Program Evaluation Home and Community-Based

Program Evaluation

Home And Community-Based Waiver Services (HCBS) program is an assistance that allows reimbursement for certain chronically ill, disable and elderly people who are not otherwise covered by the Medical aid program. The debate over the rising costs of the institutional healthcare has led to the passage of Omnibus Budget Reconciliation Act (OBRA) of 1981. (Miller, 1992). Under the HCBS program, people remain in their homes and communities, and the waivers allow people to receive services that are not covered under the traditional Medicaid program. Since 1981, states have used the autonomy of Section 1915(c) under Social Security Act to establish home and community-based waiver programs. Under this program, the states provide wide range of services to the participants, and the legislation allow states to recognize many individuals who at risks to be placed in the medical facilities in their homes, and communities. (Kitchener, Terence Miller, et al. 2005).The growth of HCBS program is traced back to 1988 when it has been identified that "a disproportionate percentage of Medicaid resources were being used for institutional long-term care." (Duckett, 2000. P 123). Additionally, many residents of both intermediate and nursing facilities frequently report unsatisfactory quality of life. With the increase in the number of deinstitutionalized people who are experiencing the developmental disabilities, many states establish the HCBS waiver program under the "Omnibus Budget Reconciliation Act of 1981 and was incorporated into the Social Security Act (the Act) at Section 1915(c)." (Duckett, 2000. P 123). This statue represents the recognition of states that many individuals are at risks of institutionalizations, and these individuals could be supported in their homes and communities. The HCBS is widely recognized by many states after the U.S. Supreme Court ruled out that states have the obligation to ensure that people with disabilities should not be forced to remain institutionalized when better and appropriate setting is available. The court also indicated that states should provide effective working plan to place qualified people in the less restrictive setting. Under the waiver programs, states can furnish array of services not otherwise covered by the Medicaid program. One of advantages of HCBS is that the participants are able to have bond with their family and friends at costs similar to the institutional care. Under the HCBS waiver, the service is provided to elderly people or individuals who are developmental and physically disables or people who are mentally retarded. The HCBS waiver is also targeted to individuals with specific illness such as people affected with AIDS or children who are technology-dependent.

Different states in the United States have flexibility in designing their HCBS programs. (Duckett, 2000). To implement HCBS program, each state must assure the federal Department of Health and Human Services (DHHS) that it will protect welfare and health of consumers. Under Alaska Home and Community-based Services, the state provides HCBS services for the children and adults experiencing diabetes, and people with experiencing developmental or mental retardation, Epilepsy, Autism, Cerebral Palsy and other people experience related disability.

This proposal formulates the research objective to provide greater understanding on the effectiveness and efficiencies of the Home and Community-Based Waiver Services program in Alaska.

Research Objectives

The research objective is as follows:

To investigate the efficiency and effectiveness of Home and Community-Based Waiver in Alaska.

The proposal explores the ability of the program to increase the number of elderly and disable people who use this program instead of being institutionalized in the hospitals or nursing homes.

Background and need for the Evaluation

Evaluation is the comparison of the impact of the program against the agreed plan. Evaluation reveals what the program has accomplished so far. The evaluation of the program is essential to assist the policy makers and consumers to determine whether the HCBS program is cost effective and is designed to serve the need of the consumers. The evaluation is very critical to assess the benefits and shortcoming of the program since it has been introduced in Alaska. Through critical evaluation of the program, the benefits and shortcoming of the program will be identified and the method to improve the program will be proposed.

The program evaluation focuses on the efficiency, effectiveness and the impact of the program on the consumers. The efficiency refers the extent the inputs such as money, staffs, time and so on have been able to provide appropriate output for the program. Effectiveness is measured as the extent the program has been to achieve its specific objectives. For example, the HCBS in Alaska is designed to improve the health of elderly disable people at costs comparable to Medicaid. Through evaluation, the impact of the program is identified, and this refers to the extent the program has been able make a difference to the problem situation. (Shapiron 2009).

The results of the evaluation is very important, and the results of the evaluation is very useful to examine the extent the program has been able to achieve its target objectives.

Anticipated use of the results of the evaluation

The results of the evaluation are very important, and the use of results will provide the greater understanding on the effectiveness and efficiency of the program. The anticipated use of the evaluation results are as follows:

First, the evaluation results will enhance greater understanding of the Alaska government on the extent the HCBS program has been able to achieve its target objectives. The evaluation will also enable the government to understand whether the program is more cost effective compared to Medicaid program.

Moreover, the evaluation results will assist the government to know the areas where the program needs improvement. In addition, the evaluation results will enhance greater understanding on the importance of the program to the community. The evaluation results will also enhance the greater understanding of the consumers and other stakeholders on the importance of the program.

Stakeholders Involvement

Stakeholder is defined as a person, group or organization that directly or indirectly have interests in the objectives and operation of a program. With respect to Home and Community-Based Waiver in Alaska, the stakeholders are consumers such elderly and, disable people, the government, and the community. Stakeholders involvement is very important to enhance the success of a program. According to UNDP (2009), engagement of stakeholders in a program is very critical to the success of the program. To achieve success in a project, there is a need to engage stakeholders in the planning, evaluating, monitoring, and improving of a program. It is vital to engage the stakeholders to evaluate the progress of a program in order to improve the program performances. The major factor that leads to the failure of a program is lack of stakeholder's involvement. Thus, this proposal will encourage broad and active involvement of the stakeholders. The stakeholders will be involved in the evaluation process of the program, and it is believed that the inputs of the stakeholders will lead to the overall success of the program.

Dissemination plans and anticipated evaluation products.

Effective dissemination plan is very important and it relies on various channels. The disseminate plan will assist the researcher to make the research findings known to the public. The anticipated research findings for this proposal will reveal that the HCBS has been able to achieve its target objectives. For example, the program has been able increase the number of elderly people and disables individuals who participate in the HCBS program. However, the anticipated program results will reveal that the challenges facing the program. The challenges such as escalating increase in the program costs and shortage of staff will be disseminated. The dissemination of these research findings will be through report, conference, electronic communication, journals, website and other information network. The research identifies the dissemination strategy to create the awareness of the findings of the proposal to the stakeholders. The proposal will attempt to consider all these media to ensure that the findings reach wide possible audience. The time frame for the dissemination plan will take approximately 90 days. Table 1 provides the dissemination strategy for the evaluation.

Table 1: Dissemination Strategy for the Evaluation

Broadcast Media

Personal Contact

Academic journals

Clinical specialty associations

Book chapters

Academic detailing

Professional meetings

Informal professional networks

Regular newspapers

Professional meeting

Radio or TV interviews

Workshops

Academic detailing

Professional conferences

Professional conferences

Technical reports

Special interest newsletters

The anticipated evaluation products is to evaluate the project effectiveness and examine whether the program has achieved the desired objectives. Evaluation plan will make use of user's experience to determine the effectiveness of the program. The collection of the feedback on the quality, effectiveness and relevancy of the program will be used for the evaluation plan. The survey will be used for the evaluation and feedback from the website will be used for the evaluation. The email address will also be displayed on the website to receive the feedback. Through the evaluation procedures, the quality of proposal will be monitored.

There are evaluation questions that could guide the program improvement. The use of the evaluation questions will be used to enhance the greater understanding of the stakeholders on the need for future improvement of the program.

C. Evaluation question(s) and aims.

The primary question that will be addressed is to identify whether HCBS program is able to provide service to the target population. The evaluation questions will also be directed to the cost effectiveness of the program. The following evaluation questions are identified:

1. Is the program meet the budget requirements of the 1915 (b)?

2. Has the program generates cost saving?

3. Has the program has been able to deliver quality health service as being stipulated by 1915(b) waiver?

4. Has the program been able to meet the needs of the participants?

a. Operational definitions.

The operation definition for the proposal is as follows:

Assessing the effectiveness and efficiency of the of HCBS program in Alaska.

What are the procedure to evaluate the effective and efficiencies of the HCBS waiver program in Alaska?

Since the proposal will employ both qualitative and quantitative techniques for data collection and analysis, the operational definition for qualitative and quantitative research study reveals that data are collected and analyzed using both qualitative and qualitative methods.

The proposal reviews the previous studies relating to the project. By reviewing the previous studies on the project, the researcher will be able to enhance his knowledge on the effectiveness and efficiencies of the HCBS in Alaska.

Literature Review

The literatures review describes the overview of the HCBS. This section also discusses the method Alaska employs to run HCBS waiver, and the effectiveness and efficiency of HCBS in Alaska are discussed. The challenges facing the state of Alaska in the implementation of the program is also discussed.

Overview of Home and Community-Based Waiver Services (HCBS)

Analysis of the institutional health provision reveals that institutional health provision continues to consume the bulk of Medicaid spending. The Medicaid program is a joint federal-state program to assist certain low income people and the program is large enough to provide standard of care to the needy people. Despite the benefits identified in the program, the program lacks flexibility to respond to various level of care. Meanwhile, the mechanisms have emerged to allow states to apply for waivers to meet the needs of certain group of population. HCBS program emerges due to the mounting pressure by the public that there is a need to find the costs effective method to provide the healthcare service to the elderly and disable individuals in the community. The passage of the HCBS is entrenched in the "Section 2 176 of the Omnibus Budget Reconciliation Act (OBRA) of 1981. Section 2176 created Section 1915(c) of the Social Security Act which authorized Medicaid waivers to provide home and community-based services." (Miller, 1992 P. 163). With the provision of the act, states are able to receive funds for the home and community-based services for the people who will be otherwise would have received the care in a nursing facility. With subsequent amendment, states are allowed to extend the service to certain low-income people such as children infected with AIDS and adults with disabilities. Typically, the HCBS is often viewed as clinical appropriate and is preferred by individual with low income because it is believed that it is cost effective than institutional care services. (Miller, 1992).

Benjamin (2001) argues that HCBS is enacted because it has been estimated that almost 12 millions Americans of all ages require long-term care and majority of those persons needing supportive assistance are elderly people. Typically, the HCBS is to provide home-based services for people with chronic impairments and the personal care assistance include activities such as bathing, dressing, eating, and instrumental activities such as shopping, cooking and housekeeping. The forces that lead to the passage of HCBS include the increase in the number of non-elderly people with chronic impairments and increase in the political pressure to expand the public funded assistance in order to give the participants more autonomy to receive their own care. Moreover, there is a believe that home and community care service approach will be less costly.

A year after the OBRA was enacted; only six states were participating in the program. State of Alaska was among the six states participating in the program. By 1991, Alaska had developed active HCBS program.

Overview of HCBS Program in Alaska

The HCBS waivers approved by the federal government allows Alaska Medicaid to provide expanded service to people who meet the home and community-based service for the specific waiver. In Alaska, the HCBS waivers are extended to the following categories of people:

Adults with Physical Disabilities (APD)

Children with Complex Medical Conditions (CCMC)

Mentally Retarded/Developmentally Disabled (MRDD)

Older Alaskans (OA)

The Department of Health and Social Services (DHSS) manage the HCBS waivers in Alaska. However, Alaska has no entity that administers the HCBS waiver. The Division of Senior and Disability Service (DSDS) oversees the entire operations, and the goal of the waiver is to provide HCBS service for people between the age of 21 and 64 who meet the level of care in a nursing facility. DHSS provides the waivers service through the network infrastructure of nursing facilities. DHSS has assisted in fostering a strong network of home and community waiver service in Alaska. Recipients of HCBS waiver programs enter the home and community-based systems through referrals, nursing facilities, hospitals, and other caregivers. DHSS staff initially performs screening to determine the eligibility of the recipients.

Despite the benefits associated with the HCBS program, there are still challenges associated with the implementation of the program in Alaska. Similar to other states that implement the waiver program, Alaska is struggling to provide long-term care service. The major reason is that there is a growing population of disable and elderly people in Alaska. Moreover, there is escalating costs of implementing the program. Thus, there is a concern that the current program needs to be reviewed to be more cost effective. The report provided by Stauffer (2008) reveals that there is escalating costs of waiver program yearly. In 2005, the overall costs of waiver program in the United States was $23.2 billions and the costs increased to $25.6 billions in 2006 revealing 10.3% increase in the costs between 2005 and 2006. The literatures are reviewed to provide greater understanding on the challenges facing the HCBS waiver program in Alaska.

Challenges of HCBS Waiver Program in Alaska

Since the authorization of the HCBS program, the state Alaska has experienced budget deficit and the deficit is due to the sharply decrease of the state revenue. The budget reduction is affecting all aspects of the state expenditures and quality improvement of the HCBS. In the recent years, Alaska has found itself incapable to deal with the reduced state revenues. The state revenues shortfall has created enormous challenge in securing quality and growth of the HCBS waiver program. (Lakin, & Prouty 2003). In the last 10 years, there is a dramatically increase in the number of HCBS recipients, and the increase is more than 118.1%. At the same time, the state expenditure on HCBS program increases by 870.9%, and there is average of $3,200 state spending per an enrolment in 2009.

The increase in the expenditures on the waiver program is due to the increase in the number of people participating in the program. Moreover, there is a significant increase in the number of people covered under the HCBS. Braddock et al. (2002) argue that one of the major challenges facing the HCBS program in Alaska is the increase in the number of people waiting to be enrolled in the program. In the last ten years, there is an increase in the number of people enrolled in the program. Over the years, the number of people enrolled in the program grows by more than one-third, and the total number of people waiting for the program also grows. There are many factors leading to the increase in the demand for the waiver program in Alaska. First, the demand for services increase as the specialized facilities by which people could receive the waiver program expands. Moreover, there is growth in the flexibility of the service. Typically, the increase is largely due to the increase in the number of people reaching the older ages and many of these people are claiming to participate in the program.

Additionally, shortage of staff is one of the major challenges facing the waiver program in Alaska. It is well recognized that there is a crisis in the recruitment, retention and training of nursing personnel in the United States. Essentially, availability of the nursing professionals is the cornerstone of the HCBS waiver program in Alaska. The challenges in recruiting and retaining the qualified workforce are a major challenge facing the program in Alaska. Typically, shortage of medical personnel is a long-term challenge in the United States. The estimation has shown that the number of medical workforce needed to manage the program will be increased by 58% in the next decade. With the shortage of staff to manage the program, Alaska could face challenges in providing the quality healthcare delivery to the participants.

Hemp, and Braddock (2003) argue that recruitment and retention of direct support staff couple with low wages are among the challenges facing the HCBS waiver program in Alaska. The turnover of direct staff and inability to recruit new staff has been detrimental to the program. The turnover refers to the withdrawal of the staff from the service. With the nature of the service that the staff is required to provide, there is increase in the staff turnover of direct care staff. The low wages giving to the HCBS staff is one of the major factors leading to the difficulties in retaining the qualified staff. Essentially, low wages lead to higher turnover.

Another challenge facing the program in Alaska is inability to monitor the quality of the program. With rapid increase in the number of participants in the program and the shortage of the staff to manage the program, there is a challenge in assuring the quality of the program in Alaska. Kapp (1996) argues that the growth and flexibility of the program have made the quality of the program to become challenging. Between 1992 and 2002, the number of the participants in the state waiver program has increase by almost 300%. With diminishing expenditure on the program and difficulties in recruiting qualified direct care staff, the quality assurance of the program has become challenging over the years.

Summary

Review of the literatures has provided greater understanding on the overview of the HCBS waiver program and how the waiver program is being implemented in Alaska. The review of the literature also reveals the benefits that the program has offered to the aged and the people with disability. Despite the benefits that the program offers to the participants, the program has faced several challenges. Among the challenges facing the program is the shortage of staff, rising costs to run the program and the increase in the number of participants.

The proposal discusses the human subjects protection and informed consent in the next section.

E. Provisions for human subjects protection and informed consent.

To complete this proposal, the researcher will need to use certain number of people as sample population. With the nature of the proposal, the researcher will need to maintain high level of confidentiality. The protection of human subject is highly important before embarking on the population sampling. The research must obtain legally effective informed consents of human subjects. Obtaining legally effective informed consents of the subject is to enhance central protection of the subjects to be used in the research. To abide by the legal procedures, the researcher must disclose the information about the research to the subjects and why the subject needs to participate in the research. To enhance informed consent, there is a need for the critical communication between the subject and the investigator. The communication could be informed of email, telephone conversation or advertisement regarding the research study. For the purpose of Health and Human Service (HHS) regulations, the investigator should seek voluntary informed consents from human subjects before participating in the research study. To enhance ethical consideration of the proposal, the human subject should be in position to decide whether he or she is ready to participate in the research. The informed consent process should ensure that all the critical information regarding the study will be disclosed to the subject or his legally authorized representative. The human subject should be able to determine the risks and potential benefits involved in participating in the research.

According to the HHS regulation, there are seven information a research should convey to each subject:

A description of foreseeable discomforts or risks of the research to the subject;

A description of foreseeable benefits of the research to the subject

A disclosure of appropriate course of treatment that might be advantageous to the subjects

A statement of confidentiality of the personal information of the subject

A statement disclosing whether there is any compensation that the subject is entitled.

A statement that participation is voluntary and refusal will incur no penalty.

An explanation of whom to contact in the case of research incurs injury to the subject. (Health and Human Service 2011).

F. Provisions for addressing cultural issues

To provide high quality research, the proposal will take into account the cultural diversity of the population. The cultural competence is the ability of a researcher to take into account the cultural and diversity of the sample population that would be used for the research purpose. In the recruitment strategies of the sample population that would be used for the research purpose, the researcher will ensure that research is applicable to diverse population. To address the cultural issues, the research will ensure that the minority as well diverse ethic group participates in the research.

G. Design and data collection methods

The research design will employ mixed methods which will combine both qualitative and quantitative techniques. One of the major reasons the proposal employs mixed methods is to integrate the benefits of both qualitative and quantitative techniques in the research. Using mixed methods for research will also address the shortcomings identified in both qualitative and quantitative techniques. The mixed methods will be used as method of data collection and data analysis. The techniques that will be used for data collection would be combination of semi-structured interview and survey. The research findings will be informed of reports, charts, graphs, tables, and data. The sample population will include the patients of Home and Community-Based Waiver Services in Alaska, and the staff of the Department of Health and Social Services in Alaska. The researcher will include diverse ethnic group in the research to address the cultural issues in the proposal. To provide greater understanding on the rational behind using the mixed methods for the proposal, the paper evaluates the proposed methodologies.

a. A description proposed evaluation methodologies

Qualitative research is a method of inquiry where researcher aims to gather in-dept understanding of the phenomenon. The qualitative research aims to understand the human behavior and the reason that governs such behavior. Effective qualitative research enables a researcher to probe into the phenomenon using tools such as observation, and interview. Typically, qualitative research gives valuable insights to the research questions. The qualitative research provides valuable information to the research not previously investigated or the study with scanty secondary research. For example, a research that is difficult to design its meaningful questionnaires survey for data collection, a qualitative research could help in understanding the findings of quantitative research. It is also rich and explanatory in nature.

In-dept interview is a tool that qualitative research employs in gaining understanding into the phenomenon. This involves asking the predetermined questions and probing issues in detail, and encourages the subjects to express their view at length. Qualitative research is advantageous when a research is too complex to be investigated by generating hypotheses. Despite the benefits that could be derived in using qualitative research, the method is subject to some shortcomings. One of the shortcomings of qualitative research is that it is time consuming. Moreover, the relationship between participants and the research may distort the findings. (Charoenruk, 2005).

Contrarily, quantitative research is described in term of empiricism and positivism. The research technique employs formal systematic method to provide findings in numerical method. Unlike qualitative method that employs inductive approach; quantitative method uses deductive approach in the knowledge attainment. Quantitative method tests theory deductively by developing hypothesis and proposes outcome of the study. The quantitative method employs sampling procedure in the data collection by using statistical sampling.

The advantage of quantitative technique is that study sample could be used to develop general laws for the large population. The shortcoming of the quantitative approach is that the use of random-selection usually employed in quantitative approach is time-consuming.

With the weakness and shortcomings identified in both qualitative and quantitative techniques, the proposal employs mixed methods by combining both qualitative and quantitative techniques.

i. Specific qualitative methodology and approach (grounded theory, case study, etc.)

The qualitative approach uses grounded theory in gaining deeper understanding into the phenomenon. With the use of grounded theory, qualitative approach is able to provide holistic focus in attaining deeper and valid understanding of the subject. Grounded theory is a systematic approach of deducting theory from data. The technique in using grounded theory in the qualitative method of data collection is that the researcher collects data through a technique such as interview. The data collected are marked with codes extracted from texts. The codes are grouped into similar concepts, and from the concepts, the researcher formulates theory. The researcher applies the theoretical framework to the phenomenon intends to be studied. (Patricia & Barry 1996).

ii . Quantitative methodology (survey, quasi-experimental design, etc.)

The research methodology in the quantitative approach is by using quasi-experimental, descriptive, correlation and experimental approach. The strength of such methods is that it provides sufficient information about the variables under investigation, and the information is able to provide prediction over the future outcome. Using this approach, the research will have ability to manipulate the independent variables and study its effects over dependent variables. Survey is a technique quantitative method uses to collect data.

b. Sampling

"Sampling is the process of selecting subjects from a population of interest so that by studying the sample we may fairly generalize our results back to the population from which they were chosen" (Trochim & Donnelly 2007 P. 1). The proposal will use systematic random sampling for the sample population. The sample population will be grouped in relation with age, sex, and ethnic group and the researcher will select one out of ten sample populations from each variable. The purpose of using systematic random sampling is to ensure that the proposal covers all interest group and the proposal addresses the cultural issues in the sampling.

i. Description of setting and proposed participants

The proposed participants will be patients of the Home and Community-Based Waiver Services (HCBS) in Alaska. The participants will also be selected from the staff of the HCBS in Alaska. The researcher will also select number of participants for the interview. The age of the participants will be from 18+. The participants will be selected from both sexes. The researcher will randomly select the participants from all ethnic groups. Since the researcher will use survey as a method of data collection, the researcher will distribute approximately 200 survey questions to the participants, it is estimated that the participants will return approximately 50 valid questionnaires. Moreover, the researcher will identify 5 people for the in-depth interview since it is noted that the researcher intends to use the mixed methods for data collection. There is a need to discuss the data collection procedure and measurement of data collection.

c. Measurement and data collection procedures

There are procedures that the proposal will use for data collection. The researcher will employ both primary and secondary research as methods of data collection. As being discussed in the previous section, the primary research will employ both qualitative and quantitative methods. The quantitative approach will use survey questionnaires and while qualitative research will employ in-dept interview to collect data. Using these techniques, the proposal will employ the following method for data collection. For the survey techniques, the researcher will depend on email to collect data from the subjects. Since large number of the survey questions will be distributed through emails, the researcher will depend on the emails to collect the data returned from the participants. Moreover, there are number of participants who will not be able to use emails. Thus, the researcher will distribute about 30% survey questionnaires by hand. The researcher will also collect the filled survey questionnaires from these participants by hands.

To ensure that the participants fill the survey questionnaires and return them on time, the researcher will employ Guba, & Lincoln (2005) approach who argues that there is a need to follow the sample population with telephone. The researcher will follow the sample population with telephone to ensure that the participants return the survey question on time.

The procedure that the researcher will use in collecting data from the interviewees will be through a portable tape recorder. During the interview process, the researcher will record all the questions posed by the researcher and the responses of the participants in the tape recorder. Moreover, the researcher will note some major points on the note pad.

The proposal will also collect secondary data for the research. The secondary data consist of the existing data that another researcher has already collected. The secondary data will be collected from several electronic database such as Science Direct, Emerald journals, and Sage database. The researcher will also search for secondary data from several academic journals. The proposal will source for large percentage of secondary data from health journals. The major reason for concentrating on the health journals to collect secondary data is to provide greater understanding on the effectiveness and efficiency of the Home and Community-Based Waiver Services program in Alaska.

There are measures that the research will employ for data collection.

First, the researcher will check all data for accuracy. The data accuracy will enhance the reliability and validity of the data.

The researcher will also check the data for suspected bias, and all data that include bias will be discarded, and all the secondary data will sourced from the reliable academic journals.

i. Data sources

There are two data sources that would be used for the evaluation questions. The proposal will use data source from the database of Alaska Department of Health and Social Services. This department has collection of state budget on HCBS program. The database also contains the number of the participants enrolled for HCBS in Alaska, and the amount of money state is spending on each participant yearly.

Moreover, the data source will be from the "National Information Centre on Health Services Research and Health Care Technology (NICHSR)." The NICHSR is the world largest medical library and it contains the key data on all state budget of the HCBS program. From the data provided, the researcher will be able to determine whether the program has been able to generate the cost saving. The data from the NICHSR will be used to compare the previous health program for the aged people and disable with the HCBS program. With this comparison, the paper will be able to determine the extent HCBS has been able to achieve cost saving. In addition, the data collected will be able to access whether the HCBS program has been able to deliver quality health service as being stipulated by 1915 (b) waiver.

Identification both Process and Outcome Measures

The process to identify whether the proposal will meet the consumer satisfaction is by using external auditor to determine whether research has been able to meet consumer satisfaction. Moreover, the proposal will also employ survey method to sample the opinion of the consumers. From the feedback from consumers and internal and external auditors, the researcher will be able to determine the extent the research has been able to meet the consumer needs.

The outcome measures will show that the program will be able to generate cost saving as being stipulated by 1915 (b) waiver. The outcome measure will also reveal that the program will improve health of the participants by 30% in the next five years.

The outcome also shows that there will be change in behavior of the medical staff towards the program. The change in bahavior will decrease the turnover of the medical staff by 40%.