See attatchment of instructions and example. Health Promotion Program Evaluation Plan Worksheet

I. Introduction and Stakeholder Engagement

Program Purpose
Many cardiovascular disease (CVD) patients lack confidence and know-how to manage their condition upon release from the hospital resulting in readmission within 30 days of discharge. A variety of lifestyle factors influence the health of cardiovascular disease patients. With encouragement, skills-building, education, and the providing of examples and modeling, patients can improve their individual health outcomes, reduce the need for hospital readmittance, and ultimately reduce deaths from cardiovascular-related issues. Volunteer health coaches will educate and work alongside women diagnosed with CVD to establish independence using the constructs of the social cognitive theory. The primary purpose of this program will be to reduce hospital readmissions of CVD patients.
Findings from the evaluations will be used to determine whether or not health coaching was effective in reducing hospital readmissions and improving self-efficacy of CVD patients receiving the coaching

Stakeholders
Table 1.1 represents the stakeholders as they relate to their interest or involvement in the planning, conducting, or evaluation of the program. As a reminder, the program is being conducted with hospital funding to reduce the number of hospital readmissions.

Table 1.1: Stakeholder Assessment and Engagement Plan (*indicates member of planning team)
Stakeholder Name
(individual or a group) Stakeholder Category
(primary, secondary, tertiary) Interest or Perspective
(program participant, staff, etc.) Role in the Evaluation
(planning team, external reviewer, etc.)
*UAB Hospital Administrators/Decision Makers primary Funder/administrator, financial interest Planning team, functionality enabler, results reviewer
*Program Administrator primary Program Staff Planning team
*Researcher/Research Team/Health Educator in this scenario
(in this case, me, Janet Walker) primary Research staff, program implementer, PI Planning team
CVD Patients primary Program participant Accurate reporting
*Health Coaches primary Program participant Planning team
*Cardiovascular Unit at UAB including nursing staff & doctors secondary Absorbing patient volume and enrolling patients in program Consulted by planning team for feasibility of tracking, training for tracking
Patient family and social system secondary Living with patient Accurate reporting
UAB Board of Directors secondary Financial Interest Results reviewer
Healthcare Community at large tertiary Financial Interest Interested in results
Health Education/Promotion Community at Large tertiary Educational Interest Interested in results; external evaluation consultant
Medicaid and Medicare tertiary Financial Interest Interested in results

2. Description of Program

See Logic Model in Appendix 1

Need
Cardiovascular disease (CVD) includes a variety of cardiac conditions with some of the most commonly known being stroke, heart attack and heart failure. More than 85.6 million Americans are living with CVD (Mozaffarian, 2016). Heart disease is the leading cause of death in Alabama, accounting for 25.78% of deaths in the state (higher than the national percentage of 18.98%) according to 2013 data (Alabama Department of Public Health, 2015).?
The current and rising prevalence of CVD (American Heart Association (AHA), 2017, Havranek et al., 2015) is an issue that is not going away and is one that is of interest to individuals as well as hospitals. In the political and financially-motivated environment that exists, a successful program will need to be mindful of the potential benefit to the larger healthcare picture not just the individual.
The population in general needs to experience a reduction in deaths from heart failure and other cardiovascular-related disease. On a more individual level, CVD patients need to be able to self-manage their care and long term health. In order to do that, they must experience improvements in the lifestyle-controlled risk factors of CVD.
Hospitals need to experience a cost savings from unpaid or under-reimbursed expenses related to treating CVD patients. One way for hospitals to make a dent in cost savings is to reduce hospital readmissions within the first 30 days of discharge. The cost of a heart failure diagnosis readmission is on average over $9,000 (Mayr, 2017), and according to the Healthcare Cost Utilization Project, the cost of readmission after a heart attack is over $13,000 (Becker, 2013). In addition, Centers for Medicare & Medicaid Services (CMS) uses 30-day readmissions to assess hospital reimbursements (Mayr, 2017), so it is best to keep the numbers low. Above-average 30-day readmission rates result in penalties for hospitals, and in 2012 CMS found thousands of hospitals with above average 30-day readmission rates in patients with pneumonia, heart attack or heart failure which resulted in a total of $300 million in penalties (Bakken, 2013). ?One in five Medicare recipients is readmitted within 30 days at an annual cost of $17 billion, with heart failure the most common culprit? (Bakken, 2013, para. 3). CMS does not track all CVD incidence, but these heart failure and heart attack costs should provide a good idea of the scope of the costs hospitals are facing.
Context
This program is planned to operate out of the University of Alabama at Birmingham (UAB) Hospital located in Birmingham, Alabama, and would serve the citizens of Jefferson County. UAB was chosen as the site for the program for a number of reasons. First, they see plenty of heart disease patients in the hospital, meaning they cannot only generate program participants, but they also have financial reasons to care about the program. Second, the hospital and university have historically demonstrated a committed, proactive and conscious effort to deal with cardiovascular disease as evidenced by the creation of the Heart Failure Clinic in 2014 (Greer, 2014) and their extensive research profile in CVD-related areas. Third, they have the knowledgeable staff and volunteer base to support the program.
This program also relies on trained health coaches to work with patients in the home setting and in larger group settings. However, training can only go so far as to formally provide the coaches tools to teach and manage interactions. The program format requires a lot of direct contact between coaches and patients, and will rely heavily on a positive working relationship between the two. Personality challenges and conflicts that may arise could impact the program?s effectiveness. Compatibility assessment would be an important part of process evaluation and could hopefully be corrected within the timeframe of the implementation.
Factors beyond the control of the program include the patient?s social network and support environment.
Population Addressed
The population being addressed with this intervention is women over age 65 that are Medicare beneficiaries and have recently been released from UAB hospital in Birmingham, Alabama, after being seen and treated for a CVD-related incident and receiving a diagnosis of CVD. This population is being used for the intervention because Medicare patient data is trackable. However, the larger population of women over age 65 should be seen as one that could potentially benefit from the program as well. Further study would need to be done to define effectiveness and applicability as it may relate to race/ethnicity, income level and/or other demographic and social factors.
Stage of Development
This program is currently in the planning phase and has not yet been implemented in the UAB setting. Although, a need (outlined above) and opportunity (described here) have been pinpointed. According to Centers for Disease Control and Prevention (CDC) data from 2012-2014, in Jefferson County, Alabama, the rate of Medicare beneficiary women being discharged home after a heart disease hospitalization is 72.3 (higher than the national rate of 68) (Centers for Disease Control and Prevention (CDC), n.d.). The rate does not vary significantly by race/ethnicity. With more women going home from the hospital as opposed to suffering death (despite heart disease being the number one killer in women (American Heart Association (AHA), 2018)), there?s an opportunity to work with them once they return home to structure their lifestyle to support healthy living with their condition.
Resources/Inputs
This program will require resources in the form of people, facilities, equipment and supplies, and funding.
People
Twenty skilled and trained health coach volunteers will be used to perform the health coaching. A licensed nutritionist/dietician, a skilled and trained physical activity coach and one program administrator will make up the remaining staff servicing the program.
Facilities
Facilities outside of the patient?s home will be supplied by UAB and consist of a commercial kitchen and a group meeting space. The kitchen and meeting space will each need to accommodate approximately 40 people.
Equipment & Supplies
Equipment and supplies will be fairly minimal beyond some basic office supplies and will include telephones, printed materials, goal setting sheets, log books, recipes, food, and cooking supplies.
Funding
Grants, donations and hospital support will provide the financial supports for the program.
Activities & Outputs
The initial implementation of the program would look like this. As members of the target population are preparing to be discharged from UAB hospital they would be provided with the opportunity to enroll in this health coaching program and encouraged by nursing staff to do so. On the day of their discharge they would meet a volunteer health coach that has been selected for them. The volunteer and the patient would make arrangements for the first in-home visit prior to leaving the hospital. The program would have the capacity to maintain 40 patients at any one time (each health coach working with a maximum of two patients at one time).
Once enrolled in program participation, the patient would receive six months of health coaching and develop a rapport with their assigned health coach. Research has proven the long term effectiveness of health coaching in a variety of settings and related to a variety of medical conditions, including CVD (Almondes, Downie, Cinar, Richards, & Freeman, 2017; Dye, Williams, & Evatt, 2016; Jelinek et al., 2009). However, there is lack of consistency in the delivery format to draw conclusions on the best way to administer the coaching.
This program is designed to have twice weekly, two hour, in-person, in-home meetings in addition to three follow-up phone calls per week. The in-person/telephone combination design was patterned after previous studies (Stewart, Blue, Walker, Morrison, McMurray, 2002; Blue, Lang, McMurray, 2001). During the in-home sessions, the health coaches will work with the patients to address lifestyle-related CVD risk factors including healthy eating habits, regular physical activity, smoking cessation, and stress management. The pair would also address CVD medication management and symptom monitoring (examples include weight checks and blood pressure monitoring). Beyond the skill- and knowledge-base-building that will take place in the one-on-one education opportunities that encourage behavioral capability, the health coach will be able to model and demonstrate behaviors while providing encouragement and social support. The modeling of behaviors related to diet and exercise have been explored in social cognitive theory research and behavioral change has been realized (Raedeke & Dlugonski, 2017; Rolling & Hong, 2016; Sallis, Grossman, Pinski, Patterson, Nader, 1987; Sallis & Owen, 1999). The health coach will also work with the patient to make necessary changes to their environment (home life and social support system) to facilitate long-term lifestyle changes. Each of the coaching elements in this program work to strengthen self-efficacy therefore instilling the confidence needed to manage self-care (Bandura, 1998).
In addition to one-on-one coaching, enrolled participants would participate in group sessions twice per month that would demonstrate meal preparation skills and appropriate and relevant physical activity ideas that could be employed at home. These group sessions not only provide an efficient way to distribute information and demonstrate skills, but they also provide interactions with other CVD patients and offer opportunities to experience social support, thereby addressing collective efficacy.
Outcomes
As a result of the program, individuals should see improvements in their knowledge as well as their ability to make a difference in CVD-related lifestyle factors including smoking cessation, diet management, physical activity and stress management. In addition, they should experience improved self-efficacy, feeling confident, encouraged and socially supported. This should lead to their ability to manage self-care and reduce hospital readmissions.
The primary outcome of the program will be seen with time as UAB hospital experiences reduced costs due to a reduction in CVD patient readmissions. In the interim, the program should demonstrate reduced readmissions.

3. Implementation

Program Implementation Activities and Team
What activities are needed to carry out the program successfully? When should each of these activities be completed? Who is responsible for conducting each activity?

See Table 3.1 for activities, responsible parties, and completion goals.

What implementation skills or approaches are needed to successfully conduct the program as planned?
The program will require the use of the skilled and trained health coach volunteers. It assumes that the coaches are all properly trained and equipped to handle the various patient interactions. Compatible relationships between health coaches and patients will be critical. Health coaches will have needed to be properly trained in teaching the self-care skills needed and have cultivated the intrapersonal skills necessary to communicate effectively and navigate situations with the patient. They will be focused on building self-efficacy with the CVD patients and addressing environmental supports as needed. Program implementation is also based on the assumptions that participants will be willing to be coached (and their home environments allow for coaching).
The program will also need the support of the UAB hospital nursing staff to encourage and support patient enrollment in the program. The evaluation components rely on detailed and accurate recording of patient admission records. It will also rely on the doctor?s offices to provide an opportunity to conduct the self-efficacy survey during patient visits.
The monthly session coaches, the dietician and the physical activity coaches, will also need to have been properly trained/educated and prepared to present their material in an engaging way suitable for the audience.

What will be the process used if there are any problems encountered during the program implementation?
If any problems or issues arise during the program implementation, the program administrator and the researcher/research team/health educator will come together to make a decision about how to efficiently and effectively document and handle the issue. The health coach and patient will be consulted as needed.
As stated previously, it?s possible that a patient and their assigned health coach are determined to not be a good fit for each other. In that case, the patient and the health coach would be contacted by the program administrator and issues would be discussed in order to find a better match for the patient.
If other circumstances arise that are making it difficult for the health coach to perform their duties as planned, they should consult the program administrator. The health coaches will be required to provide a brief report of activities and patient interaction in order to reflect on and spot any issues early in the process.
If funding or facilities issues arise, UAB hospital administrators would be consulted as well with the program administrator arranging for those discussions on an as needed basis.
All issues will be carefully documented by the program administrator and provided to the researcher so that they may be considered when evaluating the program?s process, impact and outcomes.

Table 3.1 Implementation Activities: Tasks, Timeline, Roles, and Responsibilities (note: the term ?researcher? also refers to the ?health educator? in this context)
Activity When to Start When to Complete Who is Responsible
Planning and Administrative Activity – – –
Form relationships with cardiologist doctors to determine feasibility of self-efficacy survey during visits Now within a month Researcher/Program Administrator
Train nursing staff on how to encourage and enroll patients in program Up to one month prior to program start One week prior to program start Program Administrator
Plan nutrition group sessions Prior to program start Ongoing as needed Licensed Nutritionist/Dietician
Plan physical activity group sessions Prior to program start Ongoing as needed Physical Activity Coach
Schedule twice monthly nutrition group sessions One week prior to program start Complete 3 months at a time Program Administrator
Schedule physical activity group sessions One week prior to program start Complete 3 months at a time Program Administrator
Work with hospital staff to plan data collection from hospital records systems Now within two months Researcher/Program Administrator
Implementation Activity – – –
Enroll CVD Patients immediately Ongoing (up to 40 patients at a time) Nursing Staff
Assign Health Coach to Patient When new patient is enrolled Ongoing Program Administrator
Health Coach meet patient before discharge before patient discharge before patient discharge (Ongoing) Health Coach
health coach schedule first in-home meeting with patient before patient discharge before patient discharge (Ongoing) Health Coach
Health Coach meet with patient in home and plan schedule of in-home meetings and phone calls at first in-home meeting Ongoing as needed Health Coach
Health Coach conduct in-home activities and phone calls as scheduled with first meeting ongoing up to 6-month program completion Health Coach
Record each contact in log first week of coaching at end of 6-month program enrollment Health Coach
Record weekly contact in log first week of coaching at end of 6-month program enrollment Program Participant
Conduct nutrition group sessions 2x monthly; 1st month start Ongoing Licensed Nutritionist/Dietician
Conduct physical activity group sessions 2x monthly; 1st month start Ongoing Physical Activity Coach
Evaluation Activity – – –
Review Logs with first patient-completed month When patient has completed 1 month and/or when an issue arises with patient and coach combination Program Administrator
Conduct self-efficacy surveys first in office visit Ongoing as needed in office visits
Collect reports from hospital data systems see timeline (Table 3.2) for various occurrences
Program Administrator
Analyze data from hospital reports Researcher
Analyze data from self-efficacy logs Researcher
Compile data for reporting see timeline Ongoing as needed Researcher/Program Administrator

Timeline
Implementation of the program is planned for April 2019 with planning and preparation activities taking place up until that time. This program will be considered to be in the pilot testing phase the first year from April 2019-April 2020. After the first 8 months of program implementation (assuming a minimum of 10 patients have been enrolled), pilot testing of the data collection instruments related to hospital readmission tracking, process evaluation (not elaborated in this particular project), patient self-efficacy, and patient satisfaction (not elaborated in this particular project), will be conducted. This will allow for time to review and refine those tools prior to the conclusion of the pilot year in April 2020. The second year of the program, any needed adjustments can be made and data collection tools refined in order to provide more valid and reliable data related to the program.
Weekly reports from the health coaches to the program administrator will allow for issues to be dealt with on a timely basis. Formal patient satisfaction information will be gathered monthly. A review of health coach and patient log books will take place every 6 months as a component of reviewing implementation fidelity.
Program patients and the control patients will be administered a self-efficacy evaluating survey at their regular doctor visits (assuming these take place at least 2 times during the first 6 months they have been discharged). Surveying of these will conclude once they have been discharged 6 months from initial hospital discharge.
At the 20-month implementation mark, data gathered from the pilot year and first three months of the second year will be evaluated by the stakeholders to determine if the program appears to be worth continuing and patient enrollment should continue. Ideally, at the conclusion of the second full year, a final determination of whether or not to continue the program implementation will be determined.

When will planning and administrative tasks occur?
Planning and administrative tasks will occur now through April 2019 and then ongoing as needed.
When will training for data collectors occur?
Training specifically for data collectors is not a part of this implementation. Evaluation #1 will require training for data inputters as hospital staff will need to know how to properly record patient hospital readmissions and program staff will need to know how to access data from hospital systems. Evaluation #2 is conducted as a written patient survey, so responses will be recorded by the patient and analyzed by program staff.

When will you pilot test data collection instruments?
Data collection instrument pilot testing will begin 8 months into the intervention?s program enrollment. See timeline Table 3.2 for further elaboration.
When will formal data collection, analysis, and interpretation tasks occur?
See timeline Table 3.2 and notes on the Implementation timeline for further information.
When will information dissemination tasks occur?
At the 20-month implementation mark, data gathered from the pilot year and first 3 months of the second year will be evaluated by the stakeholders to determine if the program appears to be worth continuing and patient enrollment should continue. At the conclusion of the second year, a final determination of whether or not to continue the program implementation will be determined.
Notes on Implementation Timeline (Table 3.2):
Because this implementation takes place over a long span of time and patient enrollment and participation is on a continual basis, I chose for the first year to be a pilot year with testing of evaluation tools occurring at multiple intervals as data collection continues. During the pilot year, I allow for some breaks in data collection in order to refine the tools. In the second year, data collection goes on continuously with analysis occurring at certain intervals. This timeline is created to ultimately end up at a dissemination of results to hospital administrators to determine if the program is reducing hospital readmissions and how it is influencing patient self-efficacy. It does not represent how data collection would continue for reports generated after the 20th month mark.
? Preparatory-Planning Tasks Program PILOT PHASE Pilot Testing of Evaluation Tools elaborated on in this project
EVALUATION #1
EVALUATION #2 Review and Refine Evaluation Tools
EVALUATION #1
EVALUATION #2 Program Continues into 2nd Year Ongoing Evaluation Using Tools elaborated on in this project
EVALUATION #1
EVALUATION #2 Data Analysis/Tabulation
EVALUATION #1
EVALUATION #2 Final Report Approval Dissemination of Results
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4. Evaluation Design
Note: For the purposes of this project, I am planning for two different evaluations, so I have provided the design description first to make the following content make sense
Evaluation Design
What is the design for this evaluation? (e.g., experimental, pre-post test, pre-post test with comparison group, time-series, case study, post-test only) Provide the rationale for the design selected.
The design for both evaluations will be experimental and rely on the same population sample and control group. However, I recognize that true experimental design may not be possible in the given environments and so some acceptance and documentation of those interferences will need to be made (Sharma & Petosa, 2014, 181-182).
Before conducting the intervention, baseline data on 30-day hospital readmissions related to the target population will be collected from UAB records and documented.
As the intervention begins, CVD patients will be selected at random (selecting every 3rd patient being discharged that meets the target population credentials) to offer enrollment in the health coaching program. Hospital readmission status will be tracked for all CVD patients in the target population.
Using a separate evaluation tool, CVD patient self-efficacy will be evaluated between the group of patients enrolled in the health coaching intervention and the other CVD patients discharged from UAB (upon their consent) but not enrolled in the health coaching intervention. These surveys will be conducted at regular follow-up doctor?s appointments in order to maintain consistency of environment and factors under which the survey was administered.
Patients who are offered, but decline to participate in the health coaching intervention will be excluded from both the test and control groups.
Because the intervention is complex in nature, the experimental option, which would allow for a control group, I think, would provide the most concrete evidence and greatest internal validity. If working with patients that are not part of the intervention proves problematic then self-efficacy could potentially be measured in the individual enrolled as a pre-post test. However, I prefer the original design because if we don?t have a control group (those not receiving coaching) then we would be left with questions about whether the participant?s experience is just related to the challenges of the illness that all CVD patients face or if other routine healthcare-administered educational material was having an impact. These questions would contribute to a lower internal validity.
Evaluation Questions
What 2 major questions do you intend to answer through this evaluation?
RELATED TO EVALUATION #1: Did the intervention reduce hospital 30-day readmissions of CVD patients? In, turn, did the hospital experience a cost savings?
RELATED TO EVALUATION #2: Did the health coaching positively impact self-efficacy in CVD patients? Were there any particular areas of self-care that saw an improvement in self-efficacy?
Stakeholder Needs
Who will use the evaluation findings?
RELATED TO EVALUATION #1: Primarily, hospital administrators will use the findings along with the cardiovascular unit at the hospital. In addition, the researchers/health educators will use the findings to inform future interventions.
RELATED TO EVALUATION #2: Primarily, health educators/researchers will use the findings to better understand the intervention?s impact on self-efficacy.
What do they need to learn from the evaluation?
RELATED TO EVALUATION #1: Hospital administrators and staff need to gather quantitative data on patient volume as it relates to hospital readmissions.
RELATED TO EVALUATION #2: Health educators need to learn in which areas of CVD self-care/management did patients experience improved self-efficacy.
What do intended users view as credible information?
RELATED TO EVALUATION #1: This question would best be answered if hospital patient numbers and readmission rates were known to me. However, without actual data, I?m going to venture to say that if the hospital saw a 20% reduction in hospital readmissions that would be enough to get their attention and further evaluate the program. I think that 20% would be most relevant if 60+ patients were enrolled in the program within a year. The program would easily be scalable and so participating patient volume could increase and align to hospital financial goals.
RELATED TO EVALUATION #2: Health educators would view information from the self-efficacy evaluation as credible if there were areas of self-efficacy that were evaluated differently between the test and control groups. They would be particularly interested if improvements continued to increase with program duration.
How will the findings be used?
RELATED TO EVALUATION #1: The finding from Evaluation #1 will be used to determine whether or not the program is worth continuing. It will help the hospital decide whether or not health coaching is a potentially effective method for reducing hospital readmissions of CVD patients.
RELATED TO EVALUATION #2: The findings from Evaluation #2 will be used to inform health educators/researchers and the larger health education/promotion community as to whether or not there appears to be value in health coaching as it relates to improving self-efficacy in CVD patients. It could also provide the groundwork for exploring how health coaching could be used with other patient populations as well.
What evaluation capacity will need to be built to engage these stakeholders throughout the evaluation?
RELATED TO EVALUATION #1: Proper hospital admission tracking systems/processes will need to be put in place and a regular report easily generated/compiled.
RELATED TO EVALUATION #2: A survey tool will need to be developed to measure self-efficacy.

5. Gathering Credible Evidence

Data Collection Methods
Will new data be collected to answer the evaluation questions and/or will secondary data be used?
RELATED TO EVALUATION #1: I plan to use the hospital?s digital patient records systems to obtain the data needed. In order to protect patient confidentiality, I would have to have processes in place to use some sort of identifier to learn whether or not ?Patient A? was readmitted or not. Conversations with the hospital administration and cardiovascular department would help to define what?s possible in terms of data collection. Hopefully, a new collection tool is not needed, just some methods/protocols for utilizing hospital data.
RELATED TO EVALUATION #2: However, new data will be used to answer the evaluation questions related to self-efficacy.
What methods will you use to collect or acquire the data?
RELATED TO EVALUATION #1: See above for related response.
RELATED TO EVALUATION #2: A survey tool will be used to collect data regarding self-efficacy.
Will you use a sample? If so, how will you select it?
Yes, a population sample will be used. See the description above in ?Evaluation Design?
How will you identify or create your data collection instruments?
RELATED TO EVALUATION #1: Through conversations with hospital administrators, I would hope to identify proper data collection tools.
RELATED TO EVALUATION #2: I will review the literature for other self-efficacy measurement tools and see if there is one that could be adapted for the situation.
How will you test instruments for readability, reliability, validity, and cultural appropriateness?
RELATED TO EVALUATION #1:
This evaluation will not have readability issues and cultural appropriateness is not relevant. Reviewing internal systems for reliability an