For every care plan problem related to medical, dental, and/or behavioral health care needs the nurse case manager sets at least one corresponding goal which is intended to improve/resolve that problem. At the six-month intervals (or at time of case closure), the nurse case manager reviews the care plan and evaluates progress toward established goals. Based on this evaluation, goals are determined to be met, partially met, or unmet. The data reflect the degree to which improved access to healthcare services and/or adherence to treatment plans have been achieved.  Q2 data represents a baseline since OAHR reopened after COVID-19 nurse deployments ended in March 2022.  FY 21-22 Q3-Q4 was spent reestablishing referral networks, adapting our program for post-pandemic needs, and conducting outreach. Our first referrals were received in March 2022 with slow expansion over the next 6 months. Assessments typically occur over a 1 month long period, care plan goals created, and then outcome data collected 6 months later (or at time of case closure).  In any given quarter, the denominator will only include those clients who were due for reassessment (at the six-month mark) or whose cases were closed. As a result in Q1 and Q2 there were not many data points as most of our clients had not yet been in the program for 6 months yet.  

Continue through FY 22-23 before evaluating progress and merit of this measure and success in improving healthcare delivery and/or treatment adherence.