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, 2008-2012 Source: AHCA Emergency Department Discharge Data Set 6

7. 7 Figure 2. Florida Asthma Hospitalizations by Payer, 2008-2012 7

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, 2012 11

12. Figure 7. Repeat ED Visits and Hospitalizations, 2012 12 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  http://www.childrenshosp ital.org/centers-and- services/programs/a-_- e/community-asthma- initiative- program/overview http://www.childrenshosp 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: http://pediatrics.aappubli cations.org/content/early/ 2012/02/15/peds.2010- 3472.full.pdf+html http://pediatrics.aappubli cations.org/content/early/ 2012/02/15/peds.2010- 3472.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 2000-2003 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” 30 1. 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” 31 2. 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” 32 3. 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” 33 4. 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: http://www.commonwea lthfund.org/~/media/File s/Publications/Case%2 0Study/2009/Jun/1219_ McCarthy_CCNC_case _study_624_update.pdf http://www.commonwea lthfund.org/~/media/File s/Publications/Case%2 0Study/2009/Jun/1219_ McCarthy_CCNC_case _study_624_update.pdf  http://www.ncmedicaljo urnal.com/wp- content/uploads/2013/0 9/74505.pdf http://www.ncmedicaljo 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)  http://www.healthiestweightflorida.com/activities/life-course.html http://www.healthiestweightflorida.com/activities/life-course.html  Asthma and Allergy Foundation of America’s Asthma Management and Education Online Training  Free 7-Continuing Education (CE) Credits for Nurses and Respiratory Therapists  http://www.floridahealth.gov/diseases-and- conditions/asthma/_documents/aafa-training.pdf http://www.floridahealth.gov/diseases-and- 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 850-245-4370 Julie.Dudley@flhealth.gov 41