The development of a streamlined, coordinated and sustainable evaluation methodology for a diverse chronic disease management program.

BACKGROUND The Northern Alliance Hospital Admission Risk Program-Chronic Disease Management comprises 13 services delivering care to those with chronic disease and older people with complex care needs, who are frequent hospital users. AIMS To develop and implement a system-wide approach to the evaluation of this existing program. METHODS The Northern Clinical Research Centre audited all existing, routinely collected administrative data within the program and then met with each service to develop service specific outcome measures. The evaluators then developed and implemented a system-wide evaluation approach to measure performance in terms of: client profile; access and entry; service efficiency; client outcomes; and hospital demand. RESULTS Data are collected electronically and more than 80% are derived from existing, administrative datasets, minimising staff and client burden. Additional data include client outcomes and a health related quality of life measure. The preliminary twelve month data suggest that clients have the equivalent of 'fair' or 'poor' self-reported health status (n = 862) and the average health utility scores are significantly (P < 0.05) worse than population control data. These analyses reveal, for the first time, that the Northern Alliance Hospital Admission Risk Program-Chronic Disease Management program is targeting appropriate clients. DISCUSSION This methodology will enable many prospective assessments to be performed including; client outcome evaluation, service model comparisons, and cost-utility analyses. CONCLUSION This evaluation approach demonstrates the feasibility of a highly coordinated 'whole of system' evaluation. Such an approach may ultimately contribute to the development of evidence-based policy.