presented by: julie dudleydate: november 18, 2014
TRANSCRIPT
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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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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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
Community Asthma Initiative:Evaluation of a Quality Improvement Program for Comprehensive Asthma Care
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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
Community Asthma Initiative:Evaluation of a Quality Improvement Program for Comprehensive Asthma Care
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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)
Community Asthma Initiative:Evaluation of a Quality Improvement Program for Comprehensive Asthma Care
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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
Community Asthma Initiative:Evaluation of a Quality Improvement Program for Comprehensive Asthma Care
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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
Community Asthma Initiative:Evaluation of a Quality Improvement Program for Comprehensive Asthma Care
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3. Environmental Remediation Referral to an Integrated Pest Management
exterminator Inspectional Services through the City of Boston
Community Asthma Initiative:Evaluation of a Quality Improvement Program for Comprehensive Asthma Care
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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%)
Community Asthma Initiative:Evaluation of a Quality Improvement Program for Comprehensive Asthma Care
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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.”
Community Asthma Initiative:Evaluation of a Quality Improvement Program for Comprehensive Asthma Care
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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
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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
Asthma Disease Management Program
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Asthma Disease Management Program
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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CCNC Asthma Management “Road Map”
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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CCNC Asthma Management “Road Map”
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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CCNC Asthma Management “Road Map”
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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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
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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
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Thank you for your time!
Questions & Discussion
Contact Information: Julie Dudley
Florida Department of Health Chronic Disease Prevention Program Manager