1. 1 CommunityCARE Quality Unit Achieving Better Care for Asthma

2. 2 Vested Interest The Office of Public Health Nursing Services Continuing Education Program and the Dept of Health & Hospitals Quality Unit ensures objectivity and non-bias in all of its activities. Presenters have no financial interest or relationship with manufacturer’s and /or providers of commercial products and/or services discussed in this educational activity. It is the intent of this disclosure to ensure that listeners are provided with information on which they can make their own assessments.

3. 3 Presentation Objectives By the end of this presentation, you should: Acquire knowledge about the prevalence of asthma in the Medicaid Population. Understand how Louisiana’s Asthma HEDIS measures compare to national average Know the effects of direct and 2nd hand tobacco smoke exposure on asthma Be familiar with the Asthma Change Package and the Chronic Care Model

4. 4 CommunityCARE CommunityCARE, a primary care case- management program (PCCM), is a comprehensive, community-based health care delivery system with preventive and primary health care at its foundation. The CommunityCARE Program has an established CommunityCARE Quality Unit that conducts Quality Performance Improvement (QPI) projects.

5. 5 CommunityCARE 789 CommunityCARE Providers 1,519 physicians 319 physician extenders 632, 972 linkages 678,751 eligible population

6. 6 Goals of the Quality Unit To conduct Quality Improvement Projects To promote healthy behaviors in our Medicaid population resulting in improved health outcomes. Improve medical home management by providing education, office management tools, and utilization data to providers. Develop patient self-care through education.

7. 7 QIP Structure Identification Stratification Outreach Intervention How do you identify the relevant population? How do you assign risk within the population? How do you reach the target population? How do you improve clinical outcomes?

8. 8 Why Asthma? Asthma is the most common, chronic disease of childhood. Asthma can be controlled not cured. Children living in poverty and/or inner cities have higher rates of hospitalizations and mortality from their asthma. Proven best-practice models that demonstrate improved health and cost savings. (Pediatric Asthma: Promoting Best Practice Guide for Managing Asthma in Children)

9. 9 How Common is Asthma? Approximately 20 million Americans have asthma Nine million U.S. children under 18 have been diagnosed with asthma There are approximately 5,000 deaths from asthma annually (American Academy of Allergy & Immunology)

10. 10 Asthma Prevalence in Louisiana An estimated 200,000 adults in Louisiana currently suffer from asthma. Louisiana falls within the top 25% of states for asthma related deaths. One in ten Louisiana households with children have at least one child with asthma. Females have higher rates of asthma than males in Louisiana. ( Bureau of Primary Care and Rural Health, LPHI, 2007)

11. 11 Asthma Prevalence in Louisiana (cont’d) African Americans in Louisiana are more likely to report having asthma than Caucasians. Both asthma prevalence rates and asthma death rates are increasing nationally. A burden is placed on the health care system, in the work place, and in schools in Louisiana due to absenteeism. (Bureau of Primary Care and Rural Health, 2007; MMWR, 1998)

12. 12 Prevalence of Asthma in Louisiana Louisiana Youth Tobacco Survey, 2000 The rates of asthma in Louisiana increased from during the four years (1999-2002) for which data was available on the prevalence of asthma in the state. 4.9% to 6%

13. 13 Asthma Initiatives: Phase I Individual and group education with targeted persistent asthma patients ages 5-9 Phase II Provider education: toolkits and CEU presentation for staff Phase III Quality review tool based on Chronic Care Model Provider profiles based on HEDIS measures Interventions include education and educational tools

14. 14 Education as the Intervention Works LSU Shreveport has demonstrated that with asthma education, we can improve health outcomes in impoverished and minority patients.

15. 15 Achieving Better Care for Asthma Identification ID relevant population Stratification Assign risk Outreach Reach the target Intervention Improve outcomes Aim: identify 100% of the persistent asthma patients per HEDIS Aim: identify 100% of the uncontrolled persistent asthma patients age 5-15 Aim: Contact 10/ top 15 providers per region who have uncontrolled persistent asthma patients Aim: Provider Education 10/10 per region by 12/31/05 (90providers)

16. 16 What is HEDIS? Health Plan Employer Data & Information Set HEDIS is an evolving set of standard specifications for measuring health plan performance. ©2004 by the National Committee for Quality Assurance

17. 17 Asthma HEDIS Measure Percentage of enrolled members 5-56 years of age during the measurement year who were identified as having persistent asthma patients and who were appropriately prescribed medication during the measurement year. Numerator = dispensed at least one prescription for inhaled corticosteroids, nedocromil, cromolyn sodium, leukotriene modifirers or methylxanthines during the measurement year Denominator = the eligible population ©2004 by the National Committee for Quality Assurance

18. 18 HEDIS Measure 2005 Denominator = 32,664 Numerator = 23,120 Percent on appropriate medications = 70.78% ©2004 by the National Committee for Quality Assurance

19. 19 Patient Stratification: Who are the Persistent Asthma Patients? We will identify your patients that meet the criteria for a diagnosis of Persistent Asthma using HEDIS guidelines: 1. At least four asthma medication dispensing events. 2. At least one emergency department visit with asthma as the principal diagnosis. 3. At least one acute inpatient discharge with asthma as the principal diagnosis. 4. At least four outpatient visits with asthma as one of the diagnoses AND at least two asthma medication dispensing events. HEDIS 2003, Volume 2, pp. 105 “Use of Appropriate Medications for People with Asthma”

20. 20 Louisiana Persistent Asthma Patients Regions

21. Green/dashed = national level/64.1%

22. 22 What is Asthma? A disease in which inflammation of the airways causes airflow into and out of the lungs to be restricted.

23. 23 What Happens During an Asthma Episode? 1. Muscles tighten around the airways (brochoconstriction) 2. The insides of the airways swell and make extra mucus (inflammation) Normal Airway

24. 24 Common Asthma Symptoms Coughing (most common symptom) Wheezing Tightness in Chest SOB/ Trouble Breathing Nasal Symptoms

25. 25 Cold or Respiratory Infection Strong Odors & Fumes Changes in Weather… Especially Cold Dust Cockroaches Smoke Pollen & Weeds Pets Exercise Strong Emotion

26. 26 Asthmatics and Smoking According to the EPA, between 200,000 and 1,000,000 kids with asthma have their condition worsened by second hand smoke every year. Also, passive smoking may also be responsible for thousands of new cases of asthma every year Chronic respiratory symptoms such as cough and wheezing may be attributed to second hand smoke. Children who breathe in second hand smoke are more likely to suffer from dental cavities, eye and nose irritation, and irritability * U. S. Environmental Protection Agency, 2004

27. 27 Health Risks to Children with Asthma Asthma is the most common chronic childhood disease affecting 1 in 13 school aged children on average. Exposure to secondhand smoke can cause new cases of asthma in children who have not previously shown symptoms. Exposure to secondhand smoke can trigger asthma attacks and make asthma symptoms more severe. * U. S. Environmental Protection Agency, 2004

28. 28 Serious Health Risk to Children Children are particularly vulnerable to the effects of secondhand smoke because: they are still developing physically have higher breathing rates than adults have little control over their indoor environments. * U. S. Environmental Protection Agency, 2004

29. 29 The Science Behind the Risk: 11% of children aged 6 years and under are exposed to ETS in their homes on a regular basis (4 or more days per week) compared to 20% in the 1998 National Health Interview Survey (NHIS). Parents are responsible for 90% of children’s exposure to ETS. Exposure to ETS is higher and asthma prevalence is more likely in households with low income and low education levels. Children with asthma have as much exposure to ETS as children without asthma. * U.S. Environmental Protection Agency, 2004

30. 30 CommunityCARE Quality Unit Goal: Improve medical home management by providing education, office management tools, and utilization data to providers.

31. 1.Community Resources and Policies 2. Health System Health Care Organization 3. Self- Management Support 4. Delivery System Design 5. Decision Support 6. Clinical Information Systems Informed, Activated Patient Prepared, Proactive Practice Team Chronic Care Model * Effective Clinical Practice, 1998

32. 32 Chronic Care Model in Practice Treating the “whole patient” to empower them to self manage their disease. Identification of environmental needs, family dynamics, economic needs, and specific disease education individualized for each patient/caregiver.

33. 33 Quality Reviews as part of Intervention Quality reviews of charts are completed in the PCP offices using questions derived from the domains of the Chronic Care Model Medicaid claims data using a measurement period of 1 year is used to complete reviews. Purpose is to give meaningful feedback to the provider about the quality of care they are providing

34. 34 Interventions Continued Intervention materials are given to the PCPs to help improve the quality outcomes of their asthma programs. Example of InterventionsDomain of Chronic Care Model NHLBI guidelines/recommendationsDecision Support Asthma Action PlanFamily and Self Management Support Community Resources the provide Smoking Cessation Programs (1-800-Quit-Now, MYFSF) Community Resources Educational materials to be given to patients/caregivers. Family and Self Management Support Asthma presentation (for CEUs) for PCP and their staff. Decision Support Sample tracking formsClinical Information System Sample asthma flow sheets and sample tracking forms. Decision Support

35. 35 Asthma Classifications The NAEPP (National Asthma Education and Prevention Program) has classified asthma into four categories. These are based upon: Frequency and severity of symptoms Pulmonary functions

36. NAEPP DAILY MEDICATION GUIDELINES (FOR ADULTS AND CHILDREN >5 YEARS) Severe Persistent Continuous (Day) and/or Frequent (Night) Preferred: ICS & LABA AND, if needed oral steroids not to exceed 60mg/day Moderate Persistent Every day and/or >1 night/week Preferred: ICS & LABA Alternative: ^ ICS and/or add leukotriene modifier or theophylline Mild Persistent >2/week but <1x/day and/or >2 nights/month Preferred: ICS Alternative: Leukotriene modifier, cromolyn, nedocromil or theophylline Mild Intermittent ≤2 days/week and/or ≤2 nights/month No daily meds needed ICS: Inhaled corticosteroid LABA: Long-acting inhaled beta-agonist *2002 SEVERITY SYMPTOMS DAILY/CONTROL MEDS * 2002 NAEPP Expert Panel Report

37. The Asthma Action Plan

38. The Asthma Maintenance Form * NICHQ National Initiative for Children’s Healthcare Quality, 2000

39. 39

40. 40 Contact Information Program ManagerCindy French(225) 342-9320cfrench@dhh.la.gov Region 1 NurseKathy Carter(504) 568-2827kcarter3@dhh.la.gov Region 2 NurseKaren Adams(225) 342-1851kmadams@dhh.la.gov Region 3 NurseMary Scorsone(985) 449-4722mscorson@dhh.la.gov Region 4 NurseNina Fouke(337) 262-1957nfouke@dhh.la.gov Region 5 NurseJennifer Bruney(337) 491-2600jbruney@dhh.la.gov Region 6 NurseVetreese McCue(318) 487-5655vmccue@dhh.la.gov Region 7 NurseRhonda Baird(318) 676-5159rbaird@dhh.la.gov Region 8 NurseCandice McVay(318) 362-4263cmcvay@dhh.la.gov Region 9 NurseKathy Solis(985) 543-4163ksolis@dhh.la.gov

41. 41 Questions ????

42. 42 Websites http://www.improvingchroniccare.org /change/model/components.html http://www.nichq.org/NICHQ/Topics /ChronicConditions/Asthma/Changes/ www.lamedicaid.com www.la-kidmed.com/communitycare/ commcare.html

43. 43 References American Academy of Allergy, Asthma & Immunology (2004). Pediatric Asthma: Promoting Best Practice. Guide for Managing Asthma in Children. Rochester, New York. American Academy of Allergy, Asthma & Immunology (2006). Media Resources: Media Kit. Retrieved from http://www.aaaai.org/media/resources/media_kit/asthma_statistics.stm Baylor Health Care System (2001). Rules of Two®. Retrieved from http://www.baylorhealth.com/medicalspecialties/asthma/asthmaprograms.htm#Rof2 Bureau of Primary Care and Rural Health. Chronic Disease and Prevention Control. Asthma Initiative PowerPoint. HEDIS (2006). Use of Appropriate Medications for People with Asthma. Volume 2, pp. 105. Louisiana Public Health Institute (2007). Asthma. Retrieved from http://www.lphi.org/home/health/asthma/

44. 44 Louisiana Youth Tobacco Survey (2000). Retrieved from http://www.lcltfb.org/CC- Plan/YTS_LAYOUT1.4.pdf Morbidity and Mortality Weekly Report (1998). Forecasted State-Specific Estimates of Self-Reported Asthma Prevalence -- United States, 1998, 47: 1022-1025. National Initiative for Children’s Healthcare Quality (2000). Retrieved from http://www.nichq.org/NICHQ/Topics/ChronicConditions/Asthma/Tools/ asthmamaintenanceform.htm. National Heart, Lung, and Blood Institute (NHLBI) National Asthma Education and Prevention Program, Expert Panel Report 2 (1997). Guidelines for the diagnosis and management of asthma. (NIH Publication No. 97-4051). Bethesda, MD: US Department of Health and Human Services. National Heart, Lung, and Blood Institute (NHLBI) National Asthma Education and Prevention Program, Expert Panel Report (2003). Guidelines for the diagnosis and management of asthma: Update on selected topics 2002. (NIH Publication No. 02- 5074). Bethesda, MD: US Department of Health and Human Services. References

45. 45 References U. S. Environmental Protection Agency (2005). National Survey on Environmental Management of Asthma and Children’s Exposure to Environmental Tobacco Smoke. Retrieved from http://www.epa.gov/smokefre/pdfs/survey_fact_sheet.pdf Wagner, E.H. (1998). Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice (1), 2-4.