Sourced from the Health Home comprehensive assessment which identifies service needs and
gaps in care to assist in creating a comprehensive plan of care. Assessments are completed
within 60 days of enrollment and are updated at least annually.
1. PCP results (n = 801)* show 48 members who do not have a PCP at the time of their
initial assessment. Upon a reassessment, 35 of these members did have a PCP. (35/48) =
73%.
a. p-value < 0.01%, Odds Ratio = 27.6, Confidence Interval {11.32,67.3} **
2. Housing results (n = 749)* show 64 members considered themselves homeless at the
time of their initial assessment. Upon a reassessment, 48 of these members considered
themselves housed and not homeless. (48/64) = 75%.
a. p-value = 9.353%, Odds Ratio = 6.8, Confidence Interval {3.49,13.26} **
3. Living Situation results (n = 300)* show 37 members did not have a steady place to live
at the time of their initial assessment. Upon a reassessment, 33 of these members did
have a steady place to live. (33/37) = 89%.
a. p-value = 35.8%, Odds Ratio = 1.15, Confidence Interval {0.38,3.52} **
4. Transportation results (n = 418)* show 137 members reported having a lack of reliable
transportation that kept them from medical appointments, meetings, work, or from
getting things needed for daily living at the time of their initial assessment. Upon a
reassessment, 88 of these members reported having reliable transportation. (88/137) =
64%.
a. p-value = 48.48%, Odds Ratio = 1.45, Confidence Interval {0.94,2.24} **
5. Utilities results (n = 238)* show of members who reported having a steady place to live,
8 members reported having their utilities shut off at the time of their initial assessment.
Upon a reassessment, all 8 members reported no utilities being shut off. (8/8) = 100%.
a. p-value = 81.37%, unable to calculate an Odds Ratio or Confidence Interval due
to the presence of a 0 in the contingency table **
Comprehensive Assessment data was collected from all assessments finalized between
10/1/2020 and 3/30/2022 with a minimum time between the initial assessment and
reassessment having been at least 275 days.
All members in the denominators will have been enrolled for at least 275 days.
*For the results, the comprehensive assessment was completed in its entirety for both the initial assessment and reassessment.
**Statistics were calculated using McNemar’s chi-squared test with a continuity correction and α = 0.05.
