title: Development and applications of an outcomes assessment framework for care management programs in learning health systems.
abstract: OBJECTIVE
  To develop and apply an outcomes assessment framework (OAF) for care management programs in health care delivery settings.
  
  
  BACKGROUND
  Care management (CM) refers to a regimen of organized activities that are designed to promote health in a population with particular chronic conditions or risk profiles, with focus on the triple aim for populations: improving the quality of care, advancing health outcomes, and lowering health care costs. CM has become an integral part of a care continuum for population-based health care management. To sustain a CM program, it is essential to assure and improve CM effectiveness through rigorous outcomes assessment. To this end, we constructed the OAF as the foundation of a systematic approach to CM outcomes assessment.
  
  
  RESULTS
  To construct the OAF, we first systematically analyzed the operation process of a CM program; then, based on the operation analysis, we identified causal relationships between interventions and outcomes at various implementation stages of the program. This set of causal relationships established a roadmap for the rest of the outcomes assessment. Built upon knowledge from multiple disciplines, we (1) formalized a systematic approach to CM outcomes assessment, and (2) integrated proven analytics methodologies and industrial best practices into operation-oriented CM outcomes assessment.
  
  
  CONCLUSIONS
  This systematic approach to OAF for assessing the outcomes of CM programs offers an opportunity to advance evidence-based care management. In addition, formalized CM outcomes assessment methodologies will enable us to compare CM effectiveness across health delivery settings.
authors.affiliation: U.S. Census Bureau.
authors.forename: Lin
authors.initials: L
authors.lastname: Wang
authors.affiliation: Johns Hopkins Medicine.
authors.forename: Kara
authors.initials: K
authors.lastname: Kuntz-Melcavage
authors.affiliation: University of Pennsylvania.
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Forrest
authors.affiliation: Johns Hopkins Medicine.
authors.forename: Yanyan
authors.initials: Y
authors.lastname: Lu
authors.affiliation: Johns Hopkins Medicine.
authors.forename: Leslie
authors.initials: L
authors.lastname: Piet
authors.affiliation: Johns Hopkins Medicine.
authors.forename: Kathy
authors.initials: K
authors.lastname: Evans
authors.affiliation: Johns Hopkins Medicine.
authors.forename: Maria
authors.initials: M
authors.lastname: Uriyo
authors.affiliation: Johns Hopkins Medicine.
authors.forename: Melissa
authors.initials: M
authors.lastname: Sherry
authors.affiliation: Johns Hopkins Medicine.
authors.forename: Regina
authors.initials: R
authors.lastname: Richardson
authors.affiliation: Johns Hopkins Medicine.
authors.forename: Michelle
authors.initials: M
authors.lastname: Hawkins
authors.affiliation: Johns Hopkins Medicine.
authors.forename: Donna
authors.initials: D
authors.lastname: Neale
keywords: 2014 EDM Forum Symposium; Comparative Effectiveness; Learning Health Systems; Methods; Quality Improvement