Maine AAP: Shared Vision for Asthma Quality Improvement: We “Can” Get There from Here! Amy Belisle, MD, CMMC Barbara Chilmoncyzk, MD, MMC Michael Ross, MD, EMMC

I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

State Quality Improvement Strategic Plan Connect Pediatric Practices together through the AAP to work on Quality Improvement Focus on collecting data to improve care MYOC Oral Health Risk Assessment Collaborative Medical Home Partnership Chapter Quality Network (CQN) Asthma Pilot Project

CQN Asthma Pilot Sites MAINE OHIO OREGON ALABAMA

Maine Sites Kennebec Pediatrics, Augusta Franklin Health Pediatrics, Farmington Lake Region Pediatrics, Windham Maine Coast Pediatrics, Ellsworth Intermed Pediatrics, Portland and Yarmouth Bowdoin Pediatrics, Brunswick BBCH Pediatric Clinic, Portland CMMC Pediatrics, Lewiston Medical Home Sites Husson Pediatrics, Bangor Winthrop Pediatrics Westbrook Pediatrics Allergy and Asthma Associates of Maine

How Did I Get Here?

Lesson #1: Quality Improvement is like a Japanese Adventure

Lesson #2: Follow the Tour buses

What is the Quality Gap? The gap between the care we know is best and our ability to deliver it, every time, to every patient in the way they need it.

Defining the Gap: Asthma Affecting nine million children, childhood asthma is the most common serious pediatric chronic disease. The incidence of pediatric asthma continues to grow; it accounts for 14.7 million missed school days a year and 44% of all asthma hospitalizations[1][1] Maine asthma rate 14.6% lifetime [1][1] American Academy of Allergy, Asthma and Immunology. asthma_statistics.stm

Asthma in Maine Asthma current prevalence in Maine 1 : –128,000 persons; 28,000 children are currently affected Asthma Burden in Maine : –8000 Emergency Department visits 2 –Asthma remains the leading cause of school absenteeism. –Children with asthma are more likely to report being in fair or poor health than those without asthma (27.9% vs. 6.9%). –Young children (<4 years) are the most likely to be hospitalized –In 2007, approximately 30% of children with asthma in Maine reported activity limitations, trouble sleeping and at least 1 emergency department visit for asthma. –40% of Maine’s kindergarten and 3 rd grade students with asthma had not received an action plan 1.The Burden of Asthma in New England a report by the Asthma Regional Council (ARC) The Burden of Asthma in Maine 2008, Maine CDC/HHS

Socioeconomic and Racial/Ethnic Disparities Asthma rates are less in high school graduates than non-high school graduates ( 10.4% vs. 15.7%) Asthma increases in households with $25,000 Maine Care recipients have higher rates of current asthma than those with other insurance ( 19% vs. 8%) Children Enrolled in Head Start were more likely to receive treatment for asthma than any other health condition Burden of Asthma in Maine 2008 CDC/HHS

Out in the Woods In 2005, over 60% of Maine’s 1.3 million residents lived in a rural area compared to 21% in US Highest ED visits In Aroostook and Washington Counties Highest Hospitalizations are in Penobscot and Washington Counties The Statewide Maine Asthma Plan, April 2009

Why is there a gap? Too busy, Too little time Low reimbursement Absence of systems of care Reliance on memory Poor guideline compliance Etc…..

Asthma Fatigue C o n t i n u e t o w o r k o n N H L B I g u i d e l i n e s

NHLBI Guidelines: 2007 Update to Asthma Guidelines Emphasizes the importance of asthma control Introduces new approaches for monitoring asthma The AAP trying to spread guidelines and help with implementation  Decrease gaps in care  Help move towards optimal care for children with asthma

Optimal Care >90% of patients have “optimal” asthma care (all of the following) assessment of asthma control using a validated instrument stepwise approach to identify treatment options and adjust therapy use a structured encounter form written asthma action plan patients >6 mos. of age with flu shot (or flu shot recommendation)

Global Aim Specific Aim Maine’s Aim Statement Global Aim We will build a sustainable quality improvement infrastructure within our chapter to achieve measurable improvements in the health outcomes of children within our member practices. Specific Aim From April 2009 to November 2010, we will lead a quality improvement collaborative and achieve measurable improvements in asthma outcomes with the participating 10 to 15 practices by improving use of the NHLBI/NAEPP guidelines and the documentation of quality care.

Maine’s Aim Statement Goal: 90% of practices will achieve 70% optimal care on patients seen by September Goal: 90% of practices use a structured electronic or paper asthma encounter tool 80% of the time by September Outcome Goal: 90% of practices will have at least a yearly ACT score documented in 50% of their patients > 4 years old by September 2010.

Maine’s Aim Statement: Long Term Goals Goal: All practices involved in this collaborative will continue to use a population based registry beyond the time of this grant. Goal: The AH! Asthma Health evidence based asthma tools will be used by member practices. Goal: Certified asthma educators will be available to all member practices. Goal: A committee of AAP members experienced in quality improvement will be charged with infrastructure development in the organization; this will include identifying funding sources for activities. We will have semiannual reporting of QI activities at Maine AAP Fall and Spring conferences for all of its members. Goal: The Maine AAP will partner with MaineHealth, MaineCare, the Maine CDC, Maine based Health Insurers and other organizations interested in child health improvement (such as the Maine Lung Association, the Maine Immunization Collaborative or the Maine Children's Association) to develop a sustainable approach to quality improvement in our organization.

Change is good, but Don’t reinvent the wheel Barbara Chilmoncyzk,MD MaineHealth AH! Asthma Health Program

Why should we be involved?

What is AH! A MaineHealth multidisciplinary program started in 1998 designed to improve the diagnosis and management of asthma 4 Key components: –Public policy – Education –Public Awareness – Outreach The education focus: –Formation of Partnerships with patients and providers. –Standardization of patient care and education –1:1 Self management training –Monitoring of outcomes. The defined measures: –Systems measures: hospital admissions, ED visits, LOS –Process measures: classification, controller meds, #’s seen, hospital / ED visits, flu vaccines –Outcomes measures: missed work and school, QOL indicators (e.g.ACT) Continual effort to improve / change (new guidelines, obesity, COPD)

AH! Program Model

AH! Asthma Health tools

Pediatric Population Self-Reported ED Visits (in the last 6 months) n = 193 Pre Education Post Education 22.2% 4.6%

Pediatric Population Overnight Hospital Stay n = 193 Pre Education Post Education 23.8% 0.0%

Pediatric Population Parent Missed Work (in the last 6 months and among those eligible) n = % 9.8%

CIR All Process Components Office Visit80%+ 1% Severity Class65%+15% Controller Med95%+ 1% Asthma Plan59%+ 4% Tobacco Doc.93%+ 4% CIR MaineHealth PHO Quality initiative

PHO Means

EMMC/Husson Pediatrics Asthma Initiative: A Story of Achievement Michael A. Ross, MD, FAAP

Areas of focus  Improve to data collection: staff awareness  BMI  EMR (Centricity) Protocol reminders:  Asthma Management Plans  Flu Vaccine  Active/passive Smoke exposure  ACT/other Asthma tools Roll-out of Asthma assessment tools (ACT) Registry implementation

Centricity protocol form: Increased and streamlined data collected by empowering MA staff. Physician/Provider review.

Asthma Tools: Introduction of the ACT For children unable to receive the ACT, development and implementation of other asthma metrics: -Number of symptom free days -ED visits over the last year for asthma -Admissions over the last year for asthma -Use of SABA over the last month

Smoking Data Accuracy: Smoking status Observation term cleaned up via use of standard Centricity form. Previously, had utilized data from non-trackable Well-child care forms.

Immunizations: Review of immunization data, via custom Centricity form. Phone/mail follow-up through systematic review of “NPPS Asthma list” mid-season. Form still in Development Two Mass-patient Mailings so far. Provider-dependent outreach Currently Investigating use of mass-phone system

Asthma Action Plan NPPS asthma protocols prompt the printing of Asthma management plan. Form has gone through one revision to be interchangeable with State of Maine-endorsed Asthma-school plan.

Data: Old vs. New Delta Total Number NPPS Asthmatics (+) 187 patients (+ 18.1%) Does patient have a documented Asthma ed. Plan? Not Done68.2% (+) 68.2% Has a measuring tool been used for persistent- asthmatics (ACT)? Not Done17.8% (+) 17.79% Is there Passive smoke exposure Not Done85.6% (+) 85.6% Is there active smoke exposure? 88%*85% (-) 3 %

Data: Old vs. New Delta BMI76.8%84.5%(+) 7.7% Documented use of Controller Meds for Persistent Asthmatics 94.5%98%(+) 3.5% Influenza68%65.7% *-2.3%* Office visit/year87.9%94%(+) 6.1 Severity classification80%99.32%(+) 19.32%

Data –Practice Graph

Data – Graph by provider

Data: Use of protocols NPPS: Protocols and Tools used EMMC Other: Protocols and Tools not used Total Number Asthmatics:1034 Practice A: 39 Practice B: 126 Practice C: 174 Does patient have a documented Asthma ed. Plan? 68.2%Not trackable Has a measuring tool been used for persistent-asthmatics? 17.79%Not trackable Is there Passive smoke exposure?85.6% Practice A: 61.5% Practice B: 31% Practice C: 44.8% Is there active smoke exposure?85% Practice A: 59% Practice B: 39% Practice C: 51.2%

Data: Use of protocols Protocols and Tools usedProtocols and Tools not used BMI recorded?84.5% Practice A: 88.6% Practice B: 77.78% Practice C: 75.82% Documented use of Controller Meds for Persistent Asthmatics? 98% Practice A: 100% Practice B: 100% Practice C: 50% Influenza vaccine given?65.7% Practice A: 35.9% Practice B:19.8% Practice C: 26.4% Office visit/year?94% Practice A: 84.6% Practice B: 5.6% Practice C: 81.6% Is there a Severity classification?99.32% Practice A: 20.5% Practice B: 5.6% Practice C: 6.3%

Data – use of Protocols

Assessment: Significant Improvement in Most Areas  Distribution of Asthma Action plan to patients  Rollout of Asthma Assessment tools  Determining values of Active and Passive smoke status  Obtaining patient BMI  Use of appropriate controller Meds for persistent asthmatics  Ensuring at least 1 office visit/year for all asthmatics  Determining Asthma severity classification

Areas of future development  Increase flu vaccine frequency/track flu-vaccine refusals  Develop specific AAP-based asthma-encounter form  Roll-out Husson Pediatrics asthma program to other EMMC practices  Increase use of Asthma Control Test

Asthma Care a Year From Now Healthier patients and empowered families Engaged providers and staff employing asthma guidelines Utilizing electronic records to improve quality Efficient office systems that benefit from planned care Reduced cost The best care for every patient, every time