The Board of Directors of the CHAs define the mission and vision, part of which remains to improve the health of all we serve. The

system Senior Management Team develops annual action steps to support the mission and vision and includes the specific action step to assess the communitys health status, develop interventions, and measure results. With the implementation of the CHAPIR system, the broad goal statements are now focused and translated into specific programs and services. A Health System Community Health Council, comprised of the manager of community health and key directors and department heads who are responsible for selected product lines, reviews the CHAPIR findings for each CHA, defines priorities, and develops an intervention plan that outlines annual objectives and measurable indicators. These detailed plans are then reviewed and approved by both the Senior Management Team and the Community Affairs subcommittee of the Board of Directors. Individual CHA plans are then implemented and managed by the community health manager and the relevant product-line department heads. On a quarterly basis, plan progress and necessary adjustments are reported to the Community Health Council and the Community Affairs subcom-

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93

NW Tampa New Tampa S Tampa E Tampa S Hillsborough Brandon Plant City Community Community Community Community Community Community Community 95,134 230,650 119,965 192,328 85,973 138,594 55,440 Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K Totl/R per 100K 129 135.60 75 78.84 48 50.46 34 35.74 34 35.74 22 23.13 17 17.87 6 6.31 2 2.10 1 1.05 2 0.87 4 1.73 1 0.83 7 3.03 2 1.67 0 0.00 25 10.84 4 3.33 4 2.08 0 0.00 45 19.51 15 12.50 10 5.20 0 0.00 0 0.00 61 26.45 30 25.01 29 15.08 0 0.00 0 0.00 0 0.00 55 23.85 38 31.68 48 24.96 1 1.16 2 1.44 0 0.00 95 41.19 38 31.68 77 40.04 3 3.49 5 3.61 0 0.00 150 65.03 83 69.19 119 61.87 2 2.33 16 11.54 0 0.00 285 123.56 113 94.19 135 70.19 1 1.16 23 16.60 0 0.00 205 170.88 247 128.43 3 3.49 9 6.49 0 0.00 552 287.01 4 4.65 24 17.32 0 0.00 10 11.63 45 32.47 0 0.00 79 57.00 0 0.00 0 0.00

mittee of the Board. Annual updates of the CHAPIR data will be utilized to evaluate the impact of the interventions and to reassess community health status priorities. The CHAPIR system has stimulated a variety of interventions in each of the three CHAs. In the largely African American communities of south Pinellas county, high rates of late-stage breast cancer and breast cancer mortality were detected. Bayfront St. Anthony Health Care, with external funding from the Susan G. Komen Foundation, developed the SISTERS FOR BREAST HEALTH program. This program facilitates mammogram utilization and provides breast health care to African American women over 40 years of age in the CHAPIR targeted community. The program utilizes the concept of Sistah Parties with women coming forward to open up their homes and serve as hostesses for an enjoyable evening where the focus is breast health. Barriers to annual screening mammograms are discussed such as fear, cost, lack of trust in the system, and fatalistic attitudes toward cancer. Women without insurance are referred to existing

programs for free or low-cost mammograms. Community partners and organizations supporting the SISTERS program include the American Cancer Society, Pinellas County, Victorias Secret, and Estee Lauder. The average number of women attending a party is just over 10 and about 78 parties per month have occurred since the start of the program. Preliminary data indicate that about 32 percent of the party participants have never had a mammogram and another 40 percent had their most recent mammogram more than 1 year ago, so that about 72 percent of the participants are considered eligible for a screening mammogram. In some communities in northern Pinellas county, mortality due to stroke was determined to be higher than the county, peer county, and total state rates. In neighborhoods identified for screenings by the CHAPIR system, transportation barriers were identified among elderly, minority, and low-income populations. Morton Plant Mease Health Care developed a Mobile Medical Unit, housed in a custom designed Airstream RV, to deliver primary care and

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prevention and education services directly to the affected populations. A color ultrasound unit was placed on the mobile unit to assist in stroke screenings. A nurse practitioner and nurses from MPMHC provides services from the unit. In west Pasco county, unintentional injury mortality rates were identified as a high priority problem. Unintentional deaths from all causes such as motor vehicle accidents, firearms, and poisonings are included in this indicator. Further analysis indicated that the unintentional injury problem in these communities was found primarily in two subpopulations: children and senior citizens. In the absence of injury prevention expertise among its own members, St. JosephsBaptist Health Care representatives involved existing organizations from the community. The Safe Kids Coalition and FLIPS (Florida Injury Prevention for Seniors) are now forming chapters in west Pasco county. Local hospitals are now offering assistance, the Pasco County Health Department is helping to staff the FLIPS chapter, and 10 other community organizations have volunteered to be sponsors of the Safe Kids Coalition. Findings of the CHAPIR system, as indicated by the examples of interventions, are being used to target scarce resources at the local level and to coordinate the activities with other health and human services organizations that may be addressing different components of the same health status problem. Community accountability is subsequently promoted in two very important ways. Multisectoral involvement is stimulated by the broad perspective represented by community health status objectives (e.g., reduction in infant mortality or smoking-related cancer morbidity) as opposed to more limited system operation objectives (e.g., market share or profitability). At the same time, consensus on coordinated multiagency approaches to assessment and integrated interventions become more easily achievable. From a management perspective, the key constraint on this system is the continuing lack of systematic financial incentives to reward BCHS and other providers for addressing population health status. Conceivably, the improved health status of enrolled populations will allow for increased operating margins for managed care, some of which may be shared with providers. CHAPIR and similarly constructed decision support systems, however, will be essential for those health care organizations committed to improving the health status of their communities.

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18. Shortell, S. A Model for State Health Reform. Health Affairs 11 (Spring 1992): 10827. 19. Kindig, D.A. Purchasing Population Health: Paying For Results. Ann Arbor: University of Michigan Press, 1999, pp. 15763. 20. Lasker, H.B. Report of the USPHS Public Health Data Policy Coordinating Committee. Washington, DC: Office of the Assistant Secretary for Health, U.S. Dept. of Health and Human Services, July 6, 1995. 21. Quote from unpublished internal document, A Summary Analysis of the Tampa Bay Area Joint Operating Agreement. 22. Devers, K.J., Shortell, S.M., Gillies, R.R., Anderson, D.A., Mitchell, J.B., Erickson, K.L.M. Implementing Organized Delivery Systems: An Integration Scorecard. Health Care Management Review 19, no. 3 (1994): 720. 23. Conrad, D.A., and Dowling, W.L. Vertical Integration in Health Services: Theory and Managerial Implications. Health Care Management Review 15, no. 4 (1990): 922. 24. Institute of Medicine. Measurement Tools for a Community Health Improvement Process. In Improving Health in the Community, a Role for Performance Monitoring, edited by J.S. Durch, L.A. Bailey, and M.A. Stoto. Washington, DC: National Academy Press, 1997, p. 126. 25. Studnicki, J., Steverson, B., Myers, B., Hevner, A.R., and Berndt, D.J. A Community Health Report Card: Comprehensive Assessment for Tracking Community Health (CATCH). Best Practices and Benchmarking in Healthcare 2, no. 5 (1997): 196207.