DM is a serious and complex public health problem in the U.S. The CDC (2013) estimated that 25.8 million people, or 8.3% of the U.S. population, were suffering from DM in 2011. DM can significantly affect patient’s quality of life. Additionally, DM places a significant economic burden on the U.S. healthcare system. Over the past two decades, DMPs have emerged as a promising intervention to improve health outcomes for patients suffering from chronic conditions, such as DM, and to bend the cost curve. DMP’s aim is to improve communication and follow-up so that patients can better manage their chronic condition(s) to avoid costly hospital stays and emergency room visits (Fireman, Bartlett, & Selby, 2004). The Georgia region of Kaiser Permanente (KPGA) is a fully integrated health system that serves 260,000 members at 28 medical offices along with two specialty offices in the metropolitan Atlanta area. The Center for Care Partnership, the population care division of KPGA, administers a chronic disease management program (DMP), Healthy Solutions (HS). HS exists to improve and maintain the health of chronically ill KPGA members, including patients diagnosed with diabetes mellitus (DM), by providing health coaches via telephone who counsel members on their specific chronic disease and aid members in starting or maintaining a physician approved self-care management plan. In order to determine the impact HS has on KPGA members with DM, an evaluation plan was created to evaluate the impact HS has on members’ glycated hemoglobin (A1C), blood pressure, and emergency department (ED) utilization. This capstone thoroughly details the proposed evaluation plan created for HS by using Robert Milstein and Scott Wetterhall’s six-step framework for program evaluation. Additionally, further evaluation questions are suggested and discussed in order to provide a more complete picture of program performance to stakeholders.

Este trabalho teve como objetivo avaliar a integralidade no cuidado ao CCU em um município de grande porte populacional e com tecnologia de distinta complexidade disponível. Foi utilizada uma metodologia mista (quanti-quali). Para a abordagem quantitativa utilizou-se a base de dados secundários referentes à citologias e biópsias do sistema de informação municipal e regional. A análise e os testes estatísticos foram realizados pelo software PASW statistic 17.0. A abordagem qualitativa foi realizada por meio de entrevistas semi-estruturadas com usuárias, profissionais e representantes da gestão. Os dados qualitativos foram submetidos a uma análise de conteúdo realizada com o software NVivo 9.0. Na análise dos dados secundários, identificou-se que a cobertura de Papanicolau é insuficiente, sendo concentrada em mulheres mais jovens. As biópsias realizadas são equivalentes à quantidade de citologias alteradas. Os diagnósticos mais graves, tanto de citologias quanto de biópsias, prevalecem em mulheres com idade mais avançada. A abordagem qualitativa indica como potencialidades: o acolhimento, o acesso breve a serviços de média e alta complexidade, o papel ativo da gestão municipal de saúde e como fragilidades: a dificuldade para marcação das consultas na atenção básica, a falta de preparo dos profissionais para dar o diagnóstico, a contra referência tardia por parte do serviço terciário, o incentivo ao uso do Pronto-Atendimento e a formação focada na especialidade. Constata-se neste estudo que os principais gargalos para efetivação da integralidade no município investigado estão concentrados no primeiro nível de atenção à saúde / This study aimed to analyze the completeness in the Cervical Cancer care in a city with a large population and with enough technology health equipment available to the people. It was used a mixed methodology (quantitative and qualitative). For the quantitative approach it was used the database regarding cytology and biopsy exams registered in the city. The analysis and statistical tests were performed by the statistic software SPSS 17.0. A qualitative approach was performed through interviews with users, professionals and members of the health system. Qualitative data were submitted to content analysis performed by the software NVivo 9.0. In the analysis of the content, it was found that coverage of Pap test is insufficient and is concentrated in younger women. The biopsies are equivalent to the amount of the cytology with abnormal results. The severe diagnosis, from both cytology and biopsies, are prevalent in older women. A qualitative approach indicates potentialities: the good reception of the patient, the fast access from both medium and high complexity health services, the active role of municipal health. Weaknesses: the difficulty in scheduling an appointment with a doctor, lack of training to inform the patient about the diagnosis, the encouragement to use emergency care and the overspecialization of the health professionals. It appears from this study that the main gaps for having a complete integrate healthcare system in the investigated city are concentrated in the first level of health care

Este trabalho teve como objetivo avaliar a integralidade no cuidado ao CCU em um município de grande porte populacional e com tecnologia de distinta complexidade disponível. Foi utilizada uma metodologia mista (quanti-quali). Para a abordagem quantitativa utilizou-se a base de dados secundários referentes à citologias e biópsias do sistema de informação municipal e regional. A análise e os testes estatísticos foram realizados pelo software PASW statistic 17.0. A abordagem qualitativa foi realizada por meio de entrevistas semi-estruturadas com usuárias, profissionais e representantes da gestão. Os dados qualitativos foram submetidos a uma análise de conteúdo realizada com o software NVivo 9.0. Na análise dos dados secundários, identificou-se que a cobertura de Papanicolau é insuficiente, sendo concentrada em mulheres mais jovens. As biópsias realizadas são equivalentes à quantidade de citologias alteradas. Os diagnósticos mais graves, tanto de citologias quanto de biópsias, prevalecem em mulheres com idade mais avançada. A abordagem qualitativa indica como potencialidades: o acolhimento, o acesso breve a serviços de média e alta complexidade, o papel ativo da gestão municipal de saúde e como fragilidades: a dificuldade para marcação das consultas na atenção básica, a falta de preparo dos profissionais para dar o diagnóstico, a contra referência tardia por parte do serviço terciário, o incentivo ao uso do Pronto-Atendimento e a formação focada na especialidade. Constata-se neste estudo que os principais gargalos para efetivação da integralidade no município investigado estão concentrados no primeiro nível de atenção à saúde / This study aimed to analyze the completeness in the Cervical Cancer care in a city with a large population and with enough technology health equipment available to the people. It was used a mixed methodology (quantitative and qualitative). For the quantitative approach it was used the database regarding cytology and biopsy exams registered in the city. The analysis and statistical tests were performed by the statistic software SPSS 17.0. A qualitative approach was performed through interviews with users, professionals and members of the health system. Qualitative data were submitted to content analysis performed by the software NVivo 9.0. In the analysis of the content, it was found that coverage of Pap test is insufficient and is concentrated in younger women. The biopsies are equivalent to the amount of the cytology with abnormal results. The severe diagnosis, from both cytology and biopsies, are prevalent in older women. A qualitative approach indicates potentialities: the good reception of the patient, the fast access from both medium and high complexity health services, the active role of municipal health. Weaknesses: the difficulty in scheduling an appointment with a doctor, lack of training to inform the patient about the diagnosis, the encouragement to use emergency care and the overspecialization of the health professionals. It appears from this study that the main gaps for having a complete integrate healthcare system in the investigated city are concentrated in the first level of health care