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 foremanp@health.missouri.edu Tammy Rood, PNP, AE-C roodtl@health.missouri.edu Sherri Homan, RN, PhD sherri.homan@health.mo.gov Peggy Gaddy, RRT, MBA peggy.gaddy@health.mo.gov Eric Armbrecht, PhD earmbrecht@gmail.com Benjamin Francisco, PhD, PNP, AE franciscob@health.missouri.edu ® March 26, 2012 guided by data 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 Rate per 10,000 110 100 90 80 70 60 50 40 30 20 10 0 Age 102.1 Prevalence of Childhood Asthma, age < 17, Missouri Percent 16 13.4 13.1 14.5 14.0 14 12 10 8 10.9 10.1 9.5 8.6 6 Lifetime 4 Current 2 0 2006 2007 2008 2010 Asthma Hospitalization Rates by Race and Age Group Missouri, 2008 White AfricanAmerican 66.9 49.5 46.0 43.2 42.6 39.9 31.9 24.5 24.3 19.8 10.3 Under 1 1- 4 5- 9 5.0 3.1 10 - 14 15 - 17 3.1 18 - 19 16.5 17.6 12.9 3.3 20 - 24 6.5 9.8 25 - 44 45 - 64 9.3 65 and Older All Ages *Missouri Department of Health and Senior Services. Missouri Information for Community Assessment (MICA) and Behavioral Risk Factor Surveillance System guided by data 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 Rural vs. Urban • ER visits for children highest rates in urban counties • High hospitalization rates for rural counties *Missouri Department of Health and Senior Services. Behavioral Risk Factor Surveillance System and MICA. ER Rates for Asthma Children (age 0-14), 2007-2009* guided by data Medicaid (MoHealth Net Data Project) Persistent asthma ages 6-18 140,000 Medicaid Leading Prescribed Asthma Medication by Number of Claims, Missouri 132,641 120,000 • 36.4% received inhaled corticosteroids and national average is 79.8% (Arellano, et al, 2011) 100,000 79,730 80,000 53,451 60,000 40,000 26,191 20,000 • 0 24.0% ICS medication possession ratio (MPR) adherence for all ages (SFY 2010) SA Beta Agonists Leukotriene Inhaled Steroid Inhaled Modifiers Combo Corticosteriods ICS Medication Possession Ratio Medicaid Population with Persistent Asthma, Missouri • $ 2574 paid for medication per persistent asthmatic child annually Percent 40 30 • Poor ICS medication use and adherence contributes to acute care utilization 20 35.59 37.29 22.45 23.44 13.14 13.85 37.38 23.97 Marginal and Adherent 61% or greater 13.25 Adherence 81% - 100% 10 0 *Missouri Department of Social Services, Mo Health Net 2008 2009 2010 Marginal Adherence 61% - 80% just do it. Missouri Asthma Coalition 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 leveraged resources MAPCP’s Role: Link statewide and local partners Our 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. just do it. IMPACT Asthma Kids© Care Background • 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) ® just do it. IMPACT Asthma Kids© Care Background • 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 ® just do it. ® just do it. ® School /Clinic Based IMPACT Programs • 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 just do it. Education & Care based on Real Need + Right Service at a Reasonable Cost Message Type 1) Asthma Literacy - 4 concepts ® Audience Cost Student w/asthma Low ($5-25) (school-based) 2) Key Messages - EPR3 defined Patient and family 3) Risk Reduction - 99402 and 99401 Patient and family Medium (medical home) ($40, $20 x 2 = $80) 4) Self-management Patient and family Medium ($100) - 98960 (medical home) (multiple settings) Low (bundled) Stratified = Intensity “cost” of care is appropriate for burden of disease (not just the dollars already spent on health care) just do it. Education & Care based on Real Need + Right Service at a Reasonable Cost Message Type ® Program Reach Funding 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 ABC (caregivers) ACE (school-age) 1000 - 0 to 5 1200 - 6 to 12 DHSS $100K MFH $100K 1) Asthma Literacy - 4 concepts - 98960 Stratified = Intensity “cost” of care is appropriate for burden of disease (not just the dollars already spent on health care) ® just do it. 14,000 Medicaid kids HEDIS 1) ER 2) Inpatient 3) 4 Outpatient & >1 Rx, 4) >3 asthma Rx dispensed (by school district) ® just do it. Surveillance Data Targets Interventions To date, a total of 64 health professionals have completed evidence-based asthma training in the priority ZIP-codes. Asthma Emergency Room Visit Rates for children age 5-14 by leading zip codes*, St. Louis City and County, 2006-2008 St. Louis City Zip Number Rate Code 63106 270 53.1 63113 251 38.9 63107 239 32.5 63104 228 31.9 63112 241 31.6 St. Louis County Zip Number Rate Code 63133 154 38.3 63121 347 28.6 63134 198 28.6 63136 696 24.7 63138 266 24.6 *Zip codes with 100 or more asthma ER visits among children age 5-14; rates per 1,000 population. ® just do it. Missouri Asthma Educator NetworkCredentialed Health Professionals More than 1,400 trained mid-level (6 hours) ® just do it. ® just do it. just do it. 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 (OR) CARR (99401 and 99402) - $30 incentive for role in evaluation Center for Asthma Management Asthma Academy (OR) ACE or ABC 98960 - $60 Asthma Ready Clinic Recognition Level Continuum Clinic Incentives Partners (97) Leaders (36) Free asthma education CEU/CME credit Hands on training Free asthma education and tools CEU/CME credit Hands on training Champions (8) Public recognition – press release sent to local news (print, tv, radio) for Asthma Ready 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 Center for Asthma Management ® School Nurse Report Sent Follow-up Assessment Missouri Health / Medical Home Provide asthma education and training to school staff (coaches, teachers, etc.) Incentive: $50 MacGill Gift Award Asthma Ready School Recognition Level Continuum School Nurse Incentives Partners (~250) Web-based training (no travel costs) Continuing Education Credit (2.5 hours) Leaders (~100) Letter of recognition to superintendent from ARC $20 “asthma credit” per student who completed TUAC Asthma Ready Clinic Primary Care Provider Champions (1) Mentors 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 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 Literacy Teaming 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, studentreported 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 • Initial TUAC assessments are analyzed by EPR3 algorithms to suggest additional assessments and interventions by the school nurse Well Controlled • 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) Not Well Controlled Very Poorly Controlled 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 Formfurther 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 Reportfrom 2011 Missouri School Asthma Manual just do it. Consent for Communication on 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 Not Well Controlled Well Controlled FEV1 < 80% predicted FEV1 60%-79% predicted Yes Very Poorly Controlled FEV1 < 60% predicted No Functional impairment noted on TUAC Student Forms Functional impairment in Yellow responses Yes No Ever unable to do usual activity due to asthma, or recent respiratory illness, or been to ER /Hospital (respiratory) Asthma Ready Communities February 15, 2012 Very poorly controlled asthma > 3 months Asthma Educator/Counselor with ACE/ABC to the home to administer CARAT / interventions Environmental assessment Collaborate with SN and PCP 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) Yes No Reassess next school session/semester Functional impairment in Red responses Very High Risk Green Zone > 6 months step down therapy 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 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 just do it. Changing Outcomes for Missouri Children with Asthma: MO Health Net Collaboration • 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 just do it. Changing Cost Outcomes for Missouri Children with Asthma: MO Health Net Data Project Collaboration • 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 EPR3treated group. • Remarkably, total asthma medication costs were 33% lower and total cost of care was 30% lower for the EPR3-treated patient group. just do it. SHARE CARE for KIDS with ASTHMA in Kansas City • 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 just do it. ® just do it. ® just do it. ® just do it. ® just do it. ® New Pharmacist Asthma Training Opportunity Encounter Management Application – Medication Related Problems http://mediasuite.multicastmedia.com/player.php?p=zfs85sxa systems thinking Dunklin Co. (Kennett) pop.= 31,039 LOCAL STRATEGY EXAMPLE Framework 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 Greene Co. (Springfield) pop.=269,630 KEY CONCEPTS 1. 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 just do it. Students Receiving Award for Finishing Asthma Education Benjamin Francisco, PhD, PNP, AE-C Asthma Ready®, University of Missouri