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
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
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.
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
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
Medical Home Support PCMH Hospitals & ED Specialists Labs & Imaging Community Resource for Chronic Disease Management Rx Home Care / ICM
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
New England Asthma Innovation Collaborative Project Components: Service delivery expansion Workforce development AE-C CHW (Bilingual) Committed Medicaid payers Payer and Provider Learners Community
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
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
CT Sites CAiR (Community Asthma Integrated Resources) Start-up program Childrens Medical Group (Hamden) Covers Greater New Haven Region Little Air Home Expansion of Little Air Program Middlesex Hospital Center for Chronic Care Management Covers Middlesex County care-management/asthma-management care-management/asthma-management
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
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
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
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
Current Numbers Little Air Home REFERREDENROLLED REFERRING PRACTICES TOTAL VISITS (Home and Office) (PCPs & ED)81 CAiR REFERREDENROLLED REFERRING PRACTICES TOTAL VISITS (Home and Office) (17 PCPs & ED)153
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
Little Airs Home Home