Proposed Outcomes, Measures and Data Sources

ATTACHMENT b

Proposed outcomes, measures and data sources

This page left blank for double-sided copying.

B.1. Proposed outcomes, measures, and data sources

Proposed Outcomes	Potential Measures		Potential Data Source(s)
I.1. What systems and external factors are in place in communities that could help or hinder grantees in improving outcomes? (Environmental Scan: Program Year 1 and ongoing)
Partnerships/contracts with LSPs, by type Partnerships for physical activity and healthy food	Number and types of LSP partners		MDEs Grantee applications
	Number and types of non-partner LSPs available in the community		Annual community scan Network survey Site visits
Community-based resources available/referred to Partnerships for smoking cessation	Types of referrals made to community-based resources		Grantee applications Annual Community scan Program survey Network survey MDEs Site visits
Chronic disease programs in the community and collaborated with	Types of chronic disease programs in the community (available and collaborated with)		Grantee applications Annual community scan Program survey Network survey MDEs Site visits
Partnerships to increase access to other resources/services that support healthy behaviors	Types of other resources/services in the community (available and collaborated with)		Grantee applications Annual Community scan Program survey Network survey Site visits
Resources shared	Types of resources shared with the grantee by other organizations, agencies, or programs		Grantee applications and annual program reports Annual community scan Program survey Site visits
Strength and number of partnerships	Number of partnerships		Network survey Site visits Program survey Grantee applications and annual program reports
	Strength of partnerships		Network survey Site visits Program survey Grantee applications and annual program reports
I.2. How have the ACA and other recent policy changes affected the delivery of services (e.g., effect on coverage of the services, provider case mix, provider caseload, etc.)? Which policies have facilitated and hindered WISEWOMAN implementation? (Domain 3)
Changes in policy	Changes to federal/state/local policy in provision of screening services and provider requirements		Annual community scan Program survey Site visits Previous evaluation information
Changes in provider practice related to delivery of screening, referrals, and LSPs	Changes to provider practices related to delivery of screening, referrals, and LSPs		Program survey Site visits Clinical guidelines (e.g., JNC-7) Previous evaluation information
II.1. To what extent are grantees implementing team-based care and other program components to address hypertension control according to approved protocols (i.e., with fidelity)? What are the barriers and promising approaches to implementing program models? (Domain 3)
Implementation in comparison to approved protocols	Types of team-based approaches for hypertension control		Grantee applications and annual program reports Program survey Site visits
	Fidelity to and deviations from approved protocols		Grantee applications and annual program reports Program survey Site visits
Promising approaches	Types of promising team-based approaches to hypertension control		Annual program reports Program survey Site visits
Barriers to implementation	Types of barriers to team-based hypertension control		Annual program reports Program survey Site visits
II.2. To what extent is health coaching being implemented according to approved protocols? What are the barriers and promising approaches to implementing program models? What QI processes are used to improve implementation? (Domain 3)
Health coaching implementation in comparison to approved protocols	Number of participants referred to health coaching		MDEs
	Percentage of referred participants within demographic categories of interest		MDEs
	Percentage of referred participants within demographic categories of interest		MDEs
	Percentage of referred participants with health risks		MDEs
	Average number and duration of health coaching sessions completed		MDEs
	Percentage of health coaching sessions within each setting and contact type		MDEs
	Fidelity to and deviations from approved health coaching protocols		Annual program reports Program survey Site visits Health coaching protocols
Strategies used to refer, ensure utilization, and track health coaching attendance	Types of strategies used to refer participants to health coaching		Annual program reports Program survey Site visits Health coaching protocols
	Types of strategies used to ensure participant utilization of health coaching		Annual program reports Program survey Site visits Health coaching protocols
Promising approaches	Types of promising approaches to implementation of health coaching		Annual program reports Program survey Site visits Health coaching protocols
Barriers to implementation	Types of barriers to implementing health coaching		Annual program reports Program survey Site visits Health coaching protocols
II.3. To what extent are the grantees making referrals to the LSPs according to approved protocols? What are the barriers and promising approaches to implementing program models? (Domain 3)
Process for LSP referrals in comparison to approved protocols (for example: appropriateness of the referrals and readiness to change)	Number of participants referred to LSPs		MDEs
	Percentage of referred participants within demographic categories of interest		MDEs
	Percentage of referred participants with health risks Percentage of referred participants by readiness to change status		MDEs
	Average number and duration of LSP sessions completed		MDEs
	Number of LSP completed sessions by setting and contact type		MDEs
	Fidelity to and deviations from approved LSP protocols		Annual program reports Program survey Site visits LSP protocols
Promising approaches	Types of promising approaches to implementation of LSPs		Annual program reports Program survey Site visits
Barriers to implementation	Types of barriers to implementing LSPs		Annual program reports Program survey Site visits
II.4. What linkages and referrals do grantees make to resources in the communities (by risk factor) other than LSPs/health coaching? (Domain 4)
Referrals and participation in tobacco cessation resources by type and grantee	Number of participants referred to tobacco cessation resources, by type of resource		MDEs
	Number of participants with completed tobacco cessation resource, by type of resource		MDEs
Use of other community-based referrals, not including LSPs/health coaching and tobacco cessation by grantees	Number of participants referred to other community-based resources, by type of resource Number of participants with completed community-based resources, by type of other resource		Annual program reports Program survey Network survey Site visits
II.5. What systems do the grantees have in place to track participants, their service utilization, completion of referrals, and other follow-up activities? How well the systems work? (Domains 1 and 3)
Data systems used and processes for submitting to CDC	Types of data systems used by grantees		Community scan MDEs Grantee applications and annual program reports Program survey Site visits Capacity assessment calls
	Types of data submission processes used by grantees		Community scan MDE submission Grantee applications and annual program reports Program survey Site visits Capacity assessment calls
Error and quality checks	Number and type of quality assurance checks (e.g., automated validation checks, provider data reports, chart audits) used by grantees		Community scan Grantee applications and annual program reports Program survey Site visits Capacity assessment calls
Collection and use of high quality data and information for program improvement, reporting and evaluation	Types of non-MDE data elements collected by grantees Processes used by grantees to collect MDE and non-MDE data		Community scan Grantee applications and annual program reports Program survey Site visits Capacity assessment calls
	Number of grantees using data for program improvement, reporting, evaluation and ways in which data is used		Community scan Grantee applications and reports Program survey Site visits Capacity assessment calls
II.6. What are key formal and informal partnerships exist in the community to address cardiovascular health (e.g., type of linkages and partnerships)? What is WISEWOMAN’s role in these partnerships? What are the strengths and gaps in the linkages and networks? Which ones are working? (Domains 2 and 4)
Continuity of relationship with systems and practices to support cardiovascular health	Types of cardiovascular health programs in the community (available and collaborated with)		Annual program reports Program survey Network survey Site visits
	Number of cardiovascular health partnerships		Annual program reports Program survey Network survey Site visits
	Strength of cardiovascular health partnerships		Annual program reports Program survey Network survey Site visits
II.7. What are the costs (direct and in-kind) associated with delivering WISEWOMAN?
Cost per woman served	Average cost per WISEWOMAN participant served		Program survey Grantee applications and annual program reports MDEs
Evaluation Questions: III.1. What are the changes in participant behaviors, risk, and CVD outcomes from base year to option year 2/Program Year 3? (Domains 2-4) III.4. What are the changes in disparities from base year to option year 2/Program Year 3? How did WISEWOMAN programs tailor their efforts to address disparities? (Domains 2-4) III.5. What is the effect of WISEWOMAN on outcomes, i.e., what are the changes in outcomes from base year to option year 2/Program Year 3 relative to a matched sample of participants from a secondary data? (Domains 2-4)
Risk Reduction Counseling (RRC)		Percentage of participants that complete RRC	MDEs
		Average number of completed RRC sessions per participant
		Percentage of participants receiving RRC that identify nutrition as a priority area
		Percentage of participants receiving RRC that identify physical activity as a priority area
		Percentage of participants receiving RRC who smoke that identify smoking cessation as a priority area
		Percentage of participants receiving RRC that are not taking hypertension medication as prescribed that identify hypertension medication adherence as a priority area
Readiness to Change		Percentage of participants in the “pre-contemplation” state of change	MDEs
		Percentage of participants in the “contemplation” state of change
		Percentage of participants in the “preparation” state of change
		Percentage of participants in the “action” state of change
		Percentage of participants in the “maintenance” state of change
Hypertension/blood pressure control		Percentage of participants hypertensive at baseline screening	MDEs
		Percentage of participants hypertensive at rescreening
		Percentage of participants pre-hypertensive at baseline screening
		Percentage of participants pre-hypertensive at rescreening
		Percentage of hypertensive participants with controlled hypertension at baseline screening
		Percentage of hypertensive participants with controlled hypertension at rescreening
		Percentage of hypertensive participants that monitor their blood pressure at home
Cholesterol		Percentage of participants with high cholesterol at baseline screening	MDEs
		Percentage of participants with high cholesterol at rescreening
		Percentage of participants with borderline high cholesterol at baseline screening
		Percentage of participants with borderline high cholesterol at rescreening
		Percentage of participants with high cholesterol participants with controlled cholesterol at baseline screening
		Percentage of participants with high cholesterol participants with controlled cholesterol at rescreening
Diabetes		Percentage of participants with diabetes at baseline screening	MDEs
		Percentage of participants with diabetes at rescreening
		Percentage of participants with pre-diabetes at baseline screening
		Percentage of participants with pre-diabetes at rescreening
Medication Adherence		Percentage of hypertensive participants taking medication at baseline screening	MDEs
		Percentage of hypertensive participants taking medication at rescreening
		Percentage of participants with high cholesterol participants taking prescribed medication at baseline screening
		Percentage of participants with high cholesterol participants taking prescribed medication at rescreening
		Percentage of with diabetes participants taking prescribed medication at baseline screening
		Percentage of with diabetes participants taking prescribed medication at rescreening
Cardiovascular risk factors		Percentage of participants that have been diagnosed by a healthcare provider as having any of these conditions: coronary heart disease/chest pain, heart attack, heart failure, stroke/transient ischemic attack (TIA), vascular disease, or congenital heart defects	MDEs
Diet		Percentage of participants currently watching or reducing your sodium or salt intake	MDEs
		Average amount of fruit participants eat daily
		Percentage of participants that eat two servings or more of fish weekly
		Percentage of participants that eat three ounces or more of whole grains daily
		Percentage of participants that drink less than 36 ounces (450 calories) of beverages with added sugars weekly
Exercise		Average amount of moderate physical activity that participants get in a week	MDEs
		Average amount of vigorous physical activity that participants get in a week
Tobacco use		Percentage of participants that smoke tobacco in any form	MDEs
Body Mass Index (BMI)		Percentage of participants overweight at baseline screening (BMI between 25.0 and 29.9)	MDEs
		Percentage of participants obese at baseline screening (BMI at or above 30.0)
Quality of life		Average number of days in past 30 days that participants reported their physical health was not good	MDEs
		Average number of days in past 30 days that participants reported their mental health was not good
		Average number of days in past 30 days that participants reported their mental health or physical health prevented them from doing their usual activities, such as self-care, work, or recreation
Alert values		Percentage of participants with SBP >180 or DBP >110 that have completed workup	MDEs
		Percentage of participants with GLUCOSE ≤50 or GLUCOSE ≥250 that have completed workup
III.2. What are the changes in rates of recommended referrals (and completion) to LSPs, health coaching, and tobacco cessation resources in the context of risk from base year to option year 2/Program Year 3? (Domains 2-4)
Referrals		Percentage of participants that receive referral to LSPs/health coaching resources	MDEs
		Average number of referrals to LSPs/health coaching resources received
		Percentage of participants who smoke that receive referrals to tobacco cessation resources
Completed referrals		Percentage of participants with completed referral to LSPs/health coaching resources	MDEs
		Average number of completed referrals to LSPs/health coaching resources
		Percentage of participants with completed referral to tobacco cessation resources
III.3. What are some unintended effects from the WISEWOMAN program (such as increased empowerment and social capital among individuals and the community)? (Domains 2-4)
Measures of social capital		Degree of participant involvement with community-based groups	Program survey Network survey
		Responses to questions from the SOCATa trust and cooperation composite (answered by program and network survey respondents based on their experiences with participants)
		Responses to questions from the SOCATa networks and mutual support organizations composite (answered by program and network survey respondents based on their experiences with participants)
		Responses to questions from the SOCATa exclusion composite (answered by program and network survey respondents based on their experiences with participants)
IV.1. What are the grantee characteristics that are associated with better outcomes (for example, WISEWOMAN program components, LSP and health coaching curricula, and organizational properties)? (Domains 2-4) IV.2. What are the types and characteristics of community-clinical linkages and agency/organizational-level networks that are associated with better outcomes? (Domains 2-4)
The outcomes proposed for evaluation questions III.1 and III.2 can be included as outcomes for evaluation question IV (summative evaluation).		We propose to focus on measures for the following outcomes: risk reduction counseling, readiness to change, hypertension/blood pressure control, cholesterol, diabetes, medication adherence, cardiovascular risk factors, diet, exercise, tobacco use, BMI, quality of life, referrals, and completed referrals.	MDEs

^a Social Capital Assessment Tool (SOCAT) is a multifaceted instrument designed by the World Bank to collect cognitive and structural social capital data at the household level, which is crucial to link social capital information with poverty and household welfare outcomes.

MDEs = minimum data elements