Presented by: Julie DudleyDate: November 18, 2014.

SUCCESSES IN ASTHMA MANAGEMENT: CASE STUDIES FROM BOSTON AND NORTH

CAROLINA

Presented by: Julie Dudley Date: November 18, 2014

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Overview

About Asthma Overview Of National Expert Panel Review - 3 Asthma

Guidelines Review Of Asthma Burden In Florida Case Study 1: Boston’s Community Asthma Initiative Case Study 2: North Carolina Evidence-based

successes Resources

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About Asthma

Asthma is a chronic condition that causes repeated episodes or attacks of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing

The prevalence of asthma is increasing among all populations in Florida and nationally – Medicaid bears a greater burden of uncontrolled asthma

Most people can control their asthma and live active, symptom-free, healthy lives

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National Heart, Lung, and Blood Institute (NHLBI) Expert Panel Review-3 (EPR-3) Guidelines

The Four Evidence-Based Components of Asthma Care by Providers:

1. Assessing and monitoring asthma severity and asthma control

2. Education for a partnership in care (includes self-management education & providing an asthma action plan)

3. Control of environmental factors and co-morbid conditions that affect asthma

4. Medications

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Review of Asthma Burden in Florida:Emergency Department (ED) Visits and Hospitalizations

The following slides will present data for cases with asthma listed as the primary diagnosis ICD-9 Code: 493

Keep in mind: There are more than twice as many cases with asthma listed as a secondary and tertiary diagnosis

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2008 2009 2010 2011 20120

10,000

20,000

30,000

40,000

50,000

Medicare Medicaid Commercial Self-Pay Other

Num

ber o

f Vis

itsFigure 1. Florida Asthma ED Visits by Payer, 2008-2012

Source: AHCA Emergency Department Discharge Data Set6

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2008 2009 2010 2011 20120

5,000

10,000

15,000

Medicare Medicaid Commercial Self-Pay Other

Num

ber o

f Hos

pita

lizati

ons

Source: AHCA Hospital Inpatient Discharge Data Set

Figure 2. Florida Asthma Hospitalizations by Payer, 2008-2012

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8

0-4 5-17 18-34 35-64 65+0

50

100

150

200

172.4

98.9

59.3

36.5

13.1

Rate

per

10,

000

Figure 3. Florida Asthma ED Visit Rates per 10,000 by Age Group, 2012

Source: AHCA Emergency Department Discharge Data Set (All Payers)8

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0-4 5-17 18 - 34 35 - 64 65+0

10

20

30

40

50

35.1

12.9

5.5

15.7

23.0

Rate

per

10,

000

Figure 4. Florida Asthma Hospitalization Rates per 10,000 by Age Group, 2012

Source: AHCA Hospital Inpatient Discharge Data Set (All Payers)9

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Non-Hispanic Black

Hispanic Non-Hispanic White

Other0

50

100

150

129.4

55.4

34.1 33.5

Rate

per

10,

000

Figure 5. Florida Asthma ED Visit Rates per 10,000 by Race/Ethnicity, 2012

Source: AHCA Emergency Department Discharge Data Set (All Payers)10

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Non-Hispanic Black

Hispanic Non-Hispanic White

Other0

10

20

30

40

29.1

14.212.5

8.8

Rate

per

10,

000

Source: AHCA Hospital Inpatient Discharge Data Set (All Payers)

Figure 6. Florida Asthma Hospitalization Rates per 10,000 by Race/Ethnicity, 2012

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Figure 7. Repeat ED Visits and Hospitalizations, 2012

82%

37% of Total Visits and

Total Charges

Single Visits Repeat Visits

Source: AHCA Hospital Inpatient Discharge Data Set (All Payers)

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Among Floridians with Asthma Received an Asthma Action Plan

One out of four adults with asthma (23.7%) One out of three parents of children with asthma

(33.7%) Taken a course or class on how to manage asthma:

One out of 15 adults with asthma (6.6%) One out of 10 children with asthma or their

parents(10.3%)

Source: Florida Adult Asthma Call Back Survey and Florida Child Health Survey

WE AIM TO IMPROVE THESE MEASURES! SO SHOULD YOU!

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Florida Department of Health Asthma Program & The Florida Asthma Coalition

Recently received a grant award from the CDC through August 2019 Maintaining the Asthma-Friendly School & Child Care

Awards Promoting provider compliance with EPR-3

Guidelines Establishing a “Learning and Action Network” for

Florida MCOs Facilitating local, multi-sector, collaborative QI

projects Implementing a home visiting demonstration project

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Asthma Management Success:Case Study 1

Boston’s Community Asthma

Initiative

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Community Asthma Initiative:Evaluation of a Quality Improvement Program for Comprehensive Asthma Care

Project Summary Objective: To assess the cost effectiveness of a QI

program in improving asthma outcomes. Methods: “Enhanced care model” provided to high risk

patients ages 2-18 years of age Context: 4 urban, low-income zip code areas Results:

Reduction in ED visits and Hospitalizations Improved Patient Outcomes Return on Investment: 1.45

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Objective: To assess the cost effectiveness of a QI program in

reducing:ED VisitsHospitalizationsLimitation of physical activityPatient missed schoolParent missed work


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Methods: Urban, low income patients with asthma from 4 zip codes

identified through logs of ED visits or hospitalizations Offered an “enhanced care model” Parent completed interviews conducted at enrollment and

at 6-and 12-month contacts Hospital administrative data used to assess ED visits and

hospitalizations at enrollment and 1 and 2 years after enrollment

Hospital costs of the program were compared with the hospital costs of a neighboring community with similar demographics


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Enhanced Care for One Year Included:

1. Case management (Nurse)

2. Home Visits (Nurse or Community Health Worker (CHW))

3. Environmental Assessment and Remediation (Nurse / CHW with City of Boston and Community Partners)


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1. Case management (Nurse) Coordinated care with primary care and referral

services Obtained clinical releases to allow communication

with providers and case managers (contracted through a community agency)

Conducted standardized interviews with families Established Asthma severity scores Obtained the Asthma Action Plan


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2. Home Visits Provided by a nurse or nurse supervised CHW (Bi-

lingual/bicultural in Spanish) Included:

Asthma EducationEnvironmental AssessmentRemediation materials (HEPA vacuum, bedding

encasements, and Integrated Pest Management (IPM) materials tailored to the needs of the family

Connection to community resources


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3. Environmental Remediation Referral to an Integrated Pest Management

exterminator Inspectional Services through the City of Boston


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Results: Return On Investment to Hospital

1.46 Patient Outcomes at 12 months Compared to

BaselineReduction in:

ED Visits (68.0%)Hospitalizations (84.8%)Limitation of physical activity (42.6%)Missed school (41.0%)Parent / Guardian missed work (49.7%)


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Conclusions: “Cost effectiveness calculations support the

business case for payers to cover… services and materials that are not reimbursed in a fee-for-service system.”

“The Community Asthma Initiative model provides an effective enhanced-care model that could be included in a bundled or global payment system to reduce the cost of asthma.”

“Potential for shared savings for providers and payers.”


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Learn More!

http://www.childrenshospital.org/centers-and-services/programs/a-_-e/community-asthma-initiative-program/overview

Community Asthma Initiative: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care: http://pediatrics.aappublications.org/content/early/2012/02/15/peds.2010-3472.full.pdf+html








http://pediatrics.aappublications.org/content/early/2012/02/15/peds.2010-3472.full.pdf+html






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Asthma Management Success:Case Study 2

Community Care of North Carolina (CCNC)

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Asthma Disease Management Program

Program Need in North Carolina In fiscal year 1998, NC Medicaid program spent more

than $23 million on asthma related care Approximately 14% of the Medicaid population had been

diagnosed with asthma Analysis of Medicaid claims data for Community Care

enrollees demonstrated that the primary reason for both hospital and ED visits for patients under 21 was asthma

Source: Childhood Asthma in North Carolina Report (1999)

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Project Summary Context: A public-private partnership between the state and 14

nonprofit community care networks. Providers within CCNC serve as the “medical home” for low-income adults and children enrolled in Medicaid and the State Children’s Health Insurance Program.

Methods: Local networks and primary care physicians receive supplemental funding for care management and quality improvement initiatives supported by statewide performance measurement and benchmarking activities.

Results: Reduction in ED visits and Hospitalizations Improved Patient Outcomes Cost savings to the state: 3.3 million between 2000-2003


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Methods: Developed and implemented a QI “Road Map” for

networks and participating providersEstablished a Per-Member Per-Month (PMPM) fee

for case managementEstablished a PMPM fee for the regional networks

to support the cost of care management and network administration

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CCNC Asthma Management “Road Map”

1. Build capacity for routine assessment of asthma. Adopt EPR-3 Guidelines Establish an “asthma QI champion” at each practice Implement simple questionnaire to enable providers

to quickly stage the severity Record symptom frequency on a regular basis Record peak flow readings and patient’s personal

best in the medical record / care plan Use Spacers/holding chambers when appropriate

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2. Reduce unintended variation in care. Educate all medical personnel on:

EPR-3 Guidelines proper use of maintenance medications

Offer detailed visits with physicians and staff to review and discuss prescribing histories

Use case managers Assess home environments for smoking and other

asthma triggers Coordinate sharing of information among all

caregivers

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3. Build capacity to educate patients, families and school personnel about asthma.

Use Asthma Action Plans Teach patients with asthma and caregivers how to

properly use peak flow meters, inhalers, spacers/holding chambers

Collaborate with schools and childcare staff Teach family symptom-based management for

children who can’t use peak flow meters

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4. Report outcomes and process measures to all providers and staff regularly.

Developed information system capability to collect, monitor and analyze data for measuring performance

Collect and disseminate information by physician, by practice and by network

Set goals for performance improvement targets Assess performance, encourage efforts to improve

care processes at all levels

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Chart Review Measures

Percentage of patients with a continued care visit that includes an assessment of symptoms

Percentage of patients with an Asthma Action Plan Percentage of patients with an assessment of

environmental triggers Percentage of patients with appropriate pharmacological

therapy

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Claims Derived Measures

Asthma ED Visits: Those with a primary diagnosis per 1000 asthma member-months.

Asthma Hospitalizations: Those with a primary diagnosis per 1000 asthma member-months.

Suboptimal control (beta agonist overuse): Among those with asthma diagnosis, % overusing Beta agonist (4 or more canister fill dates in any 90 day window during the measurement year).

Suboptimal control and absence of controller therapy: Among patients with beta agonist overuse as defined above, % with no dispensed controller medication during the measurement year.

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Practice and Provider Supports

Provider toolkits: EPR-3 Guidelines Office Tools: Asthma Action Plans, Patient

Questionnaires, Asthma Visit Forms to prompt providers on recommended care and patient education

Technical assistance in QI and provider educational sessions through a dedicated pediatrician or family physician leading the asthma initiative

Case management services for patients with asthma

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Results

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Conclusions

Conclusions: “CCNC focuses on improving quality while

containing costs by linking enrollees to a medical home, reforming the delivery system, providing case and disease management services, implementing continuous quality improvement techniques, and utilizing evidence-based practice guidelines and health information technology.”

“The evaluation findings suggest that the program has led to significant improvements in care as well as cost savings.”

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Learn More!

The Commonwealth Fund: http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2009/Jun/1219_McCarthy_CCNC_case_study_624_update.pdf

http://www.ncmedicaljournal.com/wp-content/uploads/2013/09/74505.pdf

http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2009/Jun/1219_McCarthy_CCNC_case_study_624_update.pdf













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Resources for Providers

Healthiest Weight Florida: A Life Course Approach Free 2-Credit Continuing Medical Education Course (CME) http://

www.healthiestweightflorida.com/activities/life-course.html

Asthma and Allergy Foundation of America’s Asthma Management and Education Online Training Free 7-Continuing Education (CE) Credits for Nurses and

Respiratory Therapists http://www.floridahealth.gov/diseases-and-conditions/asthma/_

documents/aafa-training.pdf

http://www.healthiestweightflorida.com/activities/life-course.html



http://www.floridahealth.gov/diseases-and-conditions/asthma/_documents/aafa-training.pdf



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Thank you for your time!

Questions & Discussion

Contact Information: Julie Dudley

Florida Department of Health Chronic Disease Prevention Program Manager

[email protected]

Presented by: Julie DudleyDate: November 18, 2014.

Documents

Transcript of Presented by: Julie DudleyDate: November 18, 2014.