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