MMHA 6475 Week 4 Program Logic Diagram Example

Structure, Process, Outcome: A Logic Diagram for Tamarack Hospital at Home With Numbered Arrows and Stated Assumptions

Student Name

Walden University

MMHA 6475: Program Planning, Implementation, and Evaluation

Instructor Name

Month Day, Year

Structure, Process, Outcome: A Logic Diagram for Tamarack Hospital at Home With Numbered Arrows and Stated Assumptions

Purpose of the Diagram

A logic model lays out, in one picture, the chain running from what a program has, through what it does, to what it hopes to change (W. K. Kellogg Foundation, 2004). This diagram for Tamarack Health's hospital-at-home program is organized in three bands, structure, process and outcome, following the familiar way of describing health care quality. Each box is numbered, and each arrow is numbered so that later work can refer to a specific causal claim. The arrows are claims, not facts: each states that one element is expected to lead to another, and the Week 5 stress test will examine the weakest. Below the diagram, a list of assumptions states the conditions under which the arrows are expected to hold.

The Diagram

Table 1 presents the diagram as three bands, read left to right. Box numbers appear in brackets.

Table 1

Logic Diagram: Tamarack Hospital at Home

Arrows: (1) inputs 1 to 8 make activities 9 to 13 possible; (2) activities 9 and 10 produce enrolled patients; (3) activities 11 to 13 produce completed episodes (14); (4) completed episodes (14) lead to freed bed-days (19) and fewer boarding hours (20); (5) visits and rounds on protocol (11, 12) lead to low escalation (16) and good experience (15); (6) timely delivery (17) supports low escalation (16); (7) short-term outcomes 15 to 17 lead to readmissions no worse than inpatient care (18).

Reading the Structure Band

The structure band lists what must exist before any patient goes home. Some inputs are people: visiting nurses who make the twice-daily visits, paramedics under contract who can respond to urgent needs and draw blood, hospitalists who round by video, and nurses in a command center who answer calls around the clock. Some are equipment and services: monitoring kits with blood pressure cuffs, pulse oximeters and tablets, and a courier contract that brings medications, oxygen and supplies. Two inputs are often forgotten in early drafts. Order sets and documentation templates in the electronic health record allow clinicians to admit, treat and discharge home patients the same way they would inpatients, and a payer agreement determines whether the program is paid for its episodes. Without either, the program cannot operate at scale.

Reading the Process Band

The process band lists what the program does and what it produces. Screening in the emergency department identifies patients who meet eligibility criteria; consent and transfer home enroll them. At home, each patient sees a nurse in person morning and evening and a hospitalist on screen daily, with escalation calls answered by the command center within a set response time. The output that counts these activities is the completed home episode, the program's basic unit of volume. Completed episodes appear in the process band rather than as an outcome because they measure activity, not benefit. A program could complete many episodes and still fail to free beds if the patients treated at home would not otherwise have been admitted.

Reading the Outcome Band

Outcomes are arranged in three horizons. In the short term, the program aims for good patient experience, an escalation rate within protocol limits and timely delivery of medications and tests. In the intermediate term, it aims for readmission rates no worse than for comparable inpatients, a safety outcome reflected in the Week 3 objectives. In the long term, it aims to free medical bed-days and reduce emergency department boarding in peak months. The long-term outcomes are system outcomes that depend on other factors, such as overall admission volume and discharge practices, so they are separated from outcomes the program controls more directly. Evidence from randomized and multisite studies supports the short and intermediate outcomes (Leff et al., 2005; Levine et al., 2020); the long-term outcomes are the ones Tamarack would most need to test.

Why Arrows Are Numbered

Numbering the arrows makes each causal claim addressable. Arrow 4, for example, claims that completed home episodes lead to freed bed-days and fewer boarding hours. That claim depends on who is treated at home: if the program enrolls patients who would otherwise have gone home with outpatient care, it adds activity without freeing beds. Arrow 5 claims that delivering visits and rounds on protocol keeps escalation low, which depends on the protocol's clinical design. By naming arrows, the planning team can assign each claim to the evaluation measure that tests it and to the person responsible for the activities on which it depends. Theory-driven evaluation distinguishes the causal claims a program makes from the organizational work required to give them a chance (Chen, 2015), and numbered arrows keep both visible.

Assumptions

The arrows hold only if the following assumptions hold: the courier can reach any enrolled home within the response window the protocol sets, which limits enrollment to a defined service area; enough eligible patients have a safe home setting, a working phone and, where needed, a caregiver present; hospitalists trust the program enough to refer the patients who would otherwise occupy beds, not only the lowest-risk patients; nurses and paramedics can be hired or reassigned without leaving inpatient units short; the electronic health record build is complete before launch; and at least one major payer agrees to pay for home episodes. Each assumption will appear as a readiness check in the Week 6 launch plan. If one proves false, the diagram tells the team which arrows are at risk.

References

Chen, H. T. (2015). Practical program evaluation: Theory-driven evaluation and the integrated evaluation perspective (2nd ed.). Sage.

Leff, B., Burton, L., Mader, S. L., Naughton, B., Burl, J., Inouye, S. K., Greenough, W. B., III, Guido, S., Langston, C., Frick, K. D., Steinwachs, D., & Burton, J. R. (2005). Hospital at home: Feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Annals of Internal Medicine, 143(11), 798-808. https://doi.org/10.7326/0003-4819-143-11-200512060-00008

Levine, D. M., Ouchi, K., Blanchfield, B., Saenz, A., Burke, K., Paz, M., Diamond, K., Pu, C. T., & Schnipper, J. L. (2020). Hospital-level care at home for acutely ill adults: A randomized controlled trial. Annals of Internal Medicine, 172(2), 77-85. https://doi.org/10.7326/M19-0600

W. K. Kellogg Foundation. (2004). Logic model development guide. W. K. Kellogg Foundation.