Texas Health Care Evaluations of Non-Medical Services

Overview

Health care providers, systems, and payers are developing innovative ways to identify and address non-medical drivers of health (NMDOH), which have a significant impact on health outcomes. A 2024 issue brief, “Evaluating Texas Health Care Programs Addressing Patients’ Non-Medical Needs,” highlighted the importance of evaluation in this emerging field.

This brief builds on earlier work by reviewing evaluation materials from 42 NMDOH programs in Texas by considering aspects of the Centers for Disease Control and Prevention’s 2024 “Program Evaluation Framework.” The Texas NMDOH Consortium found that most evaluations focus on process improvement and NMDOH outcomes, while assessments of health outcomes and cost-effectiveness are less common. As organizations gain more experience integrating NMDOH into care, evaluating health impact and financial sustainability will become increasingly important.

Evaluation of Non-Medical Services in Texas Health Care

Introduction to Non-Medical Drivers of Health

When it comes to health care, hospitals, clinics, doctors, and emergency rooms usually come to mind as the solutions for health. However, health is shaped by much more than clinical care alone. According to the Texas Health and Human Services Commission, NMDOH are “the conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.” For example, a 2021 study found that when community health workers addressed asthma triggers in the homes of children whose asthma was ineffectively controlled by medical intervention, asthma-related hospitalizations and missed days of school significantly decreased. A 2024 study found that among adults with chronic kidney disease, a tailored food intervention significantly reduced cardiac risk and kidney disease progression compared to medical care alone. As much as 80% of health outcomes are attributed to NMDOH according to the County Health Rankings model of health.

Recognizing this impact, health care payers, systems, and providers are increasingly screening for and addressing the NMDOH needs of their patients. The Texas NMDOH Consortium has identified over 150 NMDOH programs across the state, which are documented in the NMDOH Program Index. These programs address a variety of NMDOH, including food and nutrition, transportation, housing, and legal services.

Importance of Evaluation

Investing in NMDOH interventions is important for improving health outcomes, but for investments to be sustained, health care professionals, insurance providers, and policymakers need to know if these interventions are successful. Thus, evaluation is a critical practice to support NMDOH efforts.

Evaluation is a systematic approach to learning and refining a program’s processes and effectiveness. It provides valuable insight into what aspects of a program are functioning well or how programs can be improved. As a result, evaluation also helps mitigate the risk of allocating resources for initiatives that have uncertain or suboptimal impacts.

Health care organizations use evaluation to justify their program investments, refine their approach, and identify best practices for maximizing impact. On a broader scale, evaluation builds the evidence base needed to inform health care policy and support sustainable funding for NMDOH initiatives.

Because the integration of NMDOH screening and services in health care is relatively new, evaluation standards and practices are still being developed, creating a dynamic space for exploring different approaches. As this field develops, examining how evaluations are conducted by health care programs addressing non-medical needs is crucial. Ultimately, evaluation is key to advancing the NMDOH field as a whole. 

Program Evaluation Review

This brief examines the evaluation materials from programs listed in the Texas NMDOH Consortium’s NMDOH Program Index. The review found that approximately half of the 150 programs in the index had conducted an evaluation of their program. Materials from 42 of the 70 evaluated programs were obtained, and their approaches and structures were reviewed based on the following three categories:

• Evaluation purpose explores why an evaluation was conducted.
• Evaluation design through example case studies describes how an evaluation was conducted.
• Evaluation results characterize what was discovered from the evaluation.

These evaluation categories were developed through an iterative process that included a review of the evaluation literature, discussions among the writing team, and repeated reviews of the evaluation materials.

Evaluation Purpose, Design, and Results

Evaluation Purpose

The evaluation purpose reflects the types of questions addressed in the program evaluations. Evaluation purpose was categorized into process, impact, and cost-benefit evaluations:

• Process evaluations examine details of program implementation, such as the number of people served, quantity of services provided, participant characteristics, and/or client feedback.
• Impact evaluations examine program outcomes and effectiveness.
• Cost-benefit evaluations examine the program’s delivery price relative to the impact change.

The review found that some program evaluations considered more than one purpose, which led to a total of 46 evaluation purpose categorizations: 20 process, 21 impact, and 5 cost-benefit.

Evaluation Design Case Studies

Evaluation design refers to the approach used to conduct the evaluation and often includes consideration of key factors such as:

• Defining a clear evaluation purpose: What does the evaluation aim to learn?
• Selecting appropriate methods: Does the approach test the evaluation question?
• Ensuring reliable data sources and collection methods: Where will the information originate, and how will it be gathered?

To illustrate evaluations with these design features, this brief describes two case examples.

Case Example 1: Medical-Legal Partnership (MLP)

This medical-legal partnership (MLP) program integrates legal services within an urban primary care clinic to address health-harming legal needs (HHLNs). Those served by this program face systemic barriers to legal assistance, impacting their overall health and well-being.

To assess the impact of this MLP program, the program’s evaluation was conducted asking: Does an immediate referral to an MLP — compared to a six-month waitlist — improve mental health, health care utilization, and quality of life (QOL)?

The program used a randomized controlled trial (RCT) design to evaluate impact. Participants were low-income adults who were identified as having HHLNs, such as unsafe housing, domestic violence, lack of adequate insurance, and discrimination. By randomly assigning participants to immediate referral versus a six-month waitlist — comprising the control group — the evaluation team could assess whether earlier access to legal support improved health outcomes.

The RCT approach strengthened the program’s evaluation by reducing bias and ensuring that outcomes could be attributed to the MLP intervention. Additionally, the evaluation incorporated multiple outcome measures and periodic follow-up assessments.

Case Example 2: NMDOH Housing Program

This program provides housing support for unhoused patients with conditions that limit their ability to work or perform daily activities.

To assess its impact on health care and criminal justice contacts, the program’s evaluation was conducted, asking: Does providing stable housing reduce arrests, emergency room (ER) visits, and overall costs?

The program evaluated the return on investment (ROI) based on preexisting health information, county-level criminal justice data, and utilization management data. The evaluation population consisted of those receiving housing services through the program and a comparison group of individuals on the program’s waitlist. In tracking utilization rates for both groups, the evaluation measured the program’s effects by calculating cost savings and reductions in arrests, ER visits, and hospitalizations.

Evaluation Results

Evaluation results describe the types of reported outcomes. These results were found to focus on five distinct types:

1. Program operations focus on program delivery metrics, such as the number of people served, retention rates, or services delivered.
2. Participant satisfaction considers participant feedback on their experience with the program, such as their insights on services provided.
3. NMDOH outcome measures changes in NMDOH, such as increased consumption of fruits and vegetables or improved access to legal services.
4. Health outcome concerns changes in health indicators, such as weight or blood sugar levels.
5. Cost outcome calculates financial metrics, such as cost per participant or cost savings from averted health care encounters.

Slightly over half, 22 of 42, of the programs’ evaluation materials included results. Some programs reported multiple result types, leading to 28 total categorizations: 10 for program operations, 1 for participant satisfaction, 8 for NMDOH outcomes, 5 for health outcomes, and 4 for cost outcomes.

Review of NMDOH Program Evaluations

As NMDOH interventions are implemented in health care, evaluation will play an important role in fostering continuous quality improvement and justifying sustaining service delivery. This review offers a glimpse into current evaluation efforts being made by NMDOH programs in Texas and sheds light on opportunities for improvement.

This brief’s review found that across a selection of Texan NMDOH programs, process evaluations were common, with program operations being the most frequent result type. This aligns with a previous review of NMDOH programs, which found that evaluations primarily assessed program design and implementation. Given the lack of established best practices and the innovative nature of NMDOH programs, assessing implementation is a practical first step in evaluation.

Some program evaluations went a step further by examining NMDOH outcomes, such as increased physical activity or improved nutritional intake. These impact assessments test whether NMDOH services are meeting participants’ needs. However, they tended to stop short of measuring changes in health outcomes, such as weight, blood sugar levels, or blood pressure, which NMDOH interventions ultimately aim to improve. As organizations gain more experience in delivering NMDOH programs, they will be better positioned to evaluate their health impact and cost of delivery as well as demonstrate the value of the intervention.

Cost-benefit evaluation was the least common evaluation purpose. While it may be premature for early-stage MNDOH programs, assessing cost-effectiveness will be crucial for making informed decisions about obtaining and sustaining NMDOH investments.

With evaluation design, a well-structured, rigorous approach is important for producing reliable and useful findings for program leads, stakeholders, and participants. Rigorous evaluation is defined by thoughtful planning and implementation rather than a particular methodology. As case example 2 shows, an RCT is not always necessary for a high-quality evaluation. When an RCT design is impractical or unnecessary for the purpose of the evaluation, alternative approaches can still yield meaningful insights.

One key evaluation design recommendation is to consider the program’s unique context and to leverage its resources effectively when developing an evaluation procedure. The evaluation context includes budget, timeline, setting, and data sources. In a nascent and varied field such as NMDOH, finding creative and rigorous ways to answer critical evaluation questions is helpful for ensuring that insights remain credible, actionable, and relevant.

Conclusion

Evaluation is essential to improving and sustaining NMDOH interventions. This review reflects the nascent integration of non-medical services into health care. While most evaluations now focus on implementation, assessing impact and value will be crucial as programs mature. A key next step is identifying the supports needed for programs that have not yet begun evaluation. Addressing barriers to starting and conducting well-designed evaluations will strengthen the field and enhance the effectiveness in delivering NMDOH services that improve health.

This publication was produced on behalf of Rice University’s Baker Institute for Public Policy. Wherever feasible, the material was reviewed by external experts prior to its release. Any errors are the responsibility of the author(s) alone. 

This material may be quoted or reproduced without prior permission, provided appropriate credit is given to the author(s) and Rice University’s Baker Institute for Public Policy. The views expressed herein are those of the individual author(s) and do not necessarily represent the views of Rice University’s Baker Institute for Public Policy.