Presentation on theme: "Missouri Asthma Prevention and Control Program"— Presentation transcript:
1 Linking Asthma Care at School and the Medical Home Data, Decision-Making and Improving Outcomes Missouri Asthma Prevention and Control ProgramPaul Foreman, MA, MS, PhD Tammy Rood, PNP, AE-CSherri Homan, RN, PhD Peggy Gaddy, RRT, MBAEric Armbrecht, PhD Benjamin Francisco, PhD, PNP, AEMarch 26, 2012
2 Surveillance in Missouri guided by dataPrevalence*8.8% MO adults current asthma (2010)- up from 7.2% (2000)10.9% MO children current asthmaDisease Severity (Health Service Utilization)*Highest hospitalization rates: ages 1-4Elevated rates until age 14, lower between age 15-44Significant for African-Americans*Missouri Department of Health and Senior Services. Missouri Information for Community Assessment (MICA) and Behavioral Risk Factor Surveillance System
3 Surveillance in Missouri guided by dataPrevalence*19.6% St. Louis City children current asthma (2008)Disease Severity (Health Service Utilization)Significant for African-AmericansER visit rate almost 3x higherRural vs. UrbanER visits for childrenhighest rates in urban countiesHigh hospitalization rates for rural countiesER Rates for Asthma Children (age 0-14), **Missouri Department of Health and Senior Services. Behavioral Risk Factor Surveillance System and MICA.
4 Surveillance in Missouri guided by dataMedicaid (MoHealth Net Data Project)Persistent asthma ages 6-1836.4% received inhaled corticosteroids and national average is 79.8% (Arellano, et al, 2011)24.0% ICS medication possession ratio (MPR) adherence for all ages (SFY 2010)$ 2574 paid for medication per persistent asthmatic child annuallyPoor ICS medication use and adherence contributes to acute care utilization*Missouri Department of Social Services, Mo Health Net
5 Missouri Asthma Coalition (MAC) Successful Partnerships& Promising Interventionsjust do it.Missouri Asthma Coalition (MAC)Established in 2002CDC grant support750 people in networkPartners include:School nursesChildcare consultantsSchool boardUniversitiesAsthma coalitionsFQHCsHealth professionalsmany, many moreInterventions based on EPR3 - improve control and reduce risks and functional limitationsMissouri Asthma Coalition
6 Partnerships leveraged resources MAPCP’s Role: Link statewide and local partnersOur Little Secret : Everyone is welcome, but MAPCP strategically builds partnerships to reach target populationOur Purpose for Partnership: Leverage resources … to the max.HOW DOES PARTNERSHIP IMPROVE ASTHMA CARE?Interdisciplinary Sharing: Expertise and resourcesCoordination: Activities are planned and implemented togetherInnovation: New ideas and collaborations are fostered between stakeholdersPriorities: Partners set priorities for surveillance and interventionsRelevance: Key asthma issues move to forefront of systems-based strategies and public health planningState Plan 2005State Plan 2010Note:CDC’s $3.4 million investment in MAPCP ( ) has helped produce a >$20 million investment from MAPCP partners in activities aligned with the State Plan Putting Excellent Asthma Care Within Reach.
10 just do it.School /Clinic Based IMPACT ProgramsBased on dyad approach – clinic and school district in proximity prepared to deliver careRural and urban school districts identified as having the highest persistent childhood asthma rates and level of health risk in MissouriIdentify targets by matching the zip codes clinic sites of Federally Qualified Health Centers (FQHC) and Asthma Ready Clinics (includes Medical Homes) with local school districtsSchool nurses (17% of 1,600 total) who expressed interest in IMPACT programs after receiving 2011 Missouri School Asthma ManualSchool DistrictClinicChild &Family
11 just do it. Message Type Audience Cost Education & Care based on Real Need + Right Service at a Reasonable CostMessage TypeAudienceCost1) Asthma Literacy conceptsStudent w/asthma (school-based)Low($5-25)2) Key Messages - EPR3 definedPatient and family (medical home)(bundled)3) Risk Reduction and 99401Medium ($40, $20 x 2 = $80)4) Self-managementPatient and family(multiple settings)Medium ($100)Stratified = Intensity “cost” of care is appropriate for burden of disease (not just the dollars already spent on health care)
12 just do it. Education & Care based on Real Need + Right Service at a Reasonable CostMessage TypeProgramReachFunding1) Asthma Literacy conceptsTeaming up for Asthma Control1Kschool nursesCDC/MFH$900K2) Key Messages - EPR3 definedAsthma Ready®Clinics100 ARC, 500 MHMFH/DHSS$300K3) Risk Reduction and 99401Counseling for Asthma Risk Reduction500 Medical HomesDHSS$150 K4) Self-managementABC (caregivers)ACE (school-age)to 5to 12DHSS $100KMFH $100KStratified = Intensity “cost” of care is appropriate for burden of disease (not just the dollars already spent on health care)
14 Successful Strategies & Promising Interventionsjust do it.Surveillance Data Targets InterventionsTo date, a total of 64 health professionals have completed evidence-based asthma training in the priority ZIP-codes.
15 Missouri Asthma Educator Network-Credentialed Health Professionals Successful Strategies& Promising Interventionsjust do it.Missouri Asthma Educator Network-Credentialed Health ProfessionalsMore than1,400 trainedmid-level(6 hours)
22 TUAC Evaluation Methods and Initial Results just do it.TUAC Evaluation Methods and Initial ResultsPre-Post TUAC intervention outcome indicators for these children were derived from 2008, 2009, 2010, 2011Medicaid data:asthma outpatient visitsER visits and hospitalizationsmedication claimsper member per month (PMPM) categorical costsMissouri Department of Elementary and Secondary Education (DESE) attendance and achievement recordsAnalysis for 87 children: After TUAC intervention FEV1 significantly improved by 14.7%, inhalation technique improved significantly, student-reported impairment and smoke exposure declined significantly.
23 New, Compelling Asthma Outcome Variables just do it.New, Compelling Asthma Outcome VariablesACD Acute Care Day ScoreACD is defined as the number of daysof acute care for asthma in a given time periodIf ACD = 66 ER visits6 inpatient days or3 ER visits & 3 inpatient days
24 New, Compelling Asthma Outcome Variables just do it.New, Compelling Asthma Outcome VariablesPOPTProportion (P) of Outpatient visits (OP) to Total visits (T) including OP, ER visits & inpatient daysexpressed from 0 to1where“0” is the worst case scenario (no outpatient visits, all asthma encounters are in acute care settings)“1” is the best case scenario (only OP visits)Example1 OP visit and 9 ER visits1 OP / 1 OP + 9 ER =0.1 POPTOrOnly 10% of asthma encounterswere outpatient visits
25 New, Compelling Asthma Outcome Variables just do it.New, Compelling Asthma Outcome VariablesDPR Daily Possession RateAverage daily amount of drug (i.e., inhaled corticosteroids)available over a dispensing intervalCharting ACD, POPT & DPR to model opportunities for family member, PCP and school nurse messagingThese claims data are available within one month of event for timely actions
26 New, Compelling Asthma Outcome Variables just do it.New, Compelling Asthma Outcome VariablesDPR charts change trajectory of careMicrograms of asthma medication and EPR3 ICS dose ranges are plotted on the y axis by EPR3 guidelinesby age, sub-therapeutic, low, medium, high or very highAsthma ACD (ED and IP days) are plotted on the x axis (time)POPT is calculated and displayed. DPR graphed by actual dispensing interval, by year & 90 dayTrajectory of delivered asthma health care can be analyzed and appropriate interventions prompted by messaging members, PCPs and school nurses
27 just do it.Sub-therapeutic doses of ICS, low PopT, high ACD, high SABA
28 Two ER visits, starts ICS, SABA use drops just do it.Two ER visits, starts ICS, SABA use drops
29 just do it.ACD =1 (ED visit), high SABA, PopT = 0.83, TUAC participation, medium dose ICS
30 Intervention Data Messaging Capacity just do it.Intervention Data Messaging CapacityInitial TUAC assessments are analyzed by EPR3 algorithms to suggest additional assessments and interventions by the school nurseChildren are categorized into three zone classifications of EPR3→Parents and PCPs are alerted by school nurse regarding findings in timely mannerAll clinical interventions are collaborative with goal of moving children into the GREEN zone over time. An expert support system is needed to provide resources, analysis and messaging (ARC)Well ControlledNot Well ControlledVery Poorly Controlled
31 Clinicians Assess Impairment & Risk just do it.Clinicians Assess Impairment & Risk
32 School nurses assess impairment & risk just do it.School nurses assess impairment & risk
33 just do it.Problems and Opportunities: Alignment of School and Clinic to EPR3 Guidelines
34 School Nurse Messages PCP just do it.School Nurse Messages PCP
35 School Nurse Messages PCP (continued) just do it.School Nurse Messages PCP (continued)Objective measures of airflow by digital flow meter : FEV1 (% predicted, personal best, and % change with quick relief medicine)Objective measurement of Inhalation technique : inspiratory flow rate and inspiratory flow timeMedication Adherence by Student Report – using a Respiratory Inhaler Poster Chart : What medicines are available at home? How many missed doses of control medicine? Using a spacer with inhaled MDI medicines?Impairment by Student Report : Activity limitation or sleep disruption due to breathing problems?Tobacco Smoke Exposure by Student ReportForm encourages provider to fax updated asthma action plan to school
36 Calculate percent predicted FEV1 and peak flow just do it.Calculate percent predicted FEV1 and peak flow
37 School Nurse TUAC Follow-Up Form- further actions just do it.School Nurse TUAC Follow-Up Form- further actions
38 School Nurse Actions – Levels of Communication just do it.School Nurse Actions – Levels of CommunicationSend home a Student Asthma Status Report Form: Inform family of asthma events at school – includes subjective and objective measures, encourage communication/follow up with providerCalled and talked to the family about their child’s asthma assessment findingsMet face-to-face with this family to discuss their child’s asthma care at home and schoolCompleted and sent a “School Nurse Report of Student Asthma Assessments” to (name of health care provider)Provided an ICS Star Chart to promote inhaled corticosteroid (ICS) adherence
39 Student Asthma Status Report- from 2011 Missouri School Asthma Manual just do it.Student Asthma Status Report- from 2011 Missouri School Asthma Manual
40 Consent for Communication on Asthma Action Plan just do it.Consent for Communication on Asthma Action Plan
41 Inhaled Corticosteroid (ICS) Star Chart just do it.Inhaled Corticosteroid (ICS) Star Chart
43 just do it.Changing Outcomes for Missouri Children with Asthma: MO Health Net CollaborationIdentify populations of children suffering from the most severe asthmaClaims: high ACD, low POPT, sub-therapeutic ICS, higher cost of careSchool: exacerbations, low FEV1, high impairment, high absenteeismTrain local school and clinic (including medical homes) dyads in EPR3 guidelines for care using standardized curriculaContinuously analyze school & claims data to deploy and stratify interventions to meet their needs and the family circumstancesProduce actionable data for key cliniciansTrack individual and aggregated outcomes and evaluate using advanced scientific methodology
44 just do it.Changing Cost Outcomes for Missouri Children with Asthma: MO Health Net Data Project CollaborationPer member per month (PMPM) costs for children ages 5-18 identified with persistent asthma was $1,497 for 6,577 participants in 2010.Per member per month costs for children ages 5-18 was $1044 for 134 patients of an EPR3-compliant practice in 2010.EPR3-treated group costs were 9.6% higher for ICS medication costs and 23% higher costs for treating co-morbid conditions when compared to population mean.However the total asthma direct costs were 4.7% lower for EPR3-treated group.Remarkably, total asthma medication costs were 33% lower and total cost of care was 30% lower for the EPR3-treated patient group.
45 SHARE CARE for KIDS with ASTHMA in Kansas City just do it.SHARE CARE for KIDS with ASTHMA in Kansas CityAsthma Ready® Communities (ARC) is planning a comprehensive community initiative project named Share Care for Kids with Asthma for the greater Kansas City area in the fall ofARC will deliver standardized asthma self-management education and school nurse training to three participating school districts (27,011 children)ARC will deliver standardized EPR3 guideline training to 200 local Kansas City family practice clinics in those school districts areas surrounding the urban coreARC will support data exchanges between settings for EPR3 compliant care using innovative quality improvement platform
50 New Pharmacist Asthma Training Opportunity just do it.New Pharmacist Asthma Training OpportunityEncounter Management Application – Medication Related Problems
51 Local + Statewide = Sustainable Interventions systems thinking Dunklin Co. (Kennett) pop.= 31,039LOCAL STRATEGY EXAMPLEFramework for Community-based Approaches to Improving Asthma Care for ChildrenSimple, to-the-point, one-page summarySets goals and interventions for integrating efforts in five areas: schools, home environment assessments, primary care providers, hospitals/emergency rooms, and child careKEY CONCEPTSDemonstrate success at local levelKennett Public Schools (Dunklin County)Springfield (Greene County)Experience, testimonials and data drive expansion of successful ideasIdentify statewide policy change opportunities through community-based work (e.g., spacers)Statewide workforce development produces system-level change (e.g., LPHA staff, school nurses)Cultivate local leadershipAsthma School Nurse Award, Missouri Asthma CoalitionGreene Co. (Springfield) pop.=269,630
52 Students Receiving Award for Finishing Asthma Education just do it.Students Receiving Award for Finishing Asthma EducationBenjamin Francisco, PhD, PNP, AE-C Asthma Ready®, University of Missouri