Table 1 Process and Evaluation Indicators using RE-AIM Framework
RE-AIM dimension | Key question | Settings | Outcome measures | Timeline for monitoring and evaluation | Data source | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
Y1 | Y2 | |||||||||||
Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | |||||
Reach | What is the extent of the community’s participation in CBHIS? | Community | • % of families residing in the catchment area who participated in CBHIS • % of CBHIS participants with a diagnosis of HTN • % of CBHIS participants with uncontrolled HTN • % of CBHIS participants with elevated BP | ✓ | ✓ | ✓ | ✓ | HAS | ||||
What is the utilization of FMHC services by CBHIS participants? | FMHC | • % of CBHIS participants with HTN registered at FMHC • % of CBHIS participants with uncontrolled HTN registered at FMHC • % of CBHIS participants with elevated BP registered at FMHC | ✓ | ✓ | HAS EMR | |||||||
What are the major barriers to accessing care at FMHC? | FMHC & Community | • Barriers to accessing care at FMHC by CBHIS participants with HTN | ✓ | ✓ | FGDs | |||||||
Effectiveness | What is the impact of the PCMH-CBHIS model of care on the management of HTN at FMHC? | FMHC | • % of newly diagnosed patients with HTN from CBHIS • % of newly diagnosed patients prescribed antihypertensive medications within 90 days of identification of elevated BP by CHWs • % of FHMC patients diagnosed with HTN with ≥ 2 annual documented follow-up visits | ✓ | ✓ | EMR | ||||||
What are the barriers to HTN control amongst CBHIS participants registered at FMHC? | FMHC & Community | • Barriers to HTN control amongst patients at FMHC | ✓ | ✓ | FGDs | |||||||
What proportion of patients with HTN received comprehensive care at FMHC? | FMHC | % of patients with HTN with documented evidence of annual: • Diabetes mellitus screening • Depression screening (PHQ-2 score) • Renal function testing • Dyslipidemia screening | ✓ | ✓ | EMR | |||||||
Adoption | What is the CHWs' capacity for ongoing community engagement activities with CBHIS participants? | Community | • Number of educational sessions organized by CHWs • % of CBHIS participants who attend educational sessions • Number of data dissemination sessions organized by CHWs with CAB | ✓ | ✓ | Attendance log sheets of the session | ||||||
What is the compliance of the FMHC clinical team to HTN management guidelines? | FMHC | % of patients receiving guideline-based care: • Counselling on ≥ 1 behavioral risk factor for healthy lifestyle counselling • Choice of antihypertensive medications for newly diagnosed HTN cases | ✓ | ✓ | EMR | |||||||
Implementation | What is the fidelity of the CHWs to follow project-specific SOPs? | Community | • % of appropriate referrals generated by CHWs workers for CBHIS participants with uncontrolled HTN • % of appropriate referrals generated by CHWs for CBHIS participants with elevated BP | ✓ | ✓ | HAS | ||||||
What is the fidelity of the FMHC clinical team to follow HTN management guidelines? | FMHC | • Consistency in prescribing ACE inhibitors/ ARBs to patients with diabetes and diagnosis of HTN • Consistency in annual screening for nephropathy amongst patients with uncontrolled HTN • % of patients with documented evidence of annual CVD risk assessment • Consistency in initiating statins for FMHC patients with WHO CVD risk score ≥20% | ✓ | ✓ | EMR | |||||||
Maintenance | What is the financial impact of implementing the PCMH-CBHIS model of care for patients with HTN visiting FMHC? | FMHC | • Annual implementation cost HTN project at FMHC | ✓ | ✓ | Administrative data (revenue versus expenditure reports) | ||||||