Date of Graduation

Summer 8-9-2026

Document Access

Project/Capstone - Global access

Degree Name

Master of Public Health (MPH)

College/School

School of Nursing and Health Professions

Department/Program

Public Health

Abstract

Program Overview

This evaluation examines the Upward Health program, a multidisciplinary, community-based care model that partners with Health Plan of San Mateo (HPSM) to provide comprehensive healthcare services for high-risk Medicare and Medi-Cal beneficiaries in San Mateo County, California. The program serves adults with multiple chronic conditions, behavioral health needs, frequent emergency department (ED) utilization, and significant social determinants of health (SDOH) challenges. Through an interdisciplinary team that includes Community Health Workers (CHWs), Nurse Practitioners, Registered Nurses, Licensed Clinical Social Workers, physicians, and Mental Health Nurse Practitioners, Upward Health delivers in-home, tele-health, and community-based services designed to improve access to care, strengthen care coordination, and address medical and social needs. The purpose of this evaluation is to determine whether the program is implemented as intended and whether it improves patient outcomes by reducing avoidable healthcare utilization, increasing access to healthcare and community resources, and improving overall quality of life.

Evaluation Questions

This evaluation seeks to answer several key questions related to program implementation, outcomes, and long-term impact:

●      Is the Upward Health program being implemented according to its intended model?

●      Does participation in the program reduce emergency department visits, hospital admissions, and hospital readmissions?

●      Does the program improve patients' access to healthcare services, community resources, and care coordination while reducing barriers related to social determinants of health?

●      Does the program improve patient satisfaction, healthcare navigation, and overall quality of life while lowering healthcare costs for Health Plan of San Mateo?

Key Findings

The anticipated findings suggest that Upward Health is expected to successfully reach the medically and socially complex population it was designed to serve while demonstrating high implementation fidelity. Approximately 90% of participants are expected to complete initial assessments, 88% are anticipated to receive regular Community Health Worker contacts, and most participants are projected to receive ongoing home visits, tele-health services, care coordination, and referrals throughout the evaluation period. These findings indicate that the program consistently delivers its core services and provides sustained support to patients.

Outcome findings are expected to demonstrate meaningful improvements in healthcare utilization and patient access. Emergency department visits are projected to decrease by approximately 30%, hospital readmissions by 40%, and inpatient admissions by 25% following enrollment. Survey findings are also expected to show improved access to healthcare, increased confidence navigating the healthcare system, stronger connections to community resources, and reductions in transportation, food, medication, and care coordination barriers. Qualitative interviews are anticipated to reveal that trusting relationships with Community Health Workers, proactive outreach, and coordinated interdisciplinary care are key factors contributing to these improvements. Collectively, these findings support the program's Theory of Change by demonstrating how community-based, whole-person care can improve patient outcomes while reducing unnecessary healthcare utilization.

Recommendations

Based on the anticipated findings, the following recommendations are proposed for program stakeholders:

  1. Continue supporting and expanding the Upward Health model if reductions in emergency department utilization, hospital admissions, and readmissions are confirmed through ongoing evaluation.
  2. Strengthen outreach and patient engagement strategies for individuals experiencing housing instability, disconnected phone service, behavioral health crises, or other barriers that limit consistent participation.
  3. Enhance closed-loop referral tracking to monitor whether patients successfully receive community-based services after referrals and identify gaps in available community resources.
  4. Conduct a comprehensive cost-effectiveness analysis comparing program operating costs with reductions in healthcare utilization and expenditures to demonstrate long-term value to Health Plan of San Mateo and other stakeholders.
  5. Continue routine program evaluation and quality improvement efforts by monitoring implementation fidelity, patient outcomes, healthcare utilization, patient satisfaction, and social determinants of health to support continuous program improvement and potential expansion into other Enhanced Care Management populations.

This evaluation suggests that Upward Health's interdisciplinary, Community Health Worker-led model has the potential to improve health outcomes for medically and socially complex patients by addressing both clinical and social needs through coordinated, patient-centered care. Continued evaluation will help determine the program's long-term effectiveness, sustainability, and applicability to other health plans and communities.

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