MOHAWK VALLEY POPULATION HEALTH IMPROVEMENT PROGRAM
Data Plan
As ofOverview: In order to meet Mohawk Valley PHIP responsibilities, a specific data sharing plan has been formulated for collecting, analyzing, and utilizing data such as outcome, claims and utilization data and identifying appropriate, available sources, that include public health, regional health information organizations or other qualified entities. Mohawk Valley PHIP Bassett Research Institute staff and Healthy Communities Institute will gather data on everything from unemployment rates, poverty levels, and smoking rates to targeted disease related emergency room visits and hospitalizations. De-identified electronic medical records and insurance claims will enable the data team to track how health care services are utilized and develop regional capability for hospitals to use their existing data for
improvement. In order to promote standardization, this data plan also addresses development of metrics for performance evaluation and outcome measurement that are consistent with, to the extent possible, the Delivery System Reform Incentive Payment (DSRIP) metrics. Interrupted time series analysis will be used to track the metrics the Mohawk Valley PHIP has prioritized.
Objective: The Bassett Research Institute (BRI) will utilize data analytics and visualization to convey key health indicators.
Tasks:
1. Explore population health data sources –BRI will continuously explore available data source containing population health data for NY and provide data analysis and visualization. Access to underlying data tables will be sought. Central this will be the Community Health Indicator Reports (CHIRS) and the NYS Prevention Agenda Dashboards.
a. Links will be provided from the Mohawk Valley PHIP website to the DOH website for each of the five counties so access to the full array of indicators will be facilitated. b. BRI will gather data at prescribed intervals for each board meeting.
c. BRI will display the data in format(s) that optimize data visualization and are preferred by the Mohawk Valley PHIP board.
d. The data team including the Evaluation Team will attach a brief interpretation of data being demonstrated.
e. Aggregated de-indentified data may be gathered from data warehouse associated with regional hospital Electronic Medical Records.
Measures:
• BRI will submit to the NYSDOH on a monthly basis an overview of current efforts and future plans related to acquisition, access and analysis of relevant types of data. • BRI will invite Delivery System Reform Incentive Payment (DSRIP) PPS in the region to
Population Health Data Sources by Areas of Need
Area of Need Data Source
Prevention Agenda BRFSS and eBRFSS
NYSDOH Prevention Agenda Dashboards Health Disparities 3M Performance Metrics
American Community Survey BRFSS and eBRFSS
CDC Diabetes Interactive Atlas
County Health Indicators by Race/Ethnicity (CHIRE) County Health Rankings
Feeding America
NYSDOH Prevention Agenda Dashboards Regional Health Priorities American Community Survey
BRFSS and eBRFSS
Community Health Indicator Reports (CHIRS) County Health Rankings
Institute for Health Metrics and Evaluation SPARCS
County and Hospital Needs Assessments & Service Plans
Amercian Community Survey American Lung Association AIRNOW
BRFSS and eBRFSS County Health Rankings
Community Health Indicator Reports (CHIRS) Environmental Protection Agency
Mohawk Valley PHIP focus groups & Stakeholder Meetings National Cancer Institute
US Department of Agriculture; Food Atlas Salient
SPARCS
2. Support the interpretation of presentation of population health data – The BRI data team will participate as needed in PHIP board meetings, forums and work group discussions in order to provide timely updates.
a. Analysis of regional health and health care needs.
b. Data to support planning to improve health and achieve high quality and cost effective care.
c. Regional workforce strategy to advance the State Innovation Improvement Plan (SHIP). d. DSRIP data relevant to Mohawk Valley PHIP priorities.
Measures:
• BRI will post data summaries and presentations online.
3. Frequency of data updates – BRI will determine the frequency that key data indicators can be updated and develop a plan. This will depend on how frequently the data source updates their data.
a. Mohawk Valley PHIP will decide on the indicators most suitable to quarterly reporting and which indicators to review at the next meeting.
b. Data will be updated on the Mohawk Valley PHIP website dashboard.
c. Mohawk Valley PHIP board, BRI data team and Healthy Communities Institute will agree upon a schedule for review of data sets and ongoing reporting.
Measures:
• BRI data team will determine and document the frequency of updating key data sources through a data plan which will be reviewed with the NYSDOH by June 1, 2015.
Caveat: Some publically available data are a year or more behind. While useful for setting priorities, this data lag limits the data’s use in providing real time or even quarterly feedback to guide improvement efforts.
4. Develop key indicators – BRI staff will create a list of potential key measures for the Mohawk Valley PHIP board and stakeholders to review. The board, with input from stakeholders, will determine those measures to be tracked and reported.
a. The data team will suggest various methods of reporting each variable. They will provide examples of tabular reporting, various types of graphs, visual displays or dashboards.
b. The Mohawk Valley PHIP board will select the key health indicators within the Regional Prevention Agenda areas. Criteria for selection may include those used by Kaiser Permanente as shown in Figure labeled “Criteria for selecting health needs” below. c. The Mohawk Valley PHIP board will select the formats most suitable for efficient and
clear communication of findings and monitoring key indicators.
d. The data team will seek input from NYSDOH, other PHIPs and stakeholders to identify and track additional data sources.
e. Present preliminary dashboards to Mohawk Valley PHIP board and stakeholders and to NYSDOH for feedback. Mohawk Valley PHIP board and stakeholders will provide
feedback regarding relevant dashboards at meetings, via email or other communication. f. The data team and Healthy Communities Institute (HCI) will modify dashboards as
required.
g. Subsequently the data team will present updated dashboards at PHIP meetings and HCI will post on website; share web links with NYSDOH.
Measures:
• By June 30, 2015 the data team including the Evaluation Team will have suggested various methods of reporting each variable.
• By June 30, 2015 the data team will have identified an initial set of key measures and will start to share data as part of ongoing meetings.
• Presentations and other visualization will be shared with PHIP stakeholders and posted on the Mohawk Valley PHIP website.
Criteria for Selecting Health Needs
Criteria Definition
Magnitude/scale of the problem The health need affects a large number of people within the community.
Severity of the problem The health need has serious consequences
(morbidity, mortality, and/or economic burden for those affected
5. Conduct research to address knowledge gaps – BRI will asses any regional knowledge gaps as relate to health-factors, behaviors or other information relevant to Prevention Agenda priorities to shed light on regional Prevention Agenda dashboard findings.
a. BRI will gather a representative sample from each of the five counties
b. BRI will create a survey with input from Mohawk Valley PHIP board, stakeholders and NYSDOH
Measures:
• With input from stakeholders, BRI will identify knowledge gaps –areas where more information would improve understanding of regional prevention agenda trends and inform strategies to improve population health and address health disparities. An initial list of knowledge gaps will be indentified by August 30, 2015.
• By September 30, 2015 BRI will have developed a draft research approach for the survey with sample size, recruitment approach, proposed questions, etc. subject to NYSDOH approval.
• By November 15, 2015 BRI will start to execute an approved survey approach. • By January 31, 2016 surveys will be mailed according to sample strategy.
• By June 30, 2016 BRI staff will analyze data and present it to the NYSDOH, Mohawk Valley PHIP board and stakeholders. Data findings will also be made available on the Mohawk Valley PHIP website.