Successes in Asthma Management: Case Studies

Report
Presented by: Julie Dudley
Date: November 18, 2014
Overview
2






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
About Asthma
3

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
National Heart, Lung, and Blood Institute (NHLBI)
Expert Panel Review-3 (EPR-3) Guidelines
4
1.
The Four Evidence-Based Components of Asthma
Care by Providers:
Assessing and monitoring asthma severity and asthma
control
2.
Education for a partnership in care (includes selfmanagement education & providing an asthma action
plan)
3.
Control of environmental factors and co-morbid
conditions that affect asthma
4.
Medications
Review of Asthma Burden in Florida:
Emergency Department (ED) Visits and Hospitalizations
5


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
Figure 1. Florida Asthma ED Visits by Payer, 2008-2012
50,000
6
Number of Visits
40,000
30,000
20,000
10,000
0
2008
Medicare
6
2009
Medicaid
2010
Commercial
2011
Self-Pay
2012
Other
Source: AHCA Emergency Department Discharge Data Set
Figure 2. Florida Asthma Hospitalizations by Payer,
2008-2012
Number of Hospitalizations
7
15,000
10,000
5,000
0
2008
Medicare
7
2009
Medicaid
2010
Commercial
2011
Self-Pay
2012
Other
Source: AHCA Hospital Inpatient Discharge Data Set
Figure 3. Florida Asthma ED Visit Rates
per 10,000 by Age Group, 2012
8
200
Rate per 10,000
172.4
150
98.9
100
59.3
50
36.5
13.1
0
0-4
8
5-17
18-34
35-64
65+
Source: AHCA Emergency Department Discharge Data Set (All Payers)
Figure 4. Florida Asthma Hospitalization
Rates per 10,000 by Age Group, 2012
9
50
Rate per 10,000
40
35.1
30
23.0
20
15.7
12.9
10
5.5
0
0-4
9
5-17
18 - 34
35 - 64
65+
Source: AHCA Hospital Inpatient Discharge Data Set (All Payers)
Figure 5. Florida Asthma ED Visit Rates
per 10,000 by Race/Ethnicity, 2012
10
150
Rate per 10,000
129.4
100
55.4
50
34.1
33.5
Non-Hispanic
White
Other
0
Non-Hispanic
Black
10
Hispanic
Source: AHCA Emergency Department Discharge Data Set (All Payers)
Figure 6. Florida Asthma Hospitalization
Rates per 10,000 by Race/Ethnicity, 2012
11
40
Rate per 10,000
30
29.1
20
14.2
12.5
8.8
10
0
Non-Hispanic
Black
11
Hispanic
Non-Hispanic
White
Other
Source: AHCA Hospital Inpatient Discharge Data Set (All Payers)
Figure 7. Repeat ED Visits and Hospitalizations, 2012
12
82%
18%
Single Visits
37% of Total
Visits and
Total Charges
Repeat Visits
Source: AHCA Hospital Inpatient Discharge Data Set (All Payers)
Among Floridians with Asthma
13


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%)
WE AIM TO IMPROVE THESE MEASURES!
SO SHOULD YOU!
Source: Florida Adult Asthma Call Back Survey and Florida Child Health Survey
Florida Department of Health Asthma
Program & The Florida Asthma Coalition
14

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
Asthma Management Success:
Case Study 1
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Boston’s
Community Asthma
Initiative
Community Asthma Initiative:
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Evaluation of a Quality Improvement Program for
Comprehensive Asthma Care

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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
Community Asthma Initiative:
17
Evaluation of a Quality Improvement Program for
Comprehensive Asthma Care

Objective:
 To assess the cost effectiveness of a QI program in
reducing:
 ED Visits
 Hospitalizations
 Limitation of physical activity
 Patient missed school
 Parent missed work
Community Asthma Initiative:
18
Evaluation of a Quality Improvement Program for
Comprehensive Asthma Care

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
Community Asthma Initiative:
19
Evaluation of a Quality Improvement Program for
Comprehensive Asthma Care

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)
Community Asthma Initiative:
20
Evaluation of a Quality Improvement Program for
Comprehensive Asthma Care
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
Community Asthma Initiative:
21
Evaluation of a Quality Improvement Program for
Comprehensive Asthma Care
2. Home Visits
 Provided by a nurse or nurse supervised CHW (Bilingual/bicultural in Spanish)
 Included:
 Asthma Education
 Environmental Assessment
 Remediation materials (HEPA vacuum, bedding
encasements, and Integrated Pest Management
(IPM) materials tailored to the needs of the family
 Connection to community resources
Community Asthma Initiative:
22
Evaluation of a Quality Improvement Program for
Comprehensive Asthma Care
3. Environmental Remediation
 Referral to an Integrated Pest Management
exterminator
 Inspectional Services through the City of Boston
Community Asthma Initiative:
23
Evaluation of a Quality Improvement Program for
Comprehensive Asthma Care

Results:
 Return On Investment to Hospital
 1.46
 Patient Outcomes at 12 months Compared to
Baseline
 Reduction in:
 ED Visits (68.0%)
 Hospitalizations (84.8%)
 Limitation of physical activity (42.6%)
 Missed school (41.0%)
 Parent / Guardian missed work (49.7%)
Community Asthma Initiative:
24
Evaluation of a Quality Improvement Program for
Comprehensive Asthma Care

Conclusions:
 “Cost effectiveness calculations support the
business case for payers to cover… services and
materials that are not reimbursed in a fee-forservice 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.”
Learn More!
25

http://www.childrenshosp
ital.org/centers-andservices/programs/a-_e/community-asthmainitiativeprogram/overview

Community Asthma
Initiative: Evaluation of a
Quality Improvement
Program for
Comprehensive Asthma
Care:
http://pediatrics.aappubli
cations.org/content/early/
2012/02/15/peds.20103472.full.pdf+html
26
Asthma Management Success:
Case Study 2
Community Care of
North Carolina (CCNC)
Asthma Disease Management Program
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

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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)
Asthma Disease Management Program
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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
Asthma Disease Management Program
29

Methods:
 Developed and implemented a QI “Road Map” for
networks and participating providers
 Established a Per-Member Per-Month (PMPM) fee
for case management
 Established a PMPM fee for the regional networks
to support the cost of care management and
network administration
CCNC Asthma Management “Road Map”
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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
CCNC Asthma Management “Road Map”
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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
CCNC Asthma Management “Road Map”
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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
CCNC Asthma Management “Road Map”
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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
Chart Review Measures
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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
Claims Derived Measures
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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.
Practice and Provider Supports
36
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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
Results
37
Conclusions
38

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.”
Learn More!
39


The Commonwealth
Fund:
http://www.commonwea
lthfund.org/~/media/File
s/Publications/Case%2
0Study/2009/Jun/1219_
McCarthy_CCNC_case
_study_624_update.pdf
http://www.ncmedicaljo
urnal.com/wpcontent/uploads/2013/0
9/74505.pdf
Resources for Providers
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
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-andconditions/asthma/_documents/aafa-training.pdf
41
Thank you for your time!
Questions & Discussion
Contact Information:
Julie Dudley
Florida Department of Health
Chronic Disease Prevention Program Manager
850-245-4370
[email protected]

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