mat su draft1 lr[1]

8/14/2019 Mat Su Draft1 Lr[1]

1/35

DRAFT

MAT-SU HEALTH FOUNDATION REPORT CARD

ACCESSTO PRIMARY CARE

TEAM ACCESS:Dawn Bell

Talia Carboy

Laura Lucas

Betsy LuskJohnny Weaver

SWK 636 PROGRAM EVALUATION

Instructor: Randy Magen, PhD

December 9, 2009


2/35

MAT-SU HEALTH FOUNDATION REPORT CARDACCESSTO PRIMARY CARE

Introduction................................................................................................ 2

Mat-Su Health Foundation: History and Overview................................... 2

Research Design and Methodology

Logic Model Development.............................................................. 4

Logic Model.....................................................................................7

Six Sigma: History and Application to Health Care Issues.............7

Operationalization of Measures Using Six Sigma........................... 9

Methodology Flow Chart...............................................................10

Findings and Recommendations

Critical-to-Quality Tree................................................................. 11

Houses of Quality.......................................................................... 12

Key Performance Indicators.......................................................... 17

Reliability and Validity of Measures............................................. 24

Cultural Relevance of Measures.................................................... 25

Strengths and Limitations.........................................................................27

References and Resources........................................................................ 30

MSHF REPORT CARD ACCESSTO PRIMARY CARE 2


3/35

INTRODUCTION

The Mat-Su Health Foundations (MSHF), whose mission as a non-profit is to maximize the

investment of profits into services that will improve that health and wellness of Alaskans living

in the Mat-Su, approached the UAA Social Work Department for assistance in designing a useful

and feasible health report card. The following report summarizes the process and methodology,

findings and recommendations, and strengths and limitations of the research conducted by the

Primary Care Access Group who contributed to this effort. Our team was tasked with reviewing

existing measures of access (and barriers to access) in primary health care and with developing a

set of health care indicators that would assist the MSHF in predicting access to primary health

care in the Mat-Su Borough.

As the narrative explaining the development of our logic model will reveal, our process

encountered several obstacles and dead-ends before we arrived at a methodology that provided a

path towards reaching our final goal. This report will attempt to explain our journey in enough

detail so that one may replicate its more productive avenues of pursuit.

We began this undertaking with a brief meeting with the representative of the MSHF,

Elizabeth Ripley. In order to provide additional background to assist us in understanding our

clients needs and goals, we researched the history of organization.

MAT-SU HEALTH FOUNDATION: HISTORYAND OVERVIEW

The Mat-Su Health Foundation (MSHF) provides financial support for well-managed 501(c)(3)

organizations offering services and practical solutions to significant health related problems

impacting the citizens of the Mat-Su Borough (Mat-Su Health Foundation, 2009). The MSHF



4/35

was created in 2005, when the Valley Hospital Associations board of directors approved its

creation. The Valley Hospital Association was created in 2003 as part of a joint venture with

Triad Hospitals (Mat-Su Health Foundation, 2009). This joint venture expanded the hospital

services to the borough, with the creation of the new Mat-Su Regional Medical Center

(MSRMC) in January, 2006. MSRMC is located between the cities of Wasilla and Palmer and

offers patients an expanded array of available health-care services, technology, and health care

professionals (Mat-Su Health Foundation, 2009). The Mat-Su Health Foundation

(Foundation) is a companion cornerstone [to the MSRMC] with its mission of working in the

community towards improving the health and wellness of Mat-Su residents (Mat-Su Health

Foundation, 2009). Further, the vision of the MSHF is a community where all persons have the

opportunity for a healthy life (Mat-Su Health Foundation, 2009).

The strategic goals of the Mat-Su Health foundation are as follows (Mat-Su Health

Foundation, 2009):

Reduce barriers to health care access

Make progress on Healthy Alaska 2010 goals in the Mat-Su Borough.

Increase the capacity of nonprofits operating in the Mat-Su Borough to address the issues

of health and wellness.

Increase collaborative relations with funders and stakeholders in Alaska and other states.

The Mat-Su Health Foundation supports organizations and activities that empower

people; employ creative responses to problems; address root causes rather than symptoms; build

upon community strengths; and offer measurable improvements in health and wellness (Mat-Su

Health Foundation, 2009, p. 1). To qualify for a grant offered by MSHF, the organization must



5/35

be a nonprofit 501(c)(3) and classified as not a private foundation (Mat-Su Health Foundation,

2009, p. 1). Healthy Impact grants of $5000 and more are awarded twice a year, while grants

below $5000 are awarded any time during the year (Mat-Su Health Foundation, 2009, p. 1). In

2008 the MSHF awarded more than $2.2 million to nonprofits in grants ranging from less than

$5000 to $300,000 (Mat-Su Health Foundation, 2009).

The Mat-Su Health Foundation is currently reexamining its role in the community and

how to better address future heath needs of the Mat-Su (Prator, 2009). Deborah Prator (2009)

states that In the year ahead, we hope to better define for our grantees which health issues are a

priority for the board and will overhaul our granting process in order to measure our progress,

better articulate who and what we fund and clearly define the expectations for grantees.

RESEARCH DESIGNAND METHODOLOGY

Logic Model Development

In an attempt to address the problem statement presented at the beginning of the project, our

team had a brainstorming session to discuss different options to meet the clients needs. As a

result of this session, the team decided to reduce the definition we received in class into

manageable sections. This definition stated that our team task would be to review existing

measures of access (and barriers to access) to primary and behavioral health care, recommend

measures, and develop a plan for measuring health access as well as barriers to access, in the

Mat-Su Borough (Mat-Su Health Status Report Care Work Groups). We determined that it

would be the most beneficial to divide the task into two groups. Our team would focus on

primary health care, and the distance campus student team would focus on behavioral health



6/35

care.

Once the division of labor and direction of study was established, the team perused the

information packet that the Mat-Su Health Foundation (MSHF) provided to the class as a whole.

The information provided us with a list of grantees receiving funding from MSHF. The team

analyzed the list of grantees and established approximately 10 grantees that are involved with

access to primary care. The plan was to interview the various grantees about their services and

establish what they found successful and what they found to be ineffective in working with the

residents of the Mat-Su Valley. At this point in the development of our logic model, we

determined the problem statement to be: The Mat-Su Health Foundation seeks to measure the

effectiveness of their current activities regarding access to primary care in the MatSu Borough.

Prior to interviewing the grantees, the team received the following input from the client

that pointed us in a different direction: The problem is really access to primary care and

behavioral care to get their preventative needs met and chronic health needs met so they stay out

of the hospital. (whaddya think, should we include this quote? does it help or confuse?) We then

shifted gears and reformulated a plan that we interpreted would better address the needs of the

client. A large psychological, as well as logistical, hurdle for our team to overcome was the fact

that we placed so much time and effort into establishing a plan that led us in the wrong direction.

Lack of direct input from, and contact with, the stakeholders proved to be an ongoing problem

during this project. Chassin (2008), as well as a host of other authorities in the program

evaluation business warn (maybe we should mention Wholey here instead), the project sponsor

has a critical obligation to provide input and guidance for the group. We learned greatly from

this lesson.



7/35

At this point, the team started the process over. The team had collectively examined a

great deal of material from academic and gray literature sources, as well as existing health report

cards and data sets provided by MSHF pertaining to the issue of access to primary health care.

By contacting an outside source to help us establish a way to quantify the information that we

had gathered, we learned about a methodology known at the Six Sigma program evaluation

methods. Described as a process improvement philosophy and a business strategy

(http://www.sixsigma-lean-healthcare.com, n.d.), Six Sigma is used by organizations utilizing

data and statistical analysis to implement and/or accelerate change. Six Sigma provided a way

for our team to look at specific areas of concern for MSHF and narrow the information down

into a quantifiable way of measurement, thus enabling our team to apply a more scientific and

data-focused approach to this project. Ultimately, it enabled our team to develop a set of health

care indicators that could assist the MSHF in predicting access to primary care. In the process,

the group endured five revisions of our logic model before arriving at a process we felt confident

in. We finally arrived at our final problem statement: There is no central source of health care

determinants to indicate ease of access to primary care in the Mat-SU Valley. Our presentation

of the logic model to the representative of the MSHF met with her approval (See fig.1).

http://www.sixsigma-lean-healthcare.com/http://www.sixsigma-lean-healthcare.com/http://www.sixsigma-lean-healthcare.com/


8/35

Figure 1. Final Logic Model developed by Team Access

The following is a brief description of the development of the Six Sigma strategy, its application

to the health care arena, and an explanation of how our group utilized it to reach outcomes of our

logic model.

Six Sigma: History and Application to Health Care Issues

Improving systems and processes is no simple task, and improvement in the healthcare field adds

on new dimensions of complexity that will require advanced methods. In an article that

addressed the application of the Six Sigma methodology to the health care industry, Chassin

(2008) explained that as the method continues to grow in this field, it can take on many different

meanings. These meanings can include: rigorous and disciplined methodology that utilizes data



9/35

and statistical analysis to measure and improve operations, improvement efforts aimed at the true

root cause of the problem, and tools and strategies designed to help an organization implement or

accelerate change.

The Six Sigma methodology was developed by Motorola in the 1980s with the aim of

reducing quality costs (the costs involved in making mistakes, in not doing things right the

first time, etc.). Six Sigma is a business performance improvement strategy that aims to reduce

the number of mistakes/defects to as low as 3.4 occasions per million opportunities, (Antony,

2002). The Six Sigma methodology evolved from a manufacturing focus to include business

system and service sector improvement focus and is now used heavily in the health care industry.

For our group purposes, we have utilized Six Sigma techniques to assist in the compilation of

data in order to measure and highlight areas that the MSHF can focus on to improve access to

healthcare in the borough and reduce hospital use by those seeking primary care services.

Six Sigma was designed as a method to examine quality of products and services. Quality

in healthcare is measured by the extent to which services are going to increase the likelihood of

better health outcomes. Quality measures can be used to look at the health determinants of

people and outcomes that occur due to their care, or lack of access to care. Chassin (1998)

explained quality measures used in Six Sigma can be classified into three categories: overuse,

underuse, and misuse. It is not rare to find all of these problems in healthcare, but for the

specifics of this project we have focused on measurable indicators that impact access to health

care. Chassin (1998) identified defects in healthcare that can be defined as, the number of two-

year-olds who are not completely immunized, or pregnant women failing to receive prenatal care

in the first trimester (p. 567). These defects are also measurable indicators that have been

chosen for the Mat-Su Health Foundation to focus on. Through utilization of Six Sigma tools we



10/35

have aimed for evoking a process that will highlight access issues while minimizing bias or

subjectiveness on our parts.

Operationalization of Measures Using Six Sigma

In a process that involved over 15 hours of brainstorming during two intensive meetings, our

group pooled and discussed our collective knowledge about access issues relating to primary

care acquired through our research. It began as a low-tech, cut-and-paste process using felt

markers, newsprint and Post-it notes (See fig.2).



11/35

Figure 2. Team Access Work Group Process and Methodology



12/35

FINDINGSAND RECOMMENDATIONS

Critical-to-Quality Tree

The Six Sigma approach uses a graphic tool known as the Critical-to-Quality Tree that serves

as a helpful way to organize and summarize which indicators are needed to help improvements

be made. The group first identified the factors contributing to access issues and then divided

them into four branches of topics the team identified through a systematic review of current

measures: socioeconomic, logistics, primary care and lifestyle (See fig. 3).

Figure 3. Critical-to-Quality Tree depicting key determinants of health care access issues.



13/35

Houses of Quality

The work team then utilized another Six Sigma tool known as the House of Quality that helped

us evaluate the relationships between the various elements in the system. It is through a systems

approach that the House of Quality (HOQ) assists in identifying the requirements for improving

access to health care. Within the context of this goal, the HOQ assisted the group in determining

key indicators that the Mat-Su could focus on that would have a strong positive correlation with

the access issues experienced in the Mat-Su.

With these four House of Quality categories, the team was able to identify critical

aspects of each category (i.e. socioeconomic factors included a measure of unemployment,

population age, poverty level and education level). We identified possible measures we believed

would provide close correlation of access to primary care (aspects/indicators) (i.e.

socioeconomic measures included insurance, income, employment, education and language).

The team then took the correlation of these two areas of the House of Quality (aspects/indicators

and measurements) and ranked the measures. By ranking these measures based on the teams

experience in health care and research completed, we were able to quantify the possible

correlation between the aspects and the measures. Research was then used to confirm the

selected measures as good indicators for primary care access. The House of Qualities established

the top six indicators. For the socioeconomic House of Quality, unemployment and poverty level

became the Key Performance Indicators (see fig. 4-7).



14/35

Figure 4. Socioeconomic House of Quality



15/35

Figure 5. Logistics House of Quality

The procedure using the HOQ is as follows. First our identified determinants of health care access were arranged

in order of importance and placed into the House of Quality along with Mat-Su Health indicators and their

corresponding operational definitions (units of measurement). The correlating impact of an indicator on each

access issue was rated as a high, medium, or low. Numerical values based on order of importance of the access

issue (4,3,2,1 etc.) were then multiplied by numerical values assigned to the strength of association between the

issue and indicator (high=9, medium=3, low=1). Using this ranking system, the highest totals determined ourrecommendations for a set of six indicators and measurements that would help the Mat-Su Foundation predict

access to primary health care. Each indicator was then was described in detail in the Key Performance Indicator

summary sheet (KPI).



16/35

Figure 6. Lifestyle House of Quality



17/35

Figure 7. Primary Care House of Quality



18/35

Key Performance Indicators

Each indicator was then summarized in detail in the Key Performance Indicator charts (KPI) (see

fig. 8-13). Academic and grey literature, existing health report cards and data sets, and other

relevant sources were cited to validate the selected indicators. Much of the information that the

team provided for validity was the data that was also used for the selection of ranking during the

Six Sigma process. An important technique in the Six Sigma process was the use of a critical

ranking method that arranged different measures and aspect/indicators in a way that removed the

possibility of group think.

Papers written by individual group members, diagrams representing the flow of the

project, and six Key Performance Indicators documents were all part of the process for the

project. The main component to keeping in touch with each group member was a constant flow

of emails to and from each group member and a group commitment sheet signed and agreed on

in the beginning of the semester.

How can another group trace our steps or replicate our work?

Another group could replicate our work by educating themselves on the Six Sigma

methodologies and by developing a concrete logic model with the clients input. The process

should not even begin until a problem statement has been agreed upon by all parties. Utilizing

the Six Sigma method to select Key Performance Indicators may produce different outcomes

depending upon the experts involved in the process. The most relevant results would be found by

using this method with a cross section of experts from the Mat-Su valley to rank the importance

of the indicators.



19/35

Figure 8. Unemployment: Socioeconomic Key Performance Indicator



20/35

Figure 9. Poverty Guidelines: Socioeconomic Key Performance Indicator



21/35

Figure 10. Primary Providers: Primary Care Key Performance Indicator



22/35

Figure 11. Prenatal Care: Primary Care Key Performance Indicator



23/35

Figure 12. Specialty Providers: Logistics Key Performance Indicator



24/35

Figure 13. Alcohol Abuse: Lifestyle Key Performance Indicator



25/35

Cultural Relevance of Measures

Alaska has more indigenous people as a percentage of the population that any other state. For

this reason, Mat-Su could be regarded as one of Alaskas largest native villages. (Does everyone

else get this but me? I must be brain dead.) The remoteness of the Mat-Su area brings unique

challenges for health care providers. When the MSHF focuses on increasing number of specialty

providers in this area this will change the current culture and routine of more than 49.7% of the

population being forced to travel outside of the area for specialty services.

Cultural or associated attitudinal factors may be influential in several areas of data

reliability, measurement and outcomes. For this reason, provisions for stratified sampling may be

pertinent in future research methodology. For instance, the indicators of poverty level or income

are based on the concept of a cash economy and therefore do not take into account the

subsistence way of life or barter systems, where no money is exchanged for goods.

Cultural perspectives vary in how they define practices of maintaining good health. A

general lack of trust in the western medicine and its physicians and systems of primary care may

be correlated to cultural differences. The demand for access to specialty providers, especially

those reflecting alternative medicine, may also be influenced by culture.

Specifically, the perceived value or relevance of prenatal care for pregnant women may

vary amongst cultures. Sensitivity to these cultural differences needs to be considered by

providers of maternal health care.

Research points to the consequences of inadequate prenatal care. In a study conducted by

Grossman, Baldwin, Casey, Nixon, Hollow, and Hart (2002), the data from the period 1989 to

1991 documented 72,730 singleton births to American Indian/Alaska Native (AI/AN) parents



26/35

residing in urban areas, representing 49% of all AI/AN births in the United States. Overall 14.4%

of urban AI/AN births were to women who received inadequate careduring pregnancy, 5.7% of

pregnancies resulted in low birth weight infants, and 11.0 infants died per 1,000 live births.

Furthermore, the eld of cultural competence has recognized the inherent challenges infi

attempting to disentangle social factors (e.g., socioeconomic status, supports/stressors,

environmental hazards) from cultural factors vis--vis their in uence on the individualfl patient.

As a result, understanding and addressing the social context has emerged as a critical

component of cultural competence (Betacourt, Green, Carrillo, & Ananeh-Firempong II, 2003).

Additionally, there are cultural implications for planning for improved access to primary care

such as looking for incentives to correct the proportional underrepresentation of racial and ethnic

groups amongst the providers of primary medical care services.

Cultural relevance should be focused on a health care system that is driven by the goal of

delivering the highest-quality care to every patient regardless of race, ethnicity, culture, or

language. In addition the care should be continued for those of any level of income, access to

insurance, ability to obtain transportation, substance use or other possible barriers to access of

care.

Reliability and Validity of Measures

Studies pointing to the causal relationships between access to health care and the key indicators

we have cited support the internal validity of this reports recommendations for measures. Alaska

providers cite the number one barrier to patients accessing rural health services is the limited

numbers of provider in family practice and specialty areas (Brems, Johnson, Warner, & Roberts,

1997). The case for specialty services is worse, with more than 49.7% of residents living in the



27/35

borough receiving these services in Anchorage. There are not enough providers relative to the

population and this situation will worsen according to the population and provider projections in

the MatSu Health Plan 2005-2015. An evaluative gatekeeping study by Buzon, Franco, and

Mitchell (1997) found that access to a 24-hour primary care physician reduced inappropriate

emergency department visits from 41% to 8% (p


28/35

decades (Orerino, Pino, Blanco & Alvarez, 2006). A 1992 study found that 55% of these visits

to the ER were for non-emergent care (Nations Health, 1994). This may be due to lack of

availability of access to primary care, hours of primary care facilities, or availability of

appointments. Franco & Mitchell (1997) found that visits to the ER for inappropriate reasons

(non-emergencies) dropped from 41% to 8% when the patients had access to a primary care

physician 24 hours a day. If patients were to use primary care facilities versus the hospital for

non-emergent care, less of a burden would be placed on the ER for these services.

Measures were also used from theHealthy Alaskan 2010 Targets and Strategies for

Improved Health; Alaska Scorecard Key Issues Impacting Alaska Mental HealthTrust

Beneficiaries, Mat-Su Borough Primary Health Care Plan 2005-2015, and the Matanuska-

Susitna Borough, Alaska, Selected Economic Characteristics: 2005. These references provided

the access group with information that was reliable towards being used as a source of data for the

indicators selected.

Strengths and Limitations of Recommendations and Process

The strengths of the report card measures recommended for assessing the access to primary care

in the Mat-Su resides in the selection process that is based on the scientific Six-Sigma method.

Using the method described in the process section of the paper, the team was able to cull from

the numerous factors and measures available, and pair down to a selected few measures that may

have the greatest impact on the Mat-Su Health Foundation (MSHF). Following the selection, a

survey of current studies indicated that these factors do indeed predict poor access or usage of

primary care. The assumption follows that individuals who fail to utilize or avail themselves to

primary care will eventually end up in the hospital emergency room seeking services for



29/35

preventable health conditions. Thus the measures may provide a predictive indication of future

demand on the Mat-Su hospital for primary care. All the indicators selected are recognizable as

generally accepted factors that contribute to poor primary care usage.

There are limitations to the measures and the process utilized. Primarily, the measures are

outside the span of control by the MSHF and therefore limited on possible actions it may take to

manage the recommended measures. Where this is the case, the indicators may predict future

usage of the hospital for primary care. There is a secondary limitation based on the expertise

available when the analysis was performed on the selected measures. The team performing the

analysis had limited information about the patients who utilize the MSHF hospital for primary

care. Although the team has a collective working and academic knowledge of over 15 years in

medical and social services and examined academic literature and reviewed existing health report

cards, measure validity would be strengthened if informed by those with first hand knowledge of

the hospital patients. Not a single member of the team resides in the Mat-Su Borough and access

to those individuals with patient data and deep understanding of the Mat-Su culture was severely

restricted.

Based on these limitations the team would recommend the following to the MSHF. First,

the process should be re-run with knowledgeable experts from the Mat-Su Borough, including

civic leaders, heath professionals, and members of the business community, in essence, a cross

section of the Mat-Su community.

The second recommendation concerns an internal aspect of proposed measures. Whereas

the currently recommended measures are primarily external and outside the span of control by

the MSHF, it is recommended that the MSHF perform the Six-Sigma evaluation process with a



30/35

focus on internal measures within the Foundations span of control. The primary focus of this

secondary set of measures is the effectiveness of actions taken by the MSHF to mitigate use of

the ER for primary care. Issues such as efficient use of resources, efficiency of the ER, and

effectiveness of sponsored programs could be evaluated as internal measures.

The final recommendation concerns data collection. The MSHF Hospital may be able to

design an anonymous survey questionnaire that could be given to those individuals entering the

ER for care. Questions as to if they have had their immunizations, have a primary care physician,

abuse drugs/smoke/drink, and a select number of other high level questions could provide clear

data on why individuals are seeking primary care from the ER. There are obvious limitations and

ethical concerns that would need consideration and the challenges of creating a useful

questionnaire are many. Hence, this recommendation may be difficult to act upon.



31/35

References

Asch, S.M., Kerr, E.A., Keesey, J. (2006). Who is at greatest risk for receiving poor-quality

health care?New England Journal of Medicine, 354(11), 1147-1156.

Alaska Department of Health and Social Services, Division of Public Health. (2001).HealthyAlaskan 2010 Targets and Strategies for Improved Health; Mat-Su Borough Scorecard.

(Vol 1, Targets for Improved Health Executive Summary). State of Alaska: Department

of Health and Social Services.

Alaska Department of Labor and Workforce Development. (2009).Labor Force Statistics by

Month for the Matanuska-Susitna Borough 1990 to present. Retrieved November 29,

2009, from http://labor.alaska.gov/research/emp_ue/matsulf.htm

Alaska Scorecard: key issues impacting Alaska mental health trust beneficiaries. (2008).

Retrieved from, www.hss.state.ak.us/dph/healthplanning/scorecard

American Academy of Pediatrics. Retrieved from the www on November 30, 2009 at

http://www.aap.org/advocacy/staccess.htm

Antony, J. (2002). Design for Six Sigma: A breakthrough businessimprovement strategy for achieving competitive advantage. Work Study,51(1), 6-8.

An update of Matanuska-Susitna Borough Community Assessment. (2005). Anchorage, AK:

McDowell Group

Berk, M., Cantor, J., & Schur, C. (1995). Ability to obtain health care: Recent estimates from the

Robert Wood Johnson Foundation national access to care survey.Health Affairs, 14(3),

139-146.

Betacourt, J.R., Green, A.R., Carrillo, J.E., & Ananeh-Firempong II, O. (2003). Cultural

Competence And Health Care Disparities: Key Perspectives And Trends.Health Affairs,

24(2), 499-505. Retrieved December, 4, 2009 from

http://labor.alaska.gov/research/emp_ue/matsulf.htmhttp://www.aap.org/advocacy/staccess.htmhttp://labor.alaska.gov/research/emp_ue/matsulf.htmhttp://www.aap.org/advocacy/staccess.htm


32/35

http://content.healthaffairs.org/cgi/content/full/24/2/499

Bindman, A., Grumbach, K., & Keane, D. (1996). Primary care and emergency department

crowding.Journal of Public Health, 83(3), 372-378.

Brems, C., Johnson, M., Warner, T., & Roberts, L.W. (1997). Barriers to healthcare as reportedby rural and urban interprofessional providers.Journal of Interprofessional Care, 20(2),

105-118.

Buzon, R., Franco, S., & Mitchell, C. (1997). Primary care physician access and gatekeeping: Akey to reducing emergency department use. Clinical Pediatrics, 36(2), 63-68.

Census Borough. (August 29, 2006).Matanuska-Susitna Borough, Alaska. Selected Economic

Characteristics: 2005. Retrieved (November, 26, 2009)

http://factfinder.census.gov/servlet/ADPTable?_bm=y&- geo_id=05000US02170&-

qr_name=ACS_2005_EST_G00_DP3&-ds_name=ACS_2005_EST_G00_&-

lang=en&-redoLog=false

Cherpitel, C. & Ye, Y. (2007). Drug use and problem drinking associated with primary care

and emergency room utilization in the US general population: Data from the 2005

national alcohol survey. Drug and Alcohol Dependence. 97, (3), 226-230.

CiteHealth. Give your provider a checkup. (June, 2, 2008).Matanuska-Susitna Borough, Alaska.

Retrieved November, 29, 2009 from

http://citehealth.com/places/alaska/counties/matanuska-susitna-borough

City-data. (2003-2009).Matanuska-Susitna Borough, Alaska. Retrieved November, 29, 2009

from http://www.city-data.com/county/Matanuska-Susitna_Borough-AK.html

Chamberlain, L. (2002) Domestic Violence: A Primary Care Issue for Rural Women. Retrieved

November, 22, 2009 from http://www.ruralwomyn.net/primary_care.html

Chassin, M. (1998). Is health care ready for Six Sigma quality? MilbankQuarterly, 76 (4), 565-578.

Chassin, M. (2008). The Six Sigma initiative at Mount Sinai Medical Center.

Mount Sinai Journal of Medicine,75, 45-52.

Cherpitel, C. & Ye, Y. (2007). Drug use and problem drinking associated with primary care

and emergency room utilization in the US general population: Data from the 2005

national alcohol survey.Drug and Alcohol Dependence. 97, (3), 226-230.

Commonwealth North. Alaska Primary Health Care: Opportunities and Challenges. (2005).

Retrieved from the www on November 9, 2009 at

http://content.healthaffairs.org/cgi/content/full/24/2/499http://factfinder.census.gov/servlet/ADPTable?_bm=y&-%09geo_id=05000US02170&-%09qr_name=ACS_2005_EST_G00_DP3&-ds_name=ACS_2005_EST_G00_&-%09lang=en&-redoLog=falsehttp://factfinder.census.gov/servlet/ADPTable?_bm=y&-%09geo_id=05000US02170&-%09qr_name=ACS_2005_EST_G00_DP3&-ds_name=ACS_2005_EST_G00_&-%09lang=en&-redoLog=falsehttp://factfinder.census.gov/servlet/ADPTable?_bm=y&-%09geo_id=05000US02170&-%09qr_name=ACS_2005_EST_G00_DP3&-ds_name=ACS_2005_EST_G00_&-%09lang=en&-redoLog=falsehttp://citehealth.com/places/alaska/counties/matanuska-susitna-boroughhttp://www.city-data.com/county/Matanuska-Susitna_Borough-AK.htmlhttp://www.city-data.com/county/Matanuska-Susitna_Borough-AK.htmlhttp://www.ruralwomyn.net/primary_care.htmlhttp://www.ruralwomyn.net/primary_care.htmlhttp://content.healthaffairs.org/cgi/content/full/24/2/499http://factfinder.census.gov/servlet/ADPTable?_bm=y&-%09geo_id=05000US02170&-%09qr_name=ACS_2005_EST_G00_DP3&-ds_name=ACS_2005_EST_G00_&-%09lang=en&-redoLog=falsehttp://factfinder.census.gov/servlet/ADPTable?_bm=y&-%09geo_id=05000US02170&-%09qr_name=ACS_2005_EST_G00_DP3&-ds_name=ACS_2005_EST_G00_&-%09lang=en&-redoLog=falsehttp://factfinder.census.gov/servlet/ADPTable?_bm=y&-%09geo_id=05000US02170&-%09qr_name=ACS_2005_EST_G00_DP3&-ds_name=ACS_2005_EST_G00_&-%09lang=en&-redoLog=falsehttp://citehealth.com/places/alaska/counties/matanuska-susitna-boroughhttp://www.city-data.com/county/Matanuska-Susitna_Borough-AK.htmlhttp://www.ruralwomyn.net/primary_care.html


33/35

http://www.commonwealthnorth.org/documents_cwnorth/2005_updatedhealthcare.pdf

De La Fuente, D., Pino, J., Blanco, V., & Alvarez, A. (2007). Does better access to

primary care reduce utilization of hospital accident and emergency departments? A

time-series analysis.European Journal of Public Health, 17(2), 186-192.

doi:10.1093/eurpub/ckl085.

Franco, S., & Mitchell, C. (1997). Primary care physician access and gatekeeping: A key to

reducing emergency department use. Clinical Pediatrics, 36(2), 63-68. Retrieved from

Academic Search Premier database.

Galambos, C. (2005). Health care disparities among rural populations: A neglected frontier.

Health and Social Work, 30(3), 179-181. Retrieved from Academic Search Premier

November 1, 2009.

Ganley, E., Robb, S., & Lowe, N. (2006). Mat-Su Borough Primary Healthcare Plan 2005-

2015. Fairbanks, AK; Information Insights, Inc.

Grossman, D., Baldwin, L., Casey, S., Nixon, B., Hollow, W., & Hart, L. (2002). Disparities in

Infant Health Among American Indians and Alaska Natives in US Metropolitan Areas.

Pediatrics, 109(4), 627. Retrieved from Academic Search Premier database.

Hemingway, H., Nicholson, A., & Marmot, M. (1997). The Impact of Socioeconomic Status

on Health Functioning as Assessed by the SF-36 Questionnaire: The Whitehall Study.

American Journal of Public Health. 87(9). 1484-1490. Retrieved Decemeber, 4, 2009

from http://ajph.aphapublications.org/cgi/reprint/87/9/1484

Information Insights. (2006). Mat-Su Primary Healthcare Plan 2005-2015. Fairbanks, Alaska.

Kelman, H. & Lane, D. (1976). Use of hospital emergency room in relation to use of private

physicians.Journal of Public Health, 66(12), 1189-1191.

Keith, Brynn. (2009). Alaska Economic Trends. 29, (10). 3-19. Retrieved November 27, 2009,

from http://labor.alaska.gov/trends/oct09.pdf

Laditka, J. N., Mastanduno, M. P., Laditka, S. B., Lauria, M. R., Foster, T. C., (2005) .

Potentially Avoidable Maternity Complications: An Indicator of Access to Prenatal and

Primary Care During Pregnancy. Women & Health; 2005, Vol. 41 Issue 3, p1-26, 26p, 5charts. Retrieved from http://proxy.consortiumlibrary.org/login?

url=http://search.ebscohost.com/login.aspx?

direct=true&db=aph&AN=19526969&site=ehost-live

Majority of emergency room visits are for non-emergencies. (1994).Nation's Health, 24(4), 9.

Retrieved from Academic Search Premier database.

http://www.commonwealthnorth.org/documents_cwnorth/2005_updatedhealthcare.pdfhttp://ajph.aphapublications.org/cgi/reprint/87/9/1484http://proxy.consortiumlibrary.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=19526969&site=ehost-livehttp://proxy.consortiumlibrary.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=19526969&site=ehost-livehttp://proxy.consortiumlibrary.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=19526969&site=ehost-livehttp://www.commonwealthnorth.org/documents_cwnorth/2005_updatedhealthcare.pdfhttp://ajph.aphapublications.org/cgi/reprint/87/9/1484http://proxy.consortiumlibrary.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=19526969&site=ehost-livehttp://proxy.consortiumlibrary.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=19526969&site=ehost-livehttp://proxy.consortiumlibrary.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=19526969&site=ehost-live


34/35

Mat-Su Health Foundation document (no author) (2009) pp. 1-2

Mat-Su Health Foundation website (2009). Retrieved October 18, 2009, from

http://www.matsuhealthfoundation.org/

Patton, M. Q. (2008). Utilization focused evaluation (4th ed.). Thousand Oaks, CA:Sage Publications.

Prator, Deborah (2009). Welcome to the Mat-Su Health Foundation! Retrieved October 18,

2009, from http://www.matsuhealthfoundation.org/messagefromthechairman.php

Public Health Statistics. (2009). Retrieved November 28, 2009 from

http://www.hss.state.ak.us/dph/PHIS/census/mat_su/text.htm

Reinberg, S. (2009). Tiniest babies carry biggest costs. Retrieved from the www on November

30, 2009 at http://health.usnews.com/articles/health/healthday/2009/03/17/tiniest-babies-

carry-biggest-costs.html

Serwint, J., & Wilson, M. (1996). A randomized controlled trial of prenatal pediatric visits for

urban, low-income families.Pediatrics, 98(6), 1069. Retrieved from Academic Search

Premier database.

Sheiner, E., Hallak, M., Twizer, I., Mazor, M., Katz, M., & Shoham-Vardi, I. (2001). Lack of

prenatal care in two different societies living in the same region and sharing the same

medical facilities.Journal of Obstetrics & Gynaecology, 21(5), 453-458.

doi:10.1080/01443610120071974

Six Sigma in Healthcare Industry. (n.d.). Six Sigma in Healthcare. Retrieved December, 4, 2009from http://www.sixsigma-lean-healthcare.com/

State Health Facts. Retrieved from the www on November 30, 2009 at

http://www.statehealthfacts.org/profileglance.jsp?rgn=3

State of Alaska, Department of Health and Social Services: Infant Mortality in Alaska, (2009).

Retrieved from the www on November 9, 2009 at

http://www.hss.state.ak.us/dph/wcfh/awareness/default.htm

State of Alaska, Department of Labor and Workforce Development. (October, 2009).

Unemployment rate. Retrieved November, 29, 2009 from http://almis.labor.state.ak.us/?

PAGEID=67&SUBID=188

The Alaska Mental Health Trust Authority. (Decemeber, 2008).Alaska Scorecard Key Issues

Impacting Alaska Mental HealthTrust Beneficiaries. Retrieved December, 4, 2009 from

http://www.hss.state.ak.us/dph/healthplanning/scorecard/assets/scorecard.pdf

http://www.matsuhealthfoundation.org/messagefromthechairman.phphttp://www.hss.state.ak.us/dph/PHIS/census/mat_su/text.htmhttp://health.usnews.com/articles/health/healthday/2009/03/17/tiniest-babies-carry-biggest-costs.htmlhttp://health.usnews.com/articles/health/healthday/2009/03/17/tiniest-babies-carry-biggest-costs.htmlhttp://www.sixsigma-lean-healthcare.com/http://www.statehealthfacts.org/profileglance.jsp?rgn=3http://www.hss.state.ak.us/dph/wcfh/awareness/default.htmhttp://almis.labor.state.ak.us/?PAGEID=67&SUBID=188http://almis.labor.state.ak.us/?PAGEID=67&SUBID=188http://www.hss.state.ak.us/dph/healthplanning/scorecard/assets/scorecard.pdfhttp://www.matsuhealthfoundation.org/messagefromthechairman.phphttp://www.hss.state.ak.us/dph/PHIS/census/mat_su/text.htmhttp://health.usnews.com/articles/health/healthday/2009/03/17/tiniest-babies-carry-biggest-costs.htmlhttp://health.usnews.com/articles/health/healthday/2009/03/17/tiniest-babies-carry-biggest-costs.htmlhttp://www.sixsigma-lean-healthcare.com/http://www.statehealthfacts.org/profileglance.jsp?rgn=3http://www.hss.state.ak.us/dph/wcfh/awareness/default.htmhttp://almis.labor.state.ak.us/?PAGEID=67&SUBID=188http://almis.labor.state.ak.us/?PAGEID=67&SUBID=188http://www.hss.state.ak.us/dph/healthplanning/scorecard/assets/scorecard.pdf


35/35

The Henry J. Kaiser Family Foundation. (2007-2008).Individual State profiles: Alaska.

Retrieved November, 29, 2009 from http://www.statehealthfacts.org/profileind.jsp?

ind=134&cat=3&rgn=3

United States Department of Health and Human Services. The 2009 HSS Poverty Guidelines.

(2009). Retrieved from the www on November 9, 2009 athttp://aspe.hhs.gov/poverty/09poverty.shtml

U.S. Department of Health and Human Services. (2008). Community Health Status Report:

Matanuska-Susitna Borough Alaska. U.S. Department of Health and Human Services.

Wholey, J. S., Hatry, H. P., & Newcomer, K. E. (Eds.). (2004).Handbook of practical

program evaluation (2nd ed.). San Francisco, CA: Jossey-Bass.
http://www.statehealthfacts.org/profileind.jsp?ind=134&cat=3&rgn=3http://www.statehealthfacts.org/profileind.jsp?ind=134&cat=3&rgn=3http://www.statehealthfacts.org/profileind.jsp?ind=134&cat=3&rgn=3http://aspe.hhs.gov/poverty/09poverty.shtmlhttp://www.statehealthfacts.org/profileind.jsp?ind=134&cat=3&rgn=3http://www.statehealthfacts.org/profileind.jsp?ind=134&cat=3&rgn=3http://aspe.hhs.gov/poverty/09poverty.shtml

mat su draft1 lr[1]

Documents