Evaluative Measures a. Evaluation capacity

A recently completed grant (ending in December 2014) provides evidence of data management, analysis, and reporting in response to grant requirements. The goal of Mercy’s Diabetes

Program (funded by Methodist Health Ministries) is to develop diabetes self care skills (to improve eating habits and maintain good nutrition, to increase physical activity and to prevent diabetic complications). The program consists of initial evaluation to customize a care plan by a certified diabetic instructor. We offer a six week course, exercise classes, and home visits, as well as collaborating with local providers who provide eye exams, foot exams, dental screenings and fillings and oral health education to patients free of charge. In 2014, 25 newly diagnosed diabetic patients were enrolled in the program. Six of these patients were enrolled in the final quarter, so no terminal data are available yet for them. Of the 19 who completed the 6 month program, six reduced their A1C to below 7, four more reduced their A1C by 2 points, even though it still remained between 7.1 and 8, and nine patients showed no improvement. Overall, the project was a success, given that over 50% achieved positive results. It would be interesting

10

to know more about the factors that made a difference in whether or not patients were able to improve their A1C scores.

In addition, the data collection helped uncover unexpected issues with use of EPIC for an outpatient setting rather than a hospital. Excellent IT services from St. Louis have assisted in resolving the issues as they have arisen, and the experience is reassuring in light of the need to orient and train many more team members to use the system to record data for the Si Texas project.

Mercy Clinic has developed and established the trust and practice models that are culturally appropriate for this vastly underserved population. Therefore, to serve the local community, Mercy Clinic providers are bilingual (Spanish and English) and bicultural (natives of Laredo or Nuevo Laredo, Mexico). Trust is created in that the promotoras (community healthcare workers) live and work in the underserved areas where the patients reside. Efforts to increase the number of women who come for screenings have been successful due to these factors. However, efforts to encourage patients to return for screenings have failed in spite of mailed reminders and phone calls from the registration clerks.

A grant from the Cancer Prevention and Research Institute of Texas, titled ―Loteria de Comadres Contra el Cancer (CPRIT) is now in its third and final year. Literature clearly indicates that early detection and diagnosis are essential to decreasing the mortality and morbidity rates associated with breast and cervical cancer. The literature also illustrates that compliance is related to convenience of service, trust or the healthcare provider and culturally competent providers. The goals of the project were to (1) increase awareness and knowledge of breast, cervical, and

colorectal cancer prevention, (2) refer patients for cancer screening, and (3) establish trust among program beneficiaries. (Project reports are attached in ―Evaluation Measures‖.) In year one, it is estimated that over 1 million persons were exposed to the educational content through media.

Person to person contacts through loterias and platicas totaled 1,130. Referred for screening were 372, and those who kept appointments were 59 (32%). In year two, over 1million were again reached through media and made aware of breast cancer. Person-to-person contacts totaled 1,100, and 214 were referred for screening. Appointments kept were 55 (38.23%).

It is important to note that the patient population at Mercy is transitory and without regular or consistent phone numbers. In fact, reminder calls made by a patient representative to 211 patients between June 18 and July 3 of this year proved to have 30 phone numbers which were no longer in service. Also, 50 messages were left on voice mail or with family and those calls have yet to be returned.

A behavioral health manager was hired 6 months ago to provide integration of behavioral health services, and maintain records using the EPIC system. During the past quarter, 27 patients have been referred for behavioral health services and are being seen by the behavioral health manager and the LPC. Of these 27, pre treatment and mid or post treatment data are available for 7 although the first reportable data will be available in March 2015.

11 b. Logic model and theory of change

The logic model of Sí Three: Integration of 3D Health Services (see attached Logic Model) with respect to Focus 1 (expansion of services at existing site) is based on the Theory of Change that if healthcare providers refer patients to appropriate integrated services and track their

participation and progress then patients will improve their overall health status in all three dimensions of health (physical health, behavior health and spiritual well being). This will

ultimately lead to better health outcomes for the underserved indigent population here in Laredo.

Using resources that include existing staff, new hires funded through the grant, and collaboration with a wider range of community resources, Mercy clinic will be able to expand behavioral health and add spiritual wellness services along with better monitoring and data management.

To address Focus 3 (progress toward Level 5 Integrated Practice), the Logic Model is based on the Theory of Change that if the health care team moves from a Level 3-4 to a Level 5 Integrated Practice, providers will gain an indepth understanding of the roles of other team members and the culture of the clinic patients; patients will in turn express greater satisfaction with the team and will achieve their goals in all three health dimensions. (See attached Logic Model).

c. Lead evaluation personnel

Lead evaluation personnel will include the project manager, supported by a contracted

statistician (see Memorandum of Understanding with Texas A&M International University for services of Dr. Fernando Quintana), and a research design consultant (Dr. Susan Walker). The project manager will be a nurse practitioner (family and/or mental health), bilingual, community-oriented, who will supervise overall project activities and establish relationships with community groups (most likely churches) who agree to participate with the project team by providing

suitable meeting space for integrated care provider meetings as well as educational and supportive activities for patients in the program. Dr. Quintana is an Associate Professor of Biology and Statistics at Texas A&M International University. He also serves as an Associate Professor of Statistics at Texas A&M Health Science Center, College Station, Texas. His publications and research are detailed in his Curriculum Vitae, upon request. He is an active participant in community health research projects in the Laredo community and is currently working with a local pediatrician on a study of BMI in children. He will provide statistical analysis as well as guidance in data collection. Dr. Walker is a Professor Emerita of Nursing, Texas A&M International University. Although she retired from her position as Dean and Professor of Community Mental Health Nursing in 2007, she remains active in the community through the Area Health Education Center, Mercy Ministries and consultation with the School of Nursing and Texas A&M International University. Her special interests include grant writing, accreditation reporting, and writing about ethical and legal issues in community health and end of life. Her contribution to the Sí Three grant project will include review of data collection, interface with Dr. Quintana, interpretation of outcome data for reporting, presentations and publication. Curriculum Vitae are available on request.

12 d. Tracking progress

Clearly, a critical area to address is data collection and management. In the first quarter, project staff will develop specific templates for data entry and review these with providers and other staff to modify as needed to make them as user-friendly as possible. Time lines will be set for completion and the project manager will review forms and give feedback to the team on any issues that need to be addressed. The hiring of a data entry clerk through project funding will facilitate accomplishment of this goal, as will ongoing training and support for all staff and partners involved in use of the templates and EPIC.

e. Data collection and use

For one year patient data have been stored using EPIC (Electronic Patient Health Record) and evaluated on a quarterly basis to monitor diabetic patients’ progress toward achieving better management of their symptoms and during the past six months a behavioral health navigator was hired to provide integration of behavioral health services for these patients. With limited

resources and only a part time behavioral health manager and LPC, these data are at a preliminary level.

(Note: HIMSS Delta and CCAT still pending.) III. Collaboration

a. Formal and informal collaborations

Mercy Clinic collaborates with Methodist Healthcare Ministries (MHM) and St. Mary’s

University in San Antonio, Texas. Methodist provides a Licensed Professional Counselor (LPC) at Mercy Clinic two days a week. This marks the third year of this partnership. She counsels 40 patients a year. The LPC will treat patients who have more moderate to serious depression.

Mercy Clinic has collaborated with St. Mary’s University in San Antonio and Texas A&M International University in Laredo (TAMIU) in providing student opportunities for clinical practice in pastoral counseling and counseling psychology. TAMIU Family Nurse Practitioner students are precepted at Mercy Clinic by the three FNPs and one WHNP. Because of the lack of psychiatry services available in the community, Mercy Clinic will continue its current practice of referring patients whose needs are beyond our scope of services to our community’s only behavioral services provider, Border Region Behavioral Center. In addition, volunteer physicians and dentists provide services on a monthly basis—for example, the epilepsy clinic from San Antonio holds clinic at Mercy each month, Dr. Wells (podiatrist) offers clinic services quarterly and Dr. Hochman (retinal specialist) holds clinic for Mercy clients twice a year. Many other providers offer specialty services as well.

13 b. Collaborative community projects

Organization Time Frame Project Impact

UT Medical Branch,

Galveston 2009-2011 UTCO Community

outreach diabetes

Center San Antonio 2011 Laredo/Webb County

Community Health and

Center 2003 - present Collaboration on

various health events

a. Experience and expertise of organization

Because Mercy Clinic’s primary focus is on education, prevention and self management for people with chronic illness, approximately 80% of current referrals to the integrated healthcare program are people with diabetes. As reported in a 2013 proposal to the Hogg foundation, under Mercy’s Stage III-IV integrated health program, the following elements are in place on a small scale or in a beginning phase of implementation.

 Some mental health services are co-located in the primary care setting.

 Screening for mental health is being implemented.

 Workflows to enhance care coordination are being strengthened.

 Systematic clinical care management is being provided by a social worker or other licensed mental health provider.

 Communication about the clinical evaluation and treatment plan transpires among health care providers.

 Proactive follow-up and outcome monitoring are being recorded in a patient registry by the care manager.

 Data are being collected to assess health outcomes.

b. Organizational structure

The capability and commitment of administration, management, and the governing board and their support for the Si Three project are evident from the previous projects described above, as well as the attached letters of support from administration and board members.