1. Le Bonheur CHAMP Changing High-Risk Asthma in Memphis through Partnership Susan C. Steppe, LAPSW, Project Director

2. CMS Disclaimer Statement The project described was originally supported by Grant Number 1C1CMS331046 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services and is currently supported by Le Bonheur Children’s Hospital. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the independent evaluation contractor.

3. CHAMP Leadership Dr. Christie Michael, Medical Director, PI Dr. Dennis Stokes, PI Susan Steppe, LAPSW, Project Director, Co- Investigator Christina Underhill, Ph.D., Project Evaluator, Co-PI

4. Emergency Department Utilization – Shelby County had 4,688 ED Visits in 2013, rate of 192.6/10,000 – State of Tennessee had 15,229 ED Visits in 2013, rate of 102.1/10,000 – 31% of all ED visits in 2013 occurred in Shelby County. Data from the TDOH, Division of Planning and Assessment. Hospital Discharge Data System, (2013). Nashville, TN

5. Steps in Building Program Identify high risk patients/engage quickly Identify barriers to adherence – Lack of Knowledge/Skill – Belief system – Social determinants Build high-risk asthma clinic and community interventions to address. ENGAGE THE FAMILIES

6. Defining High-Risk Asthma NHLBI- by asthma history, social history, and comorbidities Issues to consider – Level of control, adherence and use of self- management strategies, overall RISK – Heavy users of the hospital system Pools the sickest children with the greatest health disparity into one clinic

7. Obstacles and Opportunities in High-Risk Asthma Adherence with medical regimen – moving the needle Self-management skills Fragmented care/information sharing Access to care Social determinants of health

8. Basics of CHAMP CMS Innovation Project Serves Medicaid recipients in Shelby County, TN ages 2- 18 years High system utilizers: ED visits, hospitalizations, and PICU Key Components – Registry – High-risk clinic – Community team – Community partners

9. Chief Aims of CHAMP 1. Reduce emergency department utilization by 15% from baseline by June 30, 2015 2. Reduce hospitalizations and observations by 15% by June 30, 2015 3. Produce desired results at lower cost

10. Components of the Program Medical Team – Sub-specialty clinic – Dr. Christie Michael, A&I with Pulmonology support – Dedicated RN and RT – 24/7 call line (71%) – Sick call triage and follow-up Community Based Team – 5 Community Health Workers to enroll/engage – Home visits/environmental/ meds. rec./referrals – Schools and PCPs

11. CHAMP Picture Identify patients from EMR report. Engage and enroll in home setting. Initial Clinic Visits Develop POC Asthma Education Access to 24/7 call line 3, 6, 9 month appts. Sick call as needed Access to 24/7 call line Sick Call Triage Call back to 24/7 calls Connect to PCP Home Environmental Assessment Medication Reconciliation Reinforce Asthma Education Provide POC to schools. Home visits to reinforce asthma education and do meds. rec., address social concerns Case Management CMWYNM

12. CHAMP Data Registry – UTHSC BMI Record of all CHAMP team activity Woven in work flow– use of I-pads Selected medical data is imported or entered from the EMR Monthly download of TennCare Encounter data on all enrollees Research tool for population studies A powerful tool for case management and reporting on outcomes – Medication flag – Recent encounter overview for quick reference – Ability to make prior hx “snapshot” available to PCPs

13. Quarterly ED Utilization * 33.6% reduction over 11 quarters. * This data is drawn from TennCare encounter records but has not been independently verified. 527 Patients

14. ED Utilization – 6 months* Goal Less Than 15% of BL 43.4% reduction in 6-month utilization over 11 quarters (10 reporting periods). * This data is drawn from TennCare encounter records but has not been independently verified.

15. Avoidable Hospitalizations* * This data is drawn from TennCare encounter records but has not been independently verified.

16. Quarterly Hospital/Obs.* Goal Less Than 15% of BL 48.1% reduction in the percentage of children hospitalized per quarter, over 11 quarters. * This data is drawn from TennCare encounter records but has not been independently verified.

17. Exacerbations* * This data is drawn from TennCare encounter records but has not been independently verified. 27.18% reduction in exacerbations over the 11 quarters of operation.

18. Asthma-Related Cost of Care* Comparison of pre and during CHAMP Figures drawn from actual TennCare payments (not charges) Baseline calculated in Q8 is $3812 cost per child per year. Average during CHAMP cost of care through Q 13 is $1976 Average 49.7% cost reduction per year, per child *This has not been independently verified by a third party.

19. CHAMP Receives EPA Award 2015 National Environmental Leadership Award in Asthma Management May 7, 2015 in Washington, D.C.

20. What have we learned? Education is Exceedingly Important Education is NOT ENOUGH Importance of complete picture of a patient and their individual needs/barriers Access to care remains a problem Use of technology and “simple” ideas Change involves building trust – winning the right to influence and serve

21. Future Directions Use electronic tools Identify, track, and RESPOND Enhance connections with primary providers 24/7 capability CHAMP asthma registry would be a useful statewide tool

22. Future of CHAMP Won a technical assistance award to work with Green and Healthy Homes Initiative (GHHI)- environmental interventions GHHI involves constructing framework for funding through: SOCIAL INNOVATION FUNDING Value Based Care Options – scale up/ add new populations Other funding sources (NIH, foundation)

23. CHAMP TEAM

24. CMS Statement The project described was supported by Grant Number 1C1CMS331046 from the and Human Services, Centers for Medicare & Medicaid Services and is currently funded by Le Bonheur Children’s Hospital. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the independent evaluation contractor.