Dignity Health 2MATCH Quarterly Reportterm:name... · 1. I have a steady place to live 2. I have a...

Dignity Health 2MATCH Quarterly Report

December 2019

Assessing the effectiveness of the 2MATCH Project on social

determinants of health and healthcare utilization

Prepared by:

Wendy Wolfersteig, Ph.D.

Grant Yoder, M.Ed.

Micaela Mercado, Ph.D.

Seol Ki, Ph.D.

2MATCH, December 2019

ASU-SIRC 1

Table of Figures

Figure 1 Proportion of Screenings from Target Zip codes................................... Error! Bookmark not defined.

Figure 2 Ages of Individuals Screened for 2MATCH Participation .......................................................................... 6

Figure 3 Income of Those Screened for 2MATCH Participation .............................................................................. 8

Figure 4 ED Utilization ..................................................................................................................................................... 9

Figure 5 Housing Security (n=3,035)............................................................................................................................... 9

Figure 6 Food Insecurity ................................................................................................................................................. 11

Figure 7 Safety Screenings ............................................................................................................................................... 12

Figure 8 Positive Screenings ............................................................................................................................................ 13

Figure 9 Referral Client Gender ..................................................................................................................................... 19

Figure 10 Service Offering Category Frequency (n=5,417) ....................................................................................... 20

Figure 11 Monthly Referral Count (n=5,000) .............................................................................................................. 22

Figure 12 Monthly Unique Referral Client Count (n=657) ....................................................................................... 22

Figure 13 Client Risk Stratification (n=5,000) ............................................................................................................. 23

Figure 14 Intervention Type Count ............................................................................................................................... 24


ASU-SIRC 2

Table of Tables

Table 1 Screenings from GTA .......................................................................................................................................... 3

Table 2 Monthly Screening Totals ................................................................................................................................... 4

Table 3 Screenings by Medical Center ............................................................................................................................. 5

Table 4 Ethnicity of Those Screened for 2MATCH Participation ............................................................................. 7

Table 5 Race of Those Individuals Screened for 2MATCH Participation ................................................................ 7

Table 6 Housing Issues .................................................................................................................................................... 10

Table 7 Navigation Status ................................................................................................................................................ 14

Table 8 Navigation Needs Resolution Proportions .................................................................................................... 15

Table 9 Resolution Duration ........................................................................................................................................... 15

Table 10 Referring Team ................................................................................................................................................. 16

Table 11 Receiving Services ............................................................................................................................................ 17

Table 12 Receiving Organizations .................................................................................................................................. 18

Table 13 Referral Client Age ........................................................................................................................................... 19

Table 14 Service Offering Name .................................................................................................................................... 21


ASU-SIRC 3

Evaluation Implementation Dignity Health obtained funding from CMS (5/1/2017 to 4/30/2021) to develop and implement

the To MATCH, Align Through Community Hubs (2MATCH) program to screen Medicare and

Medicaid beneficiaries seeking health services for unmet social determinants of health needs and to

connect them with appropriate services in the community through an IT solution combined with

patient advocates. In September 2018, as part of the Dignity/ASU Strategic Initiatives research

program, Dignity Health and the ASU Southwest Interdisciplinary Research Center (SIRC), Office

of Evaluation and Partner Contracts began their evaluation of the 2MATCH Align through the

community hubs initiative. During the first year of its funding, Dignity Health worked with other

consultants to accomplish the needed evaluation steps, while also consulting with the SIRC team

throughout 2018. Table 1 outlines various project milestones associated with the 2MATCH Project

in the previous quarter.

Date Meeting Purpose

9/25/2019 Year 2 Start Date for 2MATCH Evaluation

10/10/2019 Presentation at Arizona Health Equity Conference

11/13/19 Roundtable Presentation at American Evaluation Association

11/14/19 Multi-paper Presentation at American Evaluation Association

12/6/19 Presentation at Society of Teachers of Family Medicine

12/17/19 Presentation to 2MATCH Consortium

Zip Codes

As the expansion of the service area for the 2MATCH Program is being processed, this report will include analyses for the initial Geographic Target Area (GTA). The targeted zip codes are as follows:

85003, 85004, 85006, 85007, 85008, 85009, 85015, 85017, 85019, 85031, 85033, 85035, and 85040

Table 1 Screenings from GTA

Zip Code Year to Date Count

85007 109 549

85009 109 540

85015 80 347

85017 57 261

85008 27 207

85040 45 185

85019 28 168

85006 28 163

85003 34 157

85031 20 141

85035 30 137

85033 26 122

85004 9 58

Total 602 3,035


ASU-SIRC 4

Screenings

Since the 2MATCH Program’s inception, there have been 6,781 screening cases created, 990 of

which were duplicates, leaving 5,791 unique screening cases. Table 1 shows the total number of

screenings from each of the 13 zip codes in the GTA for the entire duration of the program. Table 2

shows monthly screening totals for the targeted zip codes as well as all represented zip codes.

Table 2 Monthly Screening Totals

Targeted Zip Codes All Zip Codes Percentage from

targeted zip codes

September, 2018* 5 10 50%

October, 2018 127 246 52%

November, 2018 120 224 54%

December, 2018 63 129 49%

January, 2019 151 381 40%

February, 2019 187 408 46%

March, 2019 211 518 41%

April, 2019 244 607 40%

May, 2019 248 654 38%

June, 2019 205 504 41%

July, 2019 278 699 40%

August, 2019 332 386 86%

September, 2019 323 367 88%

October, 2019 288 355 81%

November, 2019 253 303 83%

Total 3,035 5,791 52%

Figure 1 shows the proportion of screenings which came from the GTA of the 2MATCH Program.

Beginning in August 2019, new screening protocols were implemented to focus on those clients

from the GTA and resulted in a large increase in the proportion of screenings from the targeted zip

codes.

Figure 1 Proportion of Screenings from Target Zip Codes

0%

20%

40%

60%

80%

100%


ASU-SIRC 5

Quarterly Screenings

The Quarterly Screenings section will reflect data collected from September 24, 2019 to December

1, 2019. There were 733 unique screenings completed during this period, and the zip codes targeted

by the 2MATCH Program comprised a total of 602 (82%) of all screenings.

Screening Organizations

In this period, St. Joseph’s Hospital & Medical Center Emergency Department had the highest

number of screenings from the targeted zip codes with 232. Table 3 displays the screening counts

for each medical unit.

Table 3 Screenings by Medical Center

Year to

Date Total

Count

St. Joseph’s Hospital & Medical Center Inpatient 149 951

St. Joseph’s Hospital & Medical Center Emergency Department 232 766

MIHS 7th Ave Family Health Center 95 715

St. Joseph’s Hospital & Medical Center Family Medicine Clinic 65 226

Native American Connections Behavioral Health Services 54 190

Dignity St. Joseph’s Hospital and Medical Center Internal Medicine 5 99

Parsons Family Health Center at Circle the City 2 70

St. Joseph’s Pediatrics 0 14

Valle del Sol, Inc 1st Avenue Site 0 4

Total 602 3,035


ASU-SIRC 6

Screening Demographics

Age

Figure 3 shows the age breakdown for the 599 individuals from the targeted zip codes who provided

their birthdate for the 2MATCH screening. The majority of individuals were ages 18 to 64, with

80% of falling in that age range. Individuals age 65 and older represented 13% those screened in the

targeted zip codes.

Figure 2 Ages of Individuals Screened for 2MATCH Participation (n=599)

Gender

The majority of the 586 individuals who reported their gender on the 2MATCH screening were

female (61%), and the remaining 39% identified as male.

Ethnicity

Over half of those individuals screened for the 2MATCH program identified as Hispanic, Latino(a) or

of Spanish origin. Participants were able to select more than one applicable ethnic group, and Table 4

illustrates the totals for each selection.

8% 80% 13%

0-17 18-64 65+


ASU-SIRC 7

Table 4 Ethnicity of Those Screened for 2MATCH Participation

Ethnicity Total Percentage

No, not of Hispanic, Latino, or Spanish Origin 230 44%

Yes, Mexican, Mexican American, Chicano 221 42%

Yes, Another Hispanic, Latino, or Spanish origin 70 13%

Additional Groups (including Puerto Rican and Cuban) 7 1%

Total 528

Race Over half of those screened as a part of the 2MATCH identified their race as White (65%), and 11%

identified their race as Other. Table 5 shows a detailed breakdown of the race totals.

Table 5 Race of Those Individuals Screened for 2MATCH Participation

Race Total Percentage

White 318 65%

Other 53 11%

Black or African American 74 15%

American Indian or Alaska Native 34 7%

Additional groups (Including Asian or Native Hawaiian

or Other Pacific Islander) 11 2%

Total 2,551


ASU-SIRC 8

Income

Individuals were also asked to report an estimate of their annual household income from all current

financial sources on the HRSN screening tool. There were 427 individuals who provided a response

to this question. Figure 4 provides the household income for the target zip codes as well as all the

zip codes screened. The largest proportion of individuals (36%) reported an income of $10,000 or

less. Less than 1% of individuals reported an income of $75,000 or more.

Figure 3 Income of Those Screened for 2MATCH Participation

<1%

2%

8%

18%

11%

16%

9%

36%

More than 75K

More than 50K less than 75K






Less than 10K


ASU-SIRC 9

Screening Findings

Emergency Department Visits

Individuals were asked “How many times have you

received care in an emergency room (ER) over the last 12

months?” About 78% of individuals who were

screened received care in an ER in the past 12

months. Over half of those individuals visited the

ER two or more times in the past year.

Housing

Individuals were asked about housing stability as part of the HRSN screening tool. Specifically, we

asked individuals “What is your living situation?” Individuals could choose from the following

responses:

1. I have a steady place to live 2. I have a place to live today, but I am worried about losing it in the future 3. I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living

outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)

About 7% of individuals indicated they were Housing Unsure, and 12% of individuals indicated they

had No Steady Housing.

Figure 4 ED Utilization (n=602)

Figure 5 Housing Security (n=546)

35%

44%

22%

One Two or more Zero

7%

12%

81%

Housing Unsure

No Steady

Housing

Steady Housing


ASU-SIRC 10

Housing Issues

The majority of participants (73%) did not select any housing issues, and the remaining 27% selected at least one housing need. Table 6 lists the total of each types of issue individuals identified related to their housing situation. Individuals were able to select more than one housing issue.

Table 6 Housing Issues

Housing issue (number of instances) Count

Lack of heat 21

Lead paint or pipes 25

Oven or stone not working 28

Mold 40

Smoke detectors missing or not working 49

Water Leaks 58

Pests such as bugs, ants, or mice 90

None of the above 440

Total 751

Food

Individuals were asked two questions about food security on the HRSN. These questions asked

individuals about resources necessary to purchase enough food. When asked if the food they had

purchased didn’t last in the previous year, 30% of the 543 individuals who provided a response

shared this was “sometimes true” or “often true”. Additionally, when asked about worrying about food

running out in the past year, 30% of the 543 who responded indicated this was “sometimes true” or

“often true”. Though these percentages are the same, they are slightly lower than for the previous

question.


ASU-SIRC 11

Figure 6 Food Insecurity (n=543)

Transportation

Individuals were asked about access to reliable transportation by

the following: “In the past 12 months, has lack of reliable transportation

kept you from medical appointments, meetings, work or from getting to things

needed for daily living?” A total of 543 individuals provided a

response, and 22% of those individuals indicated that

transportation was a barrier to getting to things they needed for

daily living.

Utilities

Another area of interest was utility affordability. Participants were asked “In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?” A total of 540 individuals provided a response to this question. The majority of participants (88%) were not threatened to have their utilities cut off by a utility company. However, 10% of individuals had received a notice that their utilities would be shut off, and 1% reported their utilities were already shut off.

70%

70%

9%

9%

21%

21%

Within the past 12 months, you worried that

your food would run out before you got money

to buy more

Within the past 12 months, the food you

bought just didn't last and you didn't have

money to get more

Never True Often True Sometimes True

22% missing an appointment,

meeting or work because

of a lack of reliable

transportation

1% reported having their

utilities shut off in the

previous year


ASU-SIRC 12

Safety

Individuals were asked about their feelings of safety and exposure to violence. The majority of

individuals did not report any safety issues. However, 13% of participants indicated that someone

insulted or talked down to them, and 1% shared that this happened frequently. Physical violence was

the rarest form of violence, with almost 4% sharing they experienced this form of violence. Figure 8

outlines individuals’ responses to these safety questions.

Figure 7 Safety Screenings

<1%

1%

1%

1%

<1%

1%

<1%

2%

96%

87%

95%

88%

1%

5%

1%

3%

3%

6%

3%

6%

How often does anyone, including family and

friends, physically hurt you? (n=543)

How often does anyone, including framily and

friends, insult or talk down to you? (n=542)

How oftend does anyone, including family

and friends, threaten you with harm? (n=542)

How often does anyone, including family and

friends, scream or curse at you? (n=1,884)

Frequently Fairly often Never Sometimes Rarely


ASU-SIRC 13

Positive Screenings

Based on participant responses to the screening questions, it was determined if an individual

screened positive for a health-related social need. The data indicate that food was the most

frequently identified need among those screened for the 2MATCH program. About 34% of those

individuals screened “positive” for food insecurity. This was followed by Housing (23%),

Transportation (22%), Utilities (11%), and Safety (3%). Figure 8 highlights the positive screenings for

each domain.

Figure 8 Positive Screenings (n=550)

Qualification for 2MATCH

Based on responses from 602 individuals screened for participation in the 2MATCH program, a

total of 261 individuals or 43% were categorized as high risk. A total of 180 individuals or 27% who

were screened as were identified as low risk.

3%

11%

22%

23%

34%

Safety

Utilities

Transportation

Housing

Food


ASU-SIRC 14

Navigation

Navigation data have been analyzed for the period of September 23, 2018 to December 1, 2019.

There were a total of 950 unique navigation cases created of which 596 (63%) came from the

targeted zip codes. During this period, there were also a total of 2,393 unique navigation needs

identified with 1,143 navigation needs coming from from the GTA.

The majority (80%) of these needs are designated as In Progress with the resolution still pending.

There were 71 navigation needs which had been resolved. An additional 157 cases were deemed

Unresolved, indicating that the navigator attempted to follow up with the case but was unsuccessful,

the individuals opted out of navigations services, or the individual was not available for services.

Table 7 has a breakdown of domain by resolution type.

Table 7 Navigation Status

Unresolved In

Progress Resolved

SDOH Attempt

Failed Optout Unavailable

Resolution

Pending Resolved Successful Total

Food 27 23 5 331 19 9 413

Housing 19 11 4 250 11 2 296

Transportation 17 18 2 209 14 3 263

Utilities 7 15 2 102 7 3 135

Safety 2 4 0 21 2 1 29

Family Community

Support 0 0 1 1 0 0 2

Total 72 71 14 915 53 18 1,143


ASU-SIRC 15

Table 8 shows the percentage of each domain that is either resolved or in progress. All of the

domains, with the exception of Family and Community Support (n=1), have an in progress or

resolution percentage over 80%.

Table 8 Navigation Needs Resolution Proportions

SDOH Percent Resolved

or in Progress Food 87%

Housing 89%

Transportation 86%

Utilities 83%

Safety 83%

Family community support 50%

Total 86%

Navigation Duration

To date, there were 2,393 unique navigation needs created during this period. Of those, 124 cases

were labeled as Resolved. The average time between creating a navigation need case to completing a

case was 77 days. Utility assistance took the shortest amount of time to be resolved averaging 64

days, and safety took the longest amount of time averaging 94 days. Table 9 details the amount of

time it took for a case to be resolved in each domain. No domain took less than two months to

resolve.

Table 9 Resolution Duration

SDOH Average time to

resolution (days)

Food (n=46) 79

Housing (n=24) 71

Transportation (n=29) 84

Utilities (n=20) 64

Safety (n=5) 94

Average 77


ASU-SIRC 16

Referrals

For this section, cumulative referral data collected for the 2MATCH Project will be reported to

provide an overview of staff’s progress in this area. Future reports will provide details for the

specified reporting period. These data reflect the 5,000 total referral cases created over the course of

the 2MATCH Program. Referral data were collected from July 18, 2018 to November 27, 2019. It is

important to note that there were a total of 857 referral cases created prior to the official start date

of the 2MATCH Program (9/28/2018). These cases are included in the analysis. These data include

referral cases from both the Target Area and those outside of this area. SIRC is currently in the

process of determining the best method for identifying those referrals from the targeted zip codes

for future reports.

Referring users

From the 5,000 client referral cases, there were 657 unique Client ID. This means, on average, there

are almost eight referral cases created for each client. There were over 20 referring users who

completed referrals during this period. Three of the Referring Users accounted for 73% of the

referrals (Ochoa, Johnson-Elam, and Hill). A detailed breakdown of the Referring users are shown

in Appendix 1.

Referring Team There were five referring teams identified in the 2MATCH referral data. Two teams, 2MATCH Dignity Health and Native American Connections, accounted for 87.3% of the referrals. Native American Connections handled the most referrals (2,472); however, 2MATCH Dignity Health handled the most unique clients (433). Table 10 provides a breakdown of the referring teams.

Table 10 Referring Team

Referral count Percentage Unique Clients Percentage

Native American Connections 2472 49.4% 105 16.0%

2MATCH Dignity Health 1895 37.9% 433 65.9%

MIHS 415 8.3% 83 12.6%

Parsons Family Health Center 214 4.3% 33 5.0%

DEACTIVATED Villa del Sol

team 4 0.1% 3 0.5%

Total 5,000 100% 657 100%


ASU-SIRC 17

Receiving Services

Data were also collected relating to receiving services. There were 667 unique Receiving Services.

The top 13 services accounted for 24% (1,193) of the total referrals. Table 11 has a breakdown of

the receiving services.

Table 11 Receiving Services

Receiving Services Referral count Percentage Unique

Clients Percentage

Food Bank 166 3.3% 29 4.4%

Emergency Food Assistance 150 3.0% 39 5.9%

Health Care and Social Service

Navigation 145 2.9% 70 10.7%

Affordable Housing 132 2.6% 15 2.3%

ICM Food and Clothing Bank 85 1.7% 11 1.7%

First Southern Baptist Church of

Phoenix - Open Arms Ministry 77 1.5% 14 2.1%

Arizona Pediatric Resources 72 1.4% 4 0.6%

Low Income Housing 72 1.4% 8 1.2%

Emergency Support Services 66 1.3% 4 0.6%

24/7/365 Crisis Line 61 1.2% 6 0.9%

Acts Christian Transitional

Services 58 1.2% 4 0.6%

Phoenix 57 1.1% 6 0.9%

Knight Center 52 1.0% 7 1.1%

Remaining Services (Combined) 3,807 76.1% 440 67.0%

Total 5,000 100% 657 100%


ASU-SIRC 18

Receiving Organizations

There were 432 unique organizations who received clients. The top 15 organizations handled 1,200

(24%) referrals. Cultural Cup Food Bank received the most referrals (n=160), and Keogh Health

Connection (n=70) received the most unique clients. Table 12 shows the top receiving

organizations.

Table 12 Receiving Organizations

Receiving Organizations Referral

count Percentage

Unique

Clients Percentage

Cultural Cup Food Bank 160 3.2% 43 6.5%

Keogh Health Connection 145 2.9% 70 10.7%

Valley Metro 109 2.2% 25 3.8%

Phoenix Human Services Department 99 2.0% 12 1.8%

Pilgrim Rest Baptist Church 77 1.5% 33 5.0%

American Academy of Pediatrics, AZ Chapter 72 1.4% 4 0.6%

Lutheran Social Services of the Southwest 69 1.4% 8 1.2%

St Mary's Food Bank 113 1.4% 13 2.0%

Friendly House Inc 67 1.3% 4 0.6%

Crisis Response Network (CRN) 61 1.2% 6 0.9%

Arizona Department of Health Services

Women, Infants, and Children Program 59 1.2% 7 1.1%

All Tribes Assembly of God Church 54 1.1% 13 2.0%

Arizona Department of Economic Security

Division of Benefits & Medical Eligibility

Family Assistance

54 1.1% 8 1.2%

Chicanos Por La Causa 53 1.1% 8 1.2%

Other Organizations (all the rest combined) 3,800 76.1% 403 61.3%

Total 5,000 100% 657 100%


ASU-SIRC 19

Clients

Gender

Of the 657 unique clients, the majority (60%) identified as Female, 37% identified as Male, 2% did

not provide an answer, and 1% identified as Trans or Non-Binary. The breakdown of referral gender is

shown in Figure 9.

Figure 9 Referral Client Gender (n=657)

Age

In terms of the age distribution of those who received referrals, the largest group was between the

ages of 35 and 54 (43.1%). Nearly 12% were seniors over the age of 64, and 1.1% of individuals

under the age of 18 received services. The ages ranged from 1 to 87 years, and the average age was

46 years old. The age breakdowns are shown in Table 13.

Table 13 Referral Client Age

Count Percentage

0-17 7 1.1%

18-34 166 25.3%

35-54 283 43.1%

55-64 123 18.7%

65+ 78 11.9%

Total 657 100%

60%

37%

2% 1%

Female Male No answer Trans or Non-binary


ASU-SIRC 20

Service Categories A total of 12 service categories were part of the referral database. Clients were able to qualify for

more than one service resulting in 5,000 referral counts. The most common referral category was

Food (39.7%), followed by Housing (23.5%), and Transportation (14.9%). Education was the least

frequently cited service (0.1%). Figure 10 provides a detailed breakdown of the frequency of each

service category.

Figure 10 Service Offering Category Frequency (n=5,417)

0.1%

0.2%

0.4%

0.4%

0.8%

0.8%

3.8%

5.3%

10.3%

14.9%

23.5%

39.7%

Education

Family & Youth

Health

Work

Legal

Goods

Behavioral Health

Social Supports

Financial Support

Transportation

Housing

Food

Service Offering Categories (N=5,417)


ASU-SIRC 21

Service Offering Name There were 195 unique services offered during this period, with a total of 7,659 services total. The

top three services were all related to food (Emergency Food, Affordable Food, and Food Pantries). The 15

most common service offerings accounted for 27.9% of the total number of services offered. Table

14 provides a breakdown of the 15 most frequently identified service offerings.

Table 14 Service Offering Name

Service Offering Name Referral count Percentage

Emergency food 773 10.1%

Affordable food 702 9.2%

Food pantries 664 8.7%

Transportation assistance 495 6.5%

Affordable housing 453 5.9%

SNAP (food stamps) 448 5.8%

Food pantries 443 5.8%

Utility assistance 260 3.4%

Emergency food 251 3.3%

Transportation assistance 242 3.2%

Medical transportation 172 2.2%

Utility assistance 163 2.1%

Housing support services 162 2.1%

Food vouchers 156 2.0%

Homelessness prevention 141 1.8%

Other Service Offerings (Combined) 2,134 72.1%

Total 7,659 100%


ASU-SIRC 22

Referral Date Figure 11 details the number of referrals for each month over the course of the program. The

months with the highest number of referrals were October and November 2018.

Figure 11 Monthly Referral Count (n=5,000)

Figure 12 Monthly Unique Referral Client Count (n=657)

393

341

131

628608

137

354

483

324 322290

139

225 230

176141

78

0

100

200

300

400

500

600

700

31

51

28

54

38

19

31

66

37

59

38

3336

34

38 37

27

0

10

20

30

40

50

60

70


ASU-SIRC 23

Client Population

Clients participating in the 2MATCH Program are stratified into four groups: High-Risk, Low-Risk,

Opt-Out, and Usual Care. The majority (72%) of those individuals receiving referrals were categorized

as High-Risk. An additional 20% of referrals for individuals classified as Low-Risk, 3% opted out of

receiving referrals, and 5% received Usual Care.

Figure 13 Client Risk Stratification (n=5,000)

Intervention Figure 14 shows the counts of each intervention types. These were based on the 657 unique referral

cases. There were a total of 110 referral cases which did not have the intervention type specified.

There were 106 cases with monthly follow-up calls in progress, and 95 cases where the personal

interview was documented. There were only 25 individuals who declined referrals.

72%

20%

3%5%

AHC High-Risk AHC Low-Risk AHC Opt-Out AHC Usual Care


ASU-SIRC 24

Figure 14 Intervention Type Count

2

11

16

24

25

27

28

32

40

53

56

95

106

Re-opened Navigation within 1 year window

Not in Target Zipcode

Personal Interview / Action Plan Scheduled

High-Risk Attempts to Contact

Navigation Declined

2-week Follow-up Complete

Navigation / Action Plan Complete

Personal Interview/Action Plan Completed

High-Risk Lost to Follow-up

Navigation Lost to Follow-up

2-week Follow-Up Scheduled

Personal Interview / Action Plan Documented

Monthly Follow-up Calls in Progress


ASU-SIRC 25

Conclusion There has been substantial progress made in the 2MATCH Program during this period. One area of

improvement has been in the screening procedures used by staff to implement the 2MATCH

Program. The reason for this change was to reduce the substantial number of the screenings from

outside the initial 13 zip codes. Beginning in August, renewed efforts were made to focus on only

those zip codes in the GTA to great effect. Prior to August, 2019, only 44% of those participants

screened as a part of the program came from this GTA. This rate has almost doubled, as no fewer

than 80% of screenings were in the GTA since the implementation of the new screening procedure.

This marks a significant improvement, and progress toward the targets of this program.

There have been a total 602 individuals screened from the GTA since the beginning of this quarter.

Positive screenings in the five SDOH were slightly lower this quarter than the previous time period.

Food remained the most frequently cited need (34%), followed by Housing (23%), Transportation

(22%), and Utilities (11%). There was an increase in the proportion of Safety screenings (3%) during

this period. For this quarter 261 individuals were stratified as High Risk and an additional 161 were

deemed Low Risk.

The findings from the cumulative navigation highlight the challenges the 2MATCH Advocates face

to help address these SDOH. On average, resolving one of these needs takes an average of 77 days.

Resolving safety concerns takes the longest amount of time (94 days on average) and utilities cases

take on average 64 days, the shortest time period. The vast majority of navigation cases from this

period are still In Progress (80%), and only around 6% of the navigation cases are classified as Resolved.

During this quarter, the Referral data were also analyzed. There were 5,000 referral cases created

since the inception of the 2MATCH Program. At this point, these data represent all the zip codes

served by the program. Going forward, efforts will be made to limit the analysis to only those zip

codes in the GTA. The most effective method for doing this analysis will be explored in the future.

These 5,000 referral cases represented 657 clients with unique Client IDs. This indicates that there

are nearly eight referral cases for each client. Since the program begin, Native American

Connections provided the most referrals (2,472), though Dignity Health had the most unique clients

(433). The top receiving services provided to clients were Food Banks and Emergency Food Assistance.

There were 432 unique organizations receiving clients for the 2MATCH Program, and the Cultural

Cup Food Bank saw the most referrals during this period (160 referrals) and Keogh Health

Connection saw the most unique clients (70).


ASU-SIRC 26

Appendices

Appendix 1

Referring user Last Name Referral count Percentage Unique

Clients Percentage

Hill 2,379 47.6% 89 13.6%

Johnson-Elam 717 14.3% 130 19.8%

Ochoa 550 11.0% 89 13.6%

Flores 282 5.6% 88 13.4%

Enriquez 225 4.5% 39 5.9%

Altamirano 175 3.5% 29 4.4%

Torres 142 2.8% 30 4.6%

Corral Martinez 124 2.5% 36 5.5%

Saldana 114 2.3% 72 11.0%

Valenzuela 93 1.9% 16 2.4%

Velazquez 83 1.7% 14 2.1%

Rivas 39 0.8% 5 .8%

Deng 28 0.6% 3 .5%

Nuñez 18 0.4% 7 1.1%

Acevedo 10 0.2% 3 .5%

Amaya Contreras 7 0.1% 2 .3%

Fonseca 6 0.1% 1 .2%

Torrealva 4 0.1% 1 .2%

Grimes 3 0.1% 3 .5%

Total 5,000 100% 657 100%

Dignity Health 2MATCH Quarterly Reportterm:name... · 1. I have a steady place to live 2. I have a...

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Transcript of Dignity Health 2MATCH Quarterly Reportterm:name... · 1. I have a steady place to live 2. I have a...