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Presented by: Julie DudleyDate: November 18, 2014.

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1 Presented by: Julie DudleyDate: November 18, 2014

2 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

3 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

4 National Heart, Lung, and Blood Institute (NHLBI) Expert Panel Review-3 (EPR-3) Guidelines 4 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

5 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

6 6 Figure 1. Florida Asthma ED Visits by Payer, Source: AHCA Emergency Department Discharge Data Set 6

7 7 Figure 2. Florida Asthma Hospitalizations by Payer,

8 8 Figure 3. Florida Asthma ED Visit Rates per 10,000 by Age Group, 2012 Source: AHCA Emergency Department Discharge Data Set (All Payers) 8

9 9 Figure 4. Florida Asthma Hospitalization Rates per 10,000 by Age Group, 2012 Source: AHCA Hospital Inpatient Discharge Data Set (All Payers) 9

10 10 Figure 5. Florida Asthma ED Visit Rates per 10,000 by Race/Ethnicity, 2012 Source: AHCA Emergency Department Discharge Data Set (All Payers) 10

11 11 Figure 6. Florida Asthma Hospitalization Rates per 10,000 by Race/Ethnicity,

12 Figure 7. Repeat ED Visits and Hospitalizations, Source: AHCA Hospital Inpatient Discharge Data Set (All Payers)

13 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%) Source: Florida Adult Asthma Call Back Survey and Florida Child Health Survey WE AIM TO IMPROVE THESE MEASURES! SO SHOULD YOU!

14 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

15 Asthma Management Success: Case Study 1 15 Boston’s Community Asthma Initiative

16 Community Asthma Initiative: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care 16 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

17 17  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: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care

18 18  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

19 19  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

20 20 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

21 21 2. Home Visits  Provided by a nurse or nurse supervised CHW (Bi- lingual/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: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care

22 22 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

23 23  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: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care

24 24  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

25 Learn More! 25  ital.org/centers-and- services/programs/a-_- e/community-asthma- initiative- program/overview ital.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: cations.org/content/early/ 2012/02/15/peds full.pdf+html cations.org/content/early/ 2012/02/15/peds full.pdf+html

26 Asthma Management Success: Case Study 2 26 Community Care of North Carolina (CCNC)

27 Asthma Disease Management Program 27 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)

28 28 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 Asthma Disease Management Program

29 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

30 CCNC Asthma Management “Road Map” 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

31 CCNC Asthma Management “Road Map” 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

32 CCNC Asthma Management “Road Map” 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

33 CCNC Asthma Management “Road Map” 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

34 Chart Review Measures 34  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

35 Claims Derived Measures 35  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.

36 Practice and Provider Supports 36  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

37 Results 37

38 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.”

39 Learn More! 39  The Commonwealth Fund: lthfund.org/~/media/File s/Publications/Case%2 0Study/2009/Jun/1219_ McCarthy_CCNC_case _study_624_update.pdf lthfund.org/~/media/File s/Publications/Case%2 0Study/2009/Jun/1219_ McCarthy_CCNC_case _study_624_update.pdf  urnal.com/wp- content/uploads/2013/0 9/74505.pdf urnal.com/wp- content/uploads/2013/0 9/74505.pdf

40 Resources for Providers 40  Healthiest Weight Florida: A Life Course Approach  Free 2-Credit Continuing Medical Education Course (CME)   Asthma and Allergy Foundation of America’s Asthma Management and Education Online Training  Free 7-Continuing Education (CE) Credits for Nurses and Respiratory Therapists  conditions/asthma/_documents/aafa-training.pdf conditions/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


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