Linking Asthma Care at School and the Medical Home

Data, Decision-Making and Improving Outcomes

Missouri Asthma Prevention and Control Program

Paul Foreman, MA, MS, PhD Tammy Rood, PNP, AE-C foremanp@health.missouri.edu roodtl@health.missouri.edu Sherri Homan, RN, PhD Peggy Gaddy, RRT, MBA sherri.homan@health.mo.gov peggy.gaddy@health.mo.gov

Eric Armbrecht, PhD Benjamin Francisco, PhD, PNP, AE earmbrecht@gmail.com franciscob@health.missouri.edu

March 26, 2012

®

Surveillance in Missouri Prevalence*

• 8.8% MO adults current asthma (2010)

- up from 7.2% (2000)

• 10.9% MO children current asthma

Disease Severity (Health Service Utilization)*

• Highest hospitalization rates: ages 1-4• Elevated rates until age 14,

lower between age 15-44• Significant for African-Americans

guided by data

*Missouri Department of Health and Senior Services. Missouri Information for Community Assessment (MICA) and Behavioral Risk Factor Surveillance System http://health.mo.gov/data/brfss/index.php

12.9

24.3

10.35.0 3.1 3.1 3.3

6.5 9.8

16.5

9.3

43.2

102.1

66.9

49.5

24.519.8

17.6

31.9

46.039.9 42.6

0102030405060708090

100110

Under 1 1 - 4 5 - 9 10 - 14 15 - 17 18 - 19 20 - 24 25 - 44 45 - 64 65 and Older

All Ages

Rate per 10,000

Age

White

African-American

Asthma Hospitalization Rates by Race and Age Group Missouri, 2008

2006 2007 2008 2010

0

2

4

6

8

10

12

14

1613.4 13.1

14 14.5

9.5 8.6

10.110.9

Prevalence of Childhood Asthma, age < 17, Missouri

Lifetime

Current

Percent

Surveillance in Missouri Prevalence*

• 19.6% St. Louis City children current asthma (2008)

Disease Severity (Health Service Utilization)

• Significant for African-Americans• ER visit rate almost 3x higher

guided by data

*Missouri Department of Health and Senior Services. Behavioral Risk Factor Surveillance System and MICA.

Rural vs. Urban• ER visits for children highest rates in urban

counties• High hospitalization

rates for rural counties ER Rates for Asthma Children (age 0-14), 2007-2009*

Surveillance in Missouri guided by data

*Missouri Department of Social Services, Mo Health Net

Medicaid (MoHealth Net Data Project)

Persistent asthma ages 6-18

• 36.4% received inhaled corticosteroids and national average is 79.8% (Arellano, et al, 2011)

• 24.0% ICS medication possession ratio (MPR) adherence for all ages (SFY 2010)

• $ 2574 paid for medication per persistent asthmatic child annually

• Poor ICS medication use and adherence contributes to acute care utilization

2008 2009 201005

10152025303540 35.59 37.29 37.38

22.45 23.44 23.97

13.14 13.85 13.25

ICS Medication Possession Ratio Medicaid Population with Persistent Asthma, Missouri

Marginal and Adherent 61% or greater

Adherence 81% - 100%

Marginal Ad-herence 61% - 80%

Percent

SA Beta

Agonist

s

Leuko

trien

e Modifiers

Inhaled St

eroid Combo

Inhaled Corti

coste

riods

0

40,000

80,000

120,000132,641

79,73053,451

26,191

Medicaid Leading Prescribed Asthma Medication by Number of Claims, Missouri

Successful Partnerships just do it.& Promising Interventions

Missouri Asthma Coalition (MAC)

• Established in 2002• CDC grant support• 750 people in network• Partners include:

◊ School nurses◊ Childcare consultants◊ School board◊ Universities◊ Asthma coalitions◊ FQHCs◊ Health professionals◊ many, many more

• Interventions based on EPR3 - improve control and reduce risks and functional limitations

Missouri Asthma Coalition

Partnerships leveraged resources

MAPCP’s Role: Link statewide and local partnersOur Little Secret : Everyone is welcome, but MAPCP strategically builds partnerships to reach target population Our Purpose for Partnership: Leverage resources … to the max.

HOW DOES PARTNERSHIP IMPROVE ASTHMA CARE?• Interdisciplinary Sharing: Expertise and resources

• Coordination: Activities are planned and implemented together

• Innovation: New ideas and collaborations are fostered between stakeholders

• Priorities: Partners set priorities for surveillance and interventions

• Relevance: Key asthma issues move to forefront of systems-based strategies and public health planning

Note:CDC’s $3.4 million investment in MAPCP (2001-2011) has helped produce a >$20 million investment from MAPCP partners in activities aligned with the State Plan Putting Excellent Asthma Care Within Reach.

State Plan 2005

State Plan 2010

just do it.

• Asthma Ready® Clinics and Medical Homes

- clinic staff including physicians, nurse practitioners, nurses, receptionists/billing clerks and respiratory therapists receive asthma standardized medical management curricula, equipment & protocols (EPR3 compliant care)

• Asthma Ready® Schools - School nurses trained, standardized curricula - School assessments and interventions are based on EPR3 guidelines- Actionable data are documented and sent to the parents and PCP

(should be in real time)

Background®IMPACT Asthma Kids©

Care

just do it.

• Medical Homes and Asthma Ready® Clinics (ARC)- Comprehensive care in the context of individual, cultural, and

community needs: ARC address individual patient and family goals each clinic visit and refers to community partners for continuity of care

- Emphasize education through system-level protocols and interpersonal interactions:

Asthma Ready Educator uses standardized asthma literacy education tools for patients and families and validated assessment protocols for transmitting actionable data-At the center of the Medical/Health Home are the patient and family and their relationship with the primary care team

Asthma Ready care is delivered by a team, composed of a clinic provider and a nurse trained as an asthma educator

Background®IMPACT Asthma Kids©

Care

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®

just do it.

• Based on dyad approach – clinic and school district in proximity prepared to deliver care

• Rural and urban school districts identified as having the highest persistent childhood asthma rates and level of health risk in Missouri

• Identify targets by matching the zip codes clinic sites of Federally Qualified Health Centers (FQHC) and Asthma Ready Clinics (includes Medical Homes) with local school districts

• School nurses (17% of 1,600 total) who expressed interest in IMPACT programs after receiving 2011 Missouri School Asthma Manual

School District

Clinic

Child &Family

School /Clinic Based IMPACT Programs ®

just do it.

Message Type Audience Cost

1) Asthma Literacy - 4 concepts

Student w/asthma(school-based)

Low ($5-25)

2) Key Messages - EPR3 defined

Patient and family(medical home)

Low (bundled)

3) Risk Reduction - 99402 and 99401

Patient and family(medical home)

Medium ($40, $20 x 2 = $80)

4) Self-management - 98960

Patient and family(multiple settings)

Medium ($100)

Education & Care based on Real Need + Right Service at a Reasonable Cost

Stratified = Intensity “cost” of care is appropriate for burden of disease (not just the dollars already spent on health care)

®

just do it.

Message Type Program Reach Funding

1) Asthma Literacy - 4 concepts

Teaming up for Asthma Control

1K school nurses

CDC/MFH$900K

2) Key Messages - EPR3 defined

Asthma Ready®Clinics

100 ARC, 500 MH MFH/DHSS$300K

3) Risk Reduction - 99402 and 99401

Counseling for Asthma Risk Reduction

500 Medical Homes

DHSS$150 K

4) Self-management - 98960

ABC (caregivers)ACE (school-age)

1000 - 0 to 5 1200 - 6 to 12

DHSS $100KMFH $100K

Education & Care based on Real Need + Right Service at a Reasonable Cost

Stratified = Intensity “cost” of care is appropriate for burden of disease (not just the dollars already spent on health care)

®

Successful Strategies just do it.& Promising Interventions

®

14,000 Medicaid kids

HEDIS1) ER

2) Inpatient3) 4 Outpatient & >1 Rx,

4) >3 asthma Rx dispensed

(by school district)

Successful Strategies just do it.& Promising Interventions

®

Zip Code

Number Rate Zip Code

Number Rate

63106 270 53.1 63133 154 38.363113 251 38.9 63121 347 28.663107 239 32.5 63134 198 28.663104 228 31.9 63136 696 24.763112 241 31.6 63138 266 24.6

St. Louis City St. Louis County

Asthma Emergency Room Visit Rates for children age 5-14 by leading zip codes*, St. Louis City and County, 2006-2008

*Zip codes with 100 or more asthma ER visits among children age 5-14; rates per 1,000 population.

Surveillance Data Targets InterventionsTo date, a total of 64 health professionals have completed evidence-based asthma training in the priority ZIP-codes.

Successful Strategies just do it.& Promising Interventions

®

Missouri Asthma Educator Network-

Credentialed Health

Professionals

More than 1,400 trained

mid-level (6 hours)

just do it.

®

just do it.

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just do it.

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Asthma Ready Communities February 2012

ABC – Acting on Behalf of My Child to Control Asthma ACE – Asthma Control Everyday CARR – Counseling for Asthma Risk Reduction

Asthma Ready Clinic Progression Health Care Provider Levels of Intervention

No training Asthma Ready Clinic Training part 1

Asthma Ready Clinic Training part 2

3 patient assessments completed

CARR (99401 and 99402) - $30 incentive for role in evaluation

Center for Asthma Management

Asthma Academy

ACE or ABC 98960 - $60

(OR)

(OR)

Asthma Ready Clinic Recognition Level Continuum

Partners (97)

Leaders (36)

Champions (8)

Clinic Incentives Free asthma

education CEU/CME credit Hands on training

with asthma tools

Free asthma education and tools

CEU/CME credit Hands on training

with asthma tools Binder with asthma

resources

Public recognition – press release sent to local news (print, tv, radio) for Asthma Ready Champion status

Recognition on Asthma Ready website

just do it.

®

Asthma Ready Schools Progression School Nurse Levels of Intervention

No training Teaming Up For

Asthma Control training

3 student assessments completed

Home Education and Family Communication

School Nurse Report Sent

Center for Asthma Management

Asthma Ready Clinic

Missouri Health /

Medical Home

Primary Care Provider

Partners (~250)

Leaders (~100)

Champions (1)

Asthma Ready School Recognition Level Continuum

Mentors

Provide asthma education and training to school staff (coaches, teachers, etc.) Incentive: $50 MacGill Gift Award

School Nurse Incentives

Web-based training (no travel costs)

Continuing Education Credit (2.5 hours)

Free asthma education and asthma tools

(value ~ $400)

Letter of recognition to superintendent from ARC

$20 “asthma credit” per student who completed TUAC

Certificate/plaque for completion MSBA sends recognition letter/email

to superintendent $20 “asthma credit” per student who

completes TUAC follow-up/report sent Public recognition – press release sent

to local news (print/tv/radio) for Asthma Ready Champion status

Recognition on Asthma Ready website

Follow-up Assessment

just do it.

Promoting Asthma Self-Care and Improving Coordination of School Services and Clinical Care

• IMPACT Asthma Kids© – a multimedia, self management education program for students and parents (recognized by

NIH as 1 of 3 evidence-based computer approaches)

• Teaming Up for Asthma Control© – an IMPACT derivative for asthma literacy, funded by CDC, uses a standardized student

assessment to guide school nurse documentation of actionable asthma data

• Assessment– functional impairment (selected items from the Children’s Health Survey for Asthma, American Academy of

Pediatrics)

– FEV1 (forced expiratory volume in one second) – inhalation technique– recognition and adherence to ICS medications for messaging parents & primary

care providers

®

just do it.

Student Asthma LiteracyTeaming Up for Asthma Control©

IMPACT Asthma Kids©, evidence-based

(c) Benjamin Francisco, PhD, PNP, AE-C 2011

®

just do it.

TUAC Evaluation Methods and Initial Results

• Pre-Post TUAC intervention outcome indicators for these children were derived from 2008, 2009, 2010, 2011

Medicaid data:– asthma outpatient visits – ER visits and hospitalizations– medication claims– per member per month (PMPM) categorical costs

• Missouri Department of Elementary and Secondary Education (DESE) attendance and achievement records

• Analysis for 87 children: After TUAC intervention FEV1 significantly improved by 14.7%, inhalation technique improved significantly, student-reported impairment and smoke exposure declined significantly.

®

just do it.

New, Compelling Asthma Outcome Variables

• ACD Acute Care Day Score ACD is defined as the number of days

of acute care for asthma in a given time period

If ACD = 6– 6 ER visits

– 6 inpatient days or – 3 ER visits & 3 inpatient days

®

just do it.

New, Compelling Asthma Outcome Variables

• POPT – Proportion (P) of Outpatient

visits (OP) to Total visits (T) including OP, ER visits & inpatient days

– expressed from 0 to1 – where

• “0” is the worst case scenario (no outpatient visits, all asthma

encounters are in acute care settings) • “1” is the best case

scenario (only OP visits)

Example

1 OP visit and 9 ER visits

1 OP / 1 OP + 9 ER =

0.1 POPT

Or Only 10% of asthma encounters

were outpatient visits

®

just do it.

New, Compelling Asthma Outcome Variables

• DPR Daily Possession Rate

• Average daily amount of drug (i.e., inhaled corticosteroids) available over a dispensing interval

• Charting ACD, POPT & DPR to model opportunities for family member, PCP and school nurse messaging

• These claims data are available within one month of event for timely actions

®

just do it.

New, Compelling Asthma Outcome Variables

• DPR charts change trajectory of care

• Micrograms of asthma medication and EPR3 ICS dose ranges are plotted on the y axis by EPR3 guidelines

– by age, sub-therapeutic, low, medium, high or very high

• Asthma ACD (ED and IP days) are plotted on the x axis (time)

• POPT is calculated and displayed. DPR graphed by actual dispensing interval, by year & 90 day

• Trajectory of delivered asthma health care can be analyzed and appropriate interventions prompted by messaging members, PCPs and school nurses

®

just do it.

Sub-therapeutic doses of ICS, low PopT, high ACD, high SABA

just do it.

Two ER visits, starts ICS,

SABA use drops

just do it.

ACD =1 (ED visit), high SABA, PopT = 0.83,

TUAC participation, medium dose ICS

just do it.

Intervention Data Messaging Capacity

Well Controlled

Not Well Controlled

Very Poorly Controlled

• Initial TUAC assessments are analyzed by EPR3 algorithms to suggest additional assessments and interventions by the school nurse

• Children are categorized into three zone classifications of EPR3→

• Parents and PCPs are alerted by school nurse regarding findings in timely manner

• All clinical interventions are collaborative with goal of moving children into the GREEN zone over time. An expert support system is needed to provide resources, analysis and messaging (ARC)

just do it.

Clinicians Assess Impairment & Risk

just do it.

School nurses assess impairment & risk

just do it.

Problems and Opportunities: Alignment of School and Clinic to EPR3 Guidelines

just do it.

School Nurse

Messages PCP

just do it.

School Nurse Messages PCP (continued)• Objective measures of airflow by digital flow meter : FEV1 (% predicted, personal

best, and % change with quick relief medicine)

• Objective measurement of Inhalation technique : inspiratory flow rate and inspiratory flow time

• Medication Adherence by Student Report – using a Respiratory Inhaler Poster Chart : What medicines are available at home? How many missed doses of control medicine? Using a spacer with inhaled MDI medicines? • • Impairment by Student Report : Activity limitation or sleep disruption due to breathing problems?

•Tobacco Smoke Exposure by Student Report

•Form encourages provider to fax updated asthma action plan to school

just do it.

Calculate percent

predicted FEV1 and peak flow

just do it.

School Nurse TUAC

Follow-Up Form- further actions

just do it.

School Nurse Actions – Levels of Communication

• Send home a Student Asthma Status Report Form: Inform family of asthma events at school – includes subjective and objective measures, encourage communication/follow up with provider

• Called and talked to the family about their child’s asthma assessment findings

• Met face-to-face with this family to discuss their child’s asthma care at home and school

• Completed and sent a “School Nurse Report of Student Asthma Assessments” to (name of health care provider)

• Provided an ICS Star Chart to promote inhaled corticosteroid (ICS) adherence

just do it.

Student Asthma Status

Report- from 2011 Missouri School Asthma Manual

just do it.

Consent for Communicat

ionon Asthma Action Plan

http://www.rampasthma.org/info-resources/asthma-action-plans/

just do it.

Inhaled Corticosteroid (ICS) Star Chart

just do it.Teaming Up for Asthma Control

Assessment and Guidelines for School Nurse Actions

Asthma Ready Communities February 15, 2012

Well Controlled Not Well Controlled Very Poorly Controlled

Very High Risk

FEV1 < 80% predicted

Functional impairment noted on TUAC Student Forms

Reassess next school session/semester

Yes

No

Yes

No

Ever unable to do usual activity due to asthma, or recent respiratory illness, or been to ER /Hospital (respiratory)

Yes

No

Green Zone > 6 months step down

therapy

FEV1 60%-79% predicted

Functional impairment in Yellow responses

If asthma symptoms or FEV1 <80% predicted - give quick relief medicine and reassess FEV1 in 20 minutes. (Document findings. Call family/911 if no relief/improvement with quick relief medicine)

Communicate with parents regarding findings and inquire about ICS usage/adherence, inhalation technique, & barriers.

Trigger reduction (esp if smoking items involved) At school, assess ICS usage/adherence and equipment usage Functional impairment at home Review AAP with parents/guardian Child demonstrates knowledge of proper use of quick relief

inhaler Recommend PCP outpatient appointment within 2 to 6

weeks (if red, urgent PCP outpatient visit) Complete “SN Report of Student’s Asthma Assessments”

form and send to PCP Follow-up phone call to parent to record outcomes of PCP

visit and changes to AAP If red, consider administering ICS medication at school Continue weekly assessment using TSF until child in

GREEN zone for one month

FEV1 < 60% predicted

Very poorly controlled asthma > 3 months

Functional impairment in Red responses

Asthma Educator/Counselor with ACE/ABC to the home to administer CARAT / interventions

Environmental assessment Collaborate with SN and PCP

Document all actions

Assess weekly using TSF

Continue until child is in GREEN zone for one month

Acronyms AAP – Asthma Action Plan ACE – Asthma Control Everyday ABC – Acting on Behalf of My Child to Control Asthma CARAT – Child Asthma Risk Assessment Tool ER – Emergency Room FEV1 – Forced Expiratory Volume in One Second ICS – Inhaled Corticosteroids PCP – Primary Care Provider MDI – Metered Dose Inhaler SN – School Nurse TSF- TUAC Student Form TSF – TUAC Student Form

just do it.

• Identify populations of children suffering from the most severe asthma– Claims: high ACD, low POPT, sub-therapeutic ICS, higher cost of care – School: exacerbations, low FEV1, high impairment, high absenteeism

• Train local school and clinic (including medical homes) dyads in EPR3 guidelines for care using standardized curricula

• Continuously analyze school & claims data to deploy and stratify interventions to meet their needs and the family circumstances

• Produce actionable data for key clinicians

• Track individual and aggregated outcomes and evaluate using advanced scientific methodology

Changing Outcomes for Missouri Children with Asthma: MO Health Net Collaboration

just do it.

• Per member per month (PMPM) costs for children ages 5-18 identified with persistent asthma was $1,497 for 6,577 participants in 2010.

• Per member per month costs for children ages 5-18 was $1044 for 134 patients of an EPR3-compliant practice in 2010.

• EPR3-treated group costs were 9.6% higher for ICS medication costs and 23% higher costs for treating co-morbid conditions when compared to population mean.

• However the total asthma direct costs were 4.7% lower for EPR3-treated group.

• Remarkably, total asthma medication costs were 33% lower and total cost of care was 30% lower for the EPR3-treated patient group.

Changing Cost Outcomes for Missouri Children with Asthma:

MO Health Net Data Project Collaboration

just do it.

• Asthma Ready® Communities (ARC) is planning a comprehensive community initiative project named Share Care for Kids with Asthma for the greater Kansas City area in the fall of 2012-2013

• ARC will deliver standardized asthma self-management education and school nurse training to three participating school districts (27,011 children)

• ARC will deliver standardized EPR3 guideline training to 200 local Kansas City family practice clinics in those school districts areas surrounding the urban core

• ARC will support data exchanges between settings for EPR3 compliant care using innovative quality improvement platform

SHARE CARE for KIDS with ASTHMA in Kansas City

just do it.

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New Pharmacist Asthma Training Opportunity

Encounter Management Application – Medication Related Problems

http://mediasuite.multicastmedia.com/player.php?p=zfs85sxa

LOCAL STRATEGY EXAMPLEFramework for Community-based Approaches to Improving Asthma Care for Children

– Simple, to-the-point, one-page summary– Sets goals and interventions for integrating efforts in five areas:

schools, home environment assessments, primary care providers, hospitals/emergency rooms, and child care

KEY CONCEPTS1. Demonstrate success at local level

– Kennett Public Schools (Dunklin County)– Springfield (Greene County)

2. Experience, testimonials and data drive expansion of successful ideas

3. Identify statewide policy change opportunities through community-based work (e.g., spacers)

4. Statewide workforce development produces system-level change (e.g., LPHA staff, school nurses)

5. Cultivate local leadership– Asthma School Nurse Award, Missouri Asthma Coalition

systems thinking

Local + Statewide =Sustainable Interventions

Greene Co. (Springfield) pop.=269,630

Dunklin Co. (Kennett) pop.= 31,039

just do it.

Students Receiving Award for Finishing Asthma Education

Benjamin Francisco, PhD, PNP, AE-C Asthma Ready®, University of Missouri