MMHA 6540 Week 10 Integrated Initiative Draft Example

Integrated Draft: Prairie Gate's Falls Prevention Initiative, With a Six-Month Metro Pilot and Its Decision Rules

Student Name

Walden University

MMHA 6540: Population Health Management Applications

Instructor Name

Month Day, Year

Integrated Draft: Prairie Gate's Falls Prevention Initiative, With a Six-Month Metro Pilot and Its Decision Rules

About This Draft

This draft brings the initiative's earlier pieces into one document in the order the final plan will use, condensing each to its essentials. The only new section is the pilot: a six-month start in the metro county with rules, set before launch, for deciding whether to proceed, adjust or stop. Figures throughout are illustrative.

Scope and Population

The initiative serves Prairie Gate members aged 65 and older across Lindon, Ash and Corley counties, about 20,000 people, nearly all of them in its Medicare Advantage coverage. Long-stay nursing home residents and members under 65 are outside its scope. The Triple Aim's attention to cost per person (Berwick et al., 2008) guided the choice of a need where safer lives and lower avoidable spending coincide.

Burden Profile

Public sources point to higher fall rates per older resident in the two rural counties, where more people live alone in older houses. Inside the plan, a fall sends about 1,000 members a year to emergency care, some 300 of them on to an admission, while matched county ambulance records reveal hundreds more falls that never reached a hospital. Falls among older Americans have become more frequent (Moreland et al., 2020), and their medical costs are carried mostly by Medicare (Florence et al., 2018).

Need Ranking and Sensitivity

Falls ranked first of four candidate needs on a weighted matrix of members affected, avoidable cost, partner readiness and measurability, and stayed first under two alternative weightings. Social isolation, which affects many members but is hard to measure, is the strongest candidate for a later initiative.

Partner Readiness

Six partners are involved: the area agency on aging for balance classes, county ambulance services for lift-assist data, a home repair nonprofit, a contracted occupational therapy group, network primary care practices for medication review and the county health department. The repair nonprofit's single crew is the bottleneck, finishing about half the homes the full program will need each month; the chosen remedy is funding a second crew while prioritizing the most fragile members.

Blueprint

About 1,100 members qualify each year through a fall-related claim or repeated lift-assist calls. A coordinator calls within seven days; an occupational therapist assesses the home within fourteen days of enrollment; the nonprofit installs recommended changes within thirty days of that visit; and members are referred to balance classes while their practice receives a medication review request. Systematic reviews support each element for older people still living in their own homes (Gillespie et al., 2012; Sherrington et al., 2019).

Budget and Payer Case

Serving 600 participants a year costs about $660,000, roughly $800 in services per participant plus two coordinators and evaluation support, or $2.75 per member per month. At an illustrative $15,000 per avoided admission, the books balance at about 44 admissions prevented out of roughly 160 expected, an ambitious target for the first year.

Evaluation Framework

Outcome rates, counted per 1,000 participants, are judged against members meeting the same definition in counties not yet served, so that the natural improvement after a recent fall is not credited to the program (Barnett et al., 2005; Dimick & Ryan, 2014). Process measures track each blueprint step, and members report their fear of falling at enrollment and six months.

The Pilot

The initiative will begin with a six-month pilot in Lindon County, the metro county, where partners are most ready and the repair nonprofit is based. The pilot aims to enroll about 200 participants. Its budget is scaled to that size: participant services for 200 at about $800, one coordinator for six months and a share of the analyst's time, about $215,000 in all. Six months is too short to judge falls outcomes, because claims lag and admissions are relatively rare events, so the pilot is judged on process measures that can be read within the window. Table 1 sets the decision rules before launch.

Table 1

Pilot Decision Rules (Illustrative Thresholds)

Why the Rules Are Set in Advance

Writing go, adjust and stop thresholds before launch protects the plan from two temptations: declaring success on whatever result appears, and abandoning a program after a slow start that could have been fixed. If the pilot meets every go threshold, the program expands to Ash and Corley on schedule, which also creates the comparison needed for the outcome evaluation (Hemming et al., 2015). If one or two measures fall in the adjust band, the team fixes the weak step, most likely repair timing, and continues the pilot for three months. A stop result does not end the initiative but sends it back for redesign, for example if members decline enrollment because they distrust strangers in their homes, which would call for a different outreach approach rather than more of the same.

Open Items Before the Final Plan

Three items remain. The Corley ambulance data agreement is still pending. The repair nonprofit's rate for funding a second crew has not been agreed. And the pilot's safety-event definition needs the medical director's sign-off. Each has an owner and will be resolved before the final plan goes to the executive committee.

What Changed During Integration

Assembling the pieces exposed three inconsistencies, now corrected. The blueprint and the budget used different enrollment assumptions, 600 participants in one and 650 in an early version of the other; both now use 600. The evaluation framework defined the comparison group by county, but the pilot plan originally included a few Ash County members living near the metro line; they are now excluded from the pilot so the comparison stays clean. And the readiness map listed the occupational therapy group's capacity as 70 visits a month, while the blueprint assumed the pilot alone would need about 35; the therapists confirmed they can absorb the pilot and the later expansion without new hiring. Small inconsistencies like these are common when pieces are written weeks apart, and catching them now is cheaper than explaining them to the executive committee later.

References

Barnett, A. G., van der Pols, J. C., & Dobson, A. J. (2005). Regression to the mean: What it is and how to deal with it. International Journal of Epidemiology, 34(1), 215-220. https://doi.org/10.1093/ije/dyh299

Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs, 27(3), 759-769. https://doi.org/10.1377/hlthaff.27.3.759

Dimick, J. B., & Ryan, A. M. (2014). Methods for evaluating changes in health care policy: The difference-in-differences approach. JAMA, 312(22), 2401-2402. https://doi.org/10.1001/jama.2014.16153

Florence, C. S., Bergen, G., Atherly, A., Burns, E., Stevens, J., & Drake, C. (2018). Medical costs of fatal and nonfatal falls in older adults. Journal of the American Geriatrics Society, 66(4), 693-698. https://doi.org/10.1111/jgs.15304

Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., & Lamb, S. E. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2012(9), Article CD007146. https://doi.org/10.1002/14651858.CD007146.pub3

Hemming, K., Haines, T. P., Chilton, P. J., Girling, A. J., & Lilford, R. J. (2015). The stepped wedge cluster randomised trial: Rationale, design, analysis, and reporting. BMJ, 350, Article h391. https://doi.org/10.1136/bmj.h391

Moreland, B., Kakara, R., & Henry, A. (2020). Trends in nonfatal falls and fall-related injuries among adults aged 65 years or older: United States, 2012-2018. MMWR: Morbidity and Mortality Weekly Report, 69(27), 875-881. https://doi.org/10.15585/mmwr.mm6927a5

Sherrington, C., Fairhall, N. J., Wallbank, G. K., Tiedemann, A., Michaleff, Z. A., Howard, K., Clemson, L., Hopewell, S., & Lamb, S. E. (2019). Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2019(1), Article CD012424. https://doi.org/10.1002/14651858.CD012424.pub2