1. CMS Innovation Grant CT Asthma Programs PCMH Committee 12/11/13 Michael Corjulo APRN, CPNP, AE-C Veronica Mansfield APRN, AE-C, CCM Community Asthma Integrated Resources Little Air Home

2. CMS Health Care Innovation Challenge $1 billion to implement the most compelling new ideas for delivering the three-part aim:  Improved care  Better health  Lower costs

3. Asthma Regional Council of New England: A Health Resources in Action P rogram HRiA Mission: To help people live healthier lives and create healthy communities through prevention, health promotion, policy and research. ARC’s Mission: To reduce the impact of asthma across New England, through collaborations of health, housing, education, and environmental organizations with particular focus on the contribution of schools, homes, and communities to the disease and with attention to its disproportionate impact on populations at greatest risk.

4. Why a New Model of Asthma Care? Acute Sick Model of Care Too Costly Asthma Care takes time & specialized education PCPs visit time is a barrier PCMH requires this level of care We have the science and medication Need Targeted Environmental Interventions Asthma is the most avoidable cause of hospitalization

5. Chronic Disease Management Medical Home Labs / Diagnostic Imaging Rx Home Care / ICM Hospitals E.D. In Patient Specialists Medical Mental Health Pt Education Care Coordination Community & Culture

6. Medical Home Support PCMH Hospitals & ED Specialists Labs & Imaging Community Resource for Chronic Disease Management Rx Home Care / ICM

7. The Chronic Disease Management Safety Net  Shared Community Resources  Accessible to Medical Homes  Regionally-based  Shift costs from acute care  Not limited by individual payer sources  Address complex chronic disease issues  Pt/Family education and self-management training  Care coordination  Home / environmental assessments and interventions  Teams of specialty trained health care providers  Asthma and Diabetes Educators  Community Health Workers

8. New England Asthma Innovation Collaborative Project Components:  Service delivery expansion  Workforce development  AE-C  CHW (Bilingual)  Committed Medicaid payers  Payer and Provider Learners Community

9. NEAIC Partners: Health Care Providers MA:  Children’s Hospital Boston  Boston Medical Center  Baystate Children’s Hospital RI:  RI/Hasbro Hospital  St. Joseph’s Health Services CT:  Middlesex Hospital (greater Middlesex region)  Children’s Medical Group (greater New Haven region) VT:  Rutland Regional Medical Center

10. NEAIC Partners: Health Care Payers MA:  Neighborhood Health Plan  BMC HealthNet  Health New England RI:  Neighborhood Health Plan, RI CT:  CT Department of Social Services\ASO Other potential partners: MassHealth, Dept of Vermont Health Access, Aetna, Network Health, United Health Care

11. CT Sites  CAiR (Community Asthma Integrated Resources)  Start-up program  Childrens Medical Group (Hamden)  Covers Greater New Haven Region  www.pedicair.org www.pedicair.org  Little Air Home  Expansion of Little Air Program  Middlesex Hospital Center for Chronic Care Management  Covers Middlesex County  http://middlesexhospital.org/our-services/hospital-services/chronic- care-management/asthma-management http://middlesexhospital.org/our-services/hospital-services/chronic- care-management/asthma-management

12. Who Qualifies? Target PopulationEnrollment Criteria High risk asthma High cost /acute care utililization At least 70% Medicaid beneficiaries Up to 30% can be any other payer source (or none) Asthma Diagnosis Ages 2 – 17 years Live in the Greater New Haven or Middlesex County and any of the following in the past 12 month : Emergency Room Use Hospitalization Course of Oral Steroid for Asthma

13. Teams  Team Leaders  PNPs who are AE-C  RNs  Supervise CHWs  Provide Asthma Education  CHWs  Bilingual English and Spanish  MA CHW training program  Asthma specific training  Motivational Interviewing training

14. What Makes This Different?  Fundamental focus on supporting the Medical Home  Think of us like an extension of your practice  NCQA/PCMH, Easy Breathing, NHCMG  Merge clinical expertise with cultural competence  We have the time and resources to address barriers to good asthma control  We do what you want and not what you don’t  Environmental Training and Supplies  Integrated Pest Management  Real-time or prompt communication  Unique reports

15. How This Works  Review Referral  Make appt for one-time clinic visit (1 ½ - 2 hrs)  Detailed history and assessment  Initiate comprehensive education  Report concerns/recommendations to PCP  HV 1  Environmental assessment  HV 2  Deliver supplies and demonstrate use  HV 3  Optimize self-management capacity

16. Current Numbers Little Air Home REFERREDENROLLED REFERRING PRACTICES TOTAL VISITS (Home and Office) 883410 (PCPs & ED)81 CAiR REFERREDENROLLED REFERRING PRACTICES TOTAL VISITS (Home and Office) 765018 (17 PCPs & ED)153

17. Lessons Learned (so far)  Marketing a new program is a lot of work  Diplomatic persistence pays off  Providers  Families  Most families welcome the home visits (& supplies)  Although some are very challenging  Parents have been extremely appreciative  Providers are finding us easy to work with ……outcomes

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