Download Year 4 Annual Report: Volume I - Cross-Cutting Findings PDF

TitleYear 4 Annual Report: Volume I - Cross-Cutting Findings
LanguageEnglish
File Size4.2 MB
Total Pages216
Table of Contents
                            AR4 Vol 1_FINALfor508v64
		Cover
		Acknowledgments
		Table of Contents
		List of Figures
		List of Tables
		Executive Summary
			STRONG START SITES AND AWARDEES
			SUMMARY CONCLUSIONS
		Introduction
			OVERVIEW OF STRONG START ENHANCED PRENATAL CARE MODELS
				MATERNITY CARE HOMES
				GROUP PRENATAL CARE
				BIRTH CENTER CARE
			STRONG START AWARDEES AND SITES
			EVALUATION DESIGN AND DATA COLLECTION PROGRESS THROUGH YEAR 4
				PARTICIPANT-LEVEL PROCESS EVALUATION
				CASE STUDIES OF IMPLEMENTATION
				IMPACT ANALYSIS
				PROJECT REPORTS
			KEY FINDINGS FROM YEARS 1 THROUGH 3
			ORGANIZATION OF THE YEAR 4 ANNUAL REPORT
		Year 4 Findings
			PARTICIPANT-LEVEL PROCESS EVALUATION
				INTRODUCTION
				PARTICIPANT RISK PROFILES
				INTERIM OUTCOMES
				MATERNAL AND INFANT OUTCOMES
				MULTIVARIATE REGRESSION ANALYSES
				SUMMARY OF PARTICIPANT-LEVEL PROCESS EVALUATION DATA FINDINGS
			CASE STUDIES
				SUSTAINING THE STRONG START AWARDS
				AWARDEE PERSPECTIVES ON PROGRAM OUTCOMES
				KEY FEATURES OF STRONG START PROGRAMS
			MEDICAID SURVEY
				DELIVERY MODEL
				ACCESS TO PRENATAL CARE
				CONTENT OF PRENATAL CARE
				COVERED PROVIDER, PLACE OF SERVICE, AND VISIT TYPES
				COVERED MEDICATIONS AND DEVICES PROMOTING STRONG START GOALS
				COVERED ENHANCED SERVICES
				ADDITIONAL INCENTIVES AND PROGRAMS ALIGNED WITH STRONG START GOALS
				ISSUES FOR FURTHER EXPLORATION
			TECHNICAL ASSISTANCE AND DATA ACQUISITION
				INTRODUCTION
				SUMMARY OF PROGRESS: DATA APPROVAL AND RECEIPT
				KEY CHALLENGES, SOLUTIONS, AND LESSONS LEARNED
			IMPACT ANALYSIS
				ANALYTICAL APPROACH AND DATA SOURCES
			DATA PREPARATION
				Linking Birth Certificates to Medicaid Eligibility Data
				Creating Standardized Variables Across States
				Medicaid Claims Data
			LIMITATIONS OF THE DESIGN AND ENHANCEMENTS TO THE APPROACH
				Limitations
				Enhancements to the Approach
		Summary Conclusions
		Plans for Year 5
			PARTICIPANT-LEVEL PROCESS EVALUATION
			CASE STUDIES
			TECHNICAL ASSISTANCE AND DATA ACQUISITION
			IMPACT ANALYSIS
		References
		Technical Appendices
			APPENDIX A: MEDICAID AND CHIP ELIGIBILITY, BY STRONG START STATE
			APPENDIX B: PARTICIPANT-LEVEL PROCESS EVALUATION DATA SUBMITTED THROUGH Q1 2017
			APPENDIX C: DATA QUALITY REPORT
				TABLE C.1: MISSING DATA ELEMENTS BY MODEL
				TABLE C.2: MISSING DATA ELEMENTS BY AWARDEE
			APPENDIX D: PARTICIPANT-LEVEL DATA MEASURES: SCORING PROCEDURES
				CES-D
				FOOD SUFFICIENCY
				WOMEN’S EXPERIENCE OF BATTERY (WEB)
			APPENDIX E: QUALITATIVE CASE STUDY METHODOLOGY
				DATA COLLECTION
				CODING AND ANALYSIS
				YEAR 4 CASE STUDY INTERVIEW PROTOCOL
				STRONG START QUALITATIVE CODING STRUCTURE
			APPENDIX F: SUMMARY OF FINDINGS FROM 2016 AABC STRONG START SITE-LEVEL SURVEY
				BACKGROUND
				SURVEY METHODS
				FINDINGS
				AABC SITE SURVEY (STRONG START EVALUATION CASE STUDIES) AND AABC EXIT SURVEY
			APPENDIX G: INTERVIEW GUIDE FOR THE SURVEY OF STATE MEDICAID POLICIES RELATED TO STRONG START
				INTERVIEWEE BACKGROUNDS
				ELIGIBILITY/ENROLLMENT PROCESS
				BENEFITS
				PAYMENT AND INCENTIVES
				MEDICAID MONITORING AND OVERSIGHT
				OTHER PROGRAMS
			APPENDIX H: TECHNICAL ASSISTANCE STATUS TRACKER
			APPENDIX I: KEY VARIABLES CREATED FOR THE IMPACT ANALYSIS
                        
Document Text Contents
Page 1

Strong Start for Mothers and Newborns Evaluation:
YEAR 4 ANNUAL REPORT

Volume 1: Cross-Cutting Findings

Prepared for:

Caitlin Cross-Barnet and William Clark
Center for Medicare and Medicaid Innovation, DHHS
Contract No.: HHSM-500-T0004
Deliverable No.: 4.1

Prepared by:

Ian Hill (Project Director), Sarah Benatar, Brigette Courtot, Lisa Dubay, Fred Blavin, Bowen Garrett, Embry Howell,
Eva Allen, Morgan Cheeks, Sarah Thornburgh, Jenny Markell, Justin Morgan, and Hannah Todd – Urban Institute
Sharon Silow-Carroll, Jodi Bitterman, Diana Rodin, Marci Eads, and Robyn Odendahl – Health Management Associates
Lee Thompson, Kirsten Firminger, Kathryn Paez, and Jennifer Lucado – American Institutes for Research
Mark Rouse, Andrea Light, Lynn Paquin, and Emily Dunn – Briljent

February 2018

Page 2

Acknowledgments
This report was funded by the Center for Medicare and Medicaid Innovation (CMMI) at the Centers for
Medicare and Medicaid Services (CMS). We are grateful to them and to all our funders, who make it
possible for Urban to advance its mission.

The views expressed are those of the authors and should not be attributed to the Urban Institute,
its trustees, or its funders. Funders do not determine research findings or the insights and
recommendations of Urban experts. Further information on the Urban Institute s funding principles is
available at http://www.urban.org/support .

The authors would like to thank the many Strong Start awardee staff and providers across the
nation who gave so freely of their time and insights during our case studies, and who diligently collected
and submitted the process evaluation data needed for this evaluation. Our sincere thanks also go out to
the many state Vital Records and Medicaid staff who worked closely with us to provide birth certificate,
eligibility, and claims/encounter data that will enable our Impacts Analysis. Without their diligent and
painstaking efforts, we would not be able to complete this crucial component of our study.

Many evaluation team members who contributed to the Strong Start evaluation throughout the
year also deserve thanks, including Luis Basurto, Sarah Coquillat, Alyssa Harris, Stewart Hundley, Paul
Johnson, Jessica Kelly, Sybil Mendonca, Rebecca Peters, and Patricia Solleveld from the Urban
Institute; Brooke Ehrenpreis, Eileen Ellis, Linda Follenweider, Lindsey Gibson, Rebecca Kellenberg,
Margaret Kirkegaard, and Barbara Smith from Health Management Associates; Graciela Castillo, Lori
Downing, Deepa Ganachari, Jazmine Orazi, Heather Ma, Ushma Patel, Yan Wang, Manshu Yang, and
Charis Yousefian from American Institutes for Research; and Benita Sinnarajah from Briljent.

Finally, as ever, we are grateful to our federal contract officer at CMMI/DHHS, Caitlin Cross-
Barnet, Renee Mentnech
and Director of the Division of the Special Populations Research William Clark, for their thoughtful
guidance, assistance, advice, and support throughout the conduct of this evaluation.





Copyright © February 2018. Urban Institute. Permission is granted for reproduction of this file, with attribution to
the Urban Institute. Cover image via Shutterstock .

http://www.urban.org/support

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9 6 Y E A R 4 F I N D I N G S



 Challenges receiving the requested data in a timely manner can occur even when clear

guidance is provided. Once data sharing agreements are fully executed, it is necessary to build

relationships with the state data analysts and IT staff that are directly involved in developing

and transferring the data files. These staff are likely not as familiar with the specifics of the data

request and, thus, need to be brought “up to speed.” In addition, similar to delays in receiving

approval to access the data, competing demands at the state agencies often took priority over

sending the data to the Urban Institute, requiring the evaluation team to persist and apply

pressure when needed.

Lessons Learned

From these experiences, it is possible to identify a number of lessons learned that can be helpful to

policymakers, state officials, or other researchers involved in similar data acquisition and linkage

efforts; these lessons are summarized below.

 Be prepared to provide considerable guidance and support to agencies as they prepare and submit

data files. The evaluation team invested considerable time and effort to review and discuss the

specific variables requested with the state agency staff. More specifically, the team used

four strategies:

 Creating and distributing documents that specifically laid out the requested birth certificate

variables and/or data needed to create the Medicaid eligibility, claims, and encounter variables

for the Impact Analysis. In many states, these documents were sent multiple times in an

effort to reduce the likelihood of receiving incomplete data sets.

 Reviewing data layout files to identify the specific variables needed to conduct the impact

analysis. Again, this was done so that states would not need to resend data files with

“missing” variables.

 Requesting “test files” with de-identified data to identify any potential issues with the data prior

to the state agency sending the complete file. As needed, the team would schedule calls to

discuss any questions and request changes to the test files.

 Reminders regarding the transfer requirements at multiple points in the process, emphasizing that

PII and PHI be transferred in two separate files. Repeated reminders were often helpful or

required to ensure that data were transferred securely.

 Expect changes to the data sharing agreements. Even after data sharing agreements are finalized

and signed, state agencies may request amendments, depending on their resources and

expertise. For example, the District of Columbia Medicaid agency initially preferred to merge

its data with birth certificate data from the Vital Records agency to ensure data confidentiality

and privacy. However, the agency later decided that it would be more burdensome for their

staff to perform the merge and, thus, requested that the Urban Institute perform the merge.

This required existing data sharing agreements between the agencies and evaluation to be

revised and resubmitted.

 Be flexible and offer alternatives, as needed. State agencies can be underresourced and

overwhelmed at times. Therefore, it is imperative to propose solutions and offer alternatives

that help to ease the burden on states, such as offering to perform the data linkage or receiving

Medicaid eligibility data, but not claims and encounter data.

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Y E A R 4 F I N D I N G S 9 7



IMPACT ANALYSIS

The impact analysis compares outcomes for Strong Start participants to outcomes for nonparticipating

Medicaid-enrolled women and infants with similar risk profiles. This assessment relies on the best

available data and quantitative methods to account for possible confounding factors that may be

driving differences in outcomes that might otherwise be incorrectly attributed to Strong Start.

The impact analysis aims to answer the following two broad evaluation questions:

 What are the impacts of the care approaches and enhanced services supported by Strong Start

relative to traditional Medicaid prenatal care on gestational age, birth weight, and cost?

 Do impacts differ across awardees and across the three Strong Start models? If so, how?

During Year 4, the impacts and Technical Assistance (TA) teams worked closely together to request

birth certificate and Medicaid data from 20 states (as described in the previous section). We also

prepared data in several states, determined the appropriateness of various analyses, and finalized and

implemented our propensity score reweighting approach in four states.

This section first reviews the methodological approach and data sources associated with the

impacts analysis. We then describe the major data preparation and analytic tasks that the impacts team

finalized to move this component of the project forward. Finally, we discuss limitations to our approach

and enhancements to the model that we will implement in the upcoming year.

ANALYTICAL APPROACH AND DATA SOURCES

Our team will analyze the impact of Strong Start and address the three evaluation questions outlined

above after birth certificate and Medicaid data are obtained, merged, and used to create analysis files,

as later described. In this section, we:

 Present the propensity score reweighting approach used to develop a comparison group for

each site or awardee such that observable characteristics in the comparison group are nearly

identical to those of the women participating in Strong Start.

 Describe how we select the comparison group and issues related to high-risk sites or areas.

 Present detailed information on the key outcomes and matching variables used for the

propensity score reweighting approach.

The data come from birth certificates and Medicaid eligibility and claims files for both the Strong

Start participants and a group of Medicaid enrolled women not participating in Strong Start in the same

or similar geographic areas.

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T E C H N I C A L A P P E N D I C E S 2 0 3



Variable Florida Louisiana Nevada South Carolina

Claims Data

Cost Outcomes

Total Expenditures for Mother Not Available Not Available Not Available Not Available

Total Expenditures for Infant Not Available Not Available Not Available Not Available

Average Expenditures for Mother Not Available Not Available Not Available Not Available

Average Expenditures for Infant Not Available Not Available Not Available Not Available

Total Expenditure for Delivery period Not Available Not Available Not Available Not Available

Utilization Outcomes

Number of Hospital visits for Mother Not Available Not Available Not Available Not Available

Number of Hospital visits for Infant Not Available Not Available Not Available Not Available

Nursery Days Not Available Not Available Not Available Not Available

Intermediate NICU Days Not Available Not Available Not Available Not Available

High Level NICU days Not Available Not Available Not Available Not Available

Days in Unknown Level of Care Not Available Not Available Not Available Not Available

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