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CommunityCARE Quality Unit

Achieving Better Care for Asthma

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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.

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Presentation ObjectivesBy 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 averageKnow the effects of direct and 2nd hand tobacco smoke exposure on asthma Be familiar with the Asthma Change Package and the Chronic Care Model

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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.

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CommunityCARE

789 CommunityCARE Providers

1,519 physicians319 physician extenders632, 972 linkages678,751 eligible population

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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.

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QIP StructureIdentification

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?

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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)

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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)

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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)

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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)

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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

theprevalence of asthma in the state.

4.9% to 6%

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Asthma Initiatives:Phase I

Individual and group education with targeted persistent asthma patients ages 5-9

Phase IIProvider education: toolkits and CEU presentation for staff

Phase IIIQuality review tool based on Chronic Care Model Provider profiles based on HEDIS measuresInterventions include education and educational tools

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Education as the Intervention Works

LSU Shreveport has demonstrated that with asthma education, we can improve health outcomes in impoverished and minority patients.

Healthcare Utilization Data

310

245

4938 524

0

50

100

150

200

250

300

350

Initial Visit 310 245 49

Follow-up Visit 38 52 4

Missed Work/School Days

Emergency Department Visits

Hospitalizations

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Achieving Better Care for Asthma

IdentificationID relevant population

StratificationAssign risk

OutreachReach the target

InterventionImprove 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)

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What is HEDIS?

Health PlanEmployerData &InformationSet

HEDIS is an evolving set of standard specifications for measuring health plan performance.

©2004 by the National Committee for Quality Assurance

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Asthma HEDIS MeasurePercentage 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 yearDenominator = the eligible population

©2004 by the National Committee for Quality Assurance

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HEDIS Measure 2005

Denominator = 32,664Numerator = 23,120Percent on appropriate medications = 70.78%

©2004 by the National Committee for Quality Assurance

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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”

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Louisiana Persistent Asthma

Patients

0

2,000

4,000

6,000

8,000

10,000

12,000

I II III IV V VI VII VIII IX

Pre-Hurricanes Sep-06

Regions

0

.1

.2

.3

.4

.5

.6

.7

.8

.9

1

Fra

ctio

n o

f Pat

ient

s

Graph shows only CC PCPs with 10+ patients

overall level = 61%, red = stat sig diff > .05 from overall levelsymbol size proportional to # of patients, range 10 to 650

Appropriate Asthma Medications , Adjusteddenominator: HEDIS asthma denominator

Green/dashed = national level/64.1%

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What is Asthma?

A disease in which inflammation of the airways causes airflow into and out of the lungs to be restricted.

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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

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Common Asthma Symptoms

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

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Cold or Respiratory Infection

Strong Odors

& Fumes

Changes in Weather…

Especially ColdDust

Cockroaches

Smoke

Pollen & Weeds

Pets

Exercise

Strong Emotion

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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

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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

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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

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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

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CommunityCARE Quality Unit Goal:

Improve medical home management by providing education, office management tools, and utilization data to providers.

1. Community Resources and Policies

2. Health SystemHealth Care Organization

3. Self-Management

Support

4. DeliverySystemDesign

5. Decision Support

6. Clinical Information

Systems

Informed,ActivatedPatient

Prepared,Proactive

Practice Team

Chronic Care Model

* Effective Clinical Practice, 1998

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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.

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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 ModelMedicaid 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

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Interventions ContinuedIntervention materials are given to the PCPs to help improve the quality outcomes of their asthma programs.

Example of Interventions Domain of Chronic Care Model

NHLBI guidelines/recommendations Decision Support

Asthma Action Plan Family 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 forms Clinical Information System

Sample asthma flow sheets and sample tracking forms.

Decision Support

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Asthma Classifications

The NAEPP (National Asthma Education and Prevention Program) has classified asthma into four categories.These are based upon:

Frequency and severity of symptomsPulmonary functions

NAEPP DAILY MEDICATION GUIDELINES

(FOR ADULTS AND CHILDREN >5

YEARS)

Severe Persistent

Continuous (Day) and/orFrequent (Night)

Preferred: ICS & LABAAND, if needed oral steroids not to exceed 60mg/day

Moderate Persistent

Every day and/or>1 night/week

Preferred: ICS & LABAAlternative: ^ ICS and/or add leukotriene modifier or theophylline

Mild Persistent

>2/week but <1x/day and/or>2 nights/month

Preferred: ICSAlternative: Leukotriene modifier, cromolyn, nedocromil or theophylline

Mild Intermittent

≤2 days/week and/or≤2 nights/month

No daily meds needed

ICS: Inhaled corticosteroidLABA: Long-acting inhaled beta-agonist *2002

SEVERITY SYMPTOMS DAILY/CONTROL MEDS

* 2002 NAEPP Expert Panel Report

The Asthma Action Plan

The Asthma

Maintenance

Form

* NICHQ National Initiative for Children’s Healthcare Quality, 2000

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Contact InformationProgram Manager Cindy French (225) 342-9320 cfrench@dhh.la.go

v

Region 1 Nurse Kathy Carter (504) 568-2827 kcarter3@dhh.la.gov

Region 2 Nurse Karen Adams (225) 342-1851 kmadams@dhh.la.gov

Region 3 Nurse Mary Scorsone (985) 449-4722 mscorson@dhh.la.gov

Region 4 Nurse Nina Fouke (337) 262-1957 nfouke@dhh.la.gov

Region 5 Nurse Jennifer Bruney (337) 491-2600 jbruney@dhh.la.gov

Region 6 Nurse Vetreese McCue (318) 487-5655 vmccue@dhh.la.gov

Region 7 Nurse Rhonda Baird (318) 676-5159 rbaird@dhh.la.gov

Region 8 Nurse Candice McVay (318) 362-4263 cmcvay@dhh.la.gov

Region 9 Nurse Kathy Solis (985) 543-4163 ksolis@dhh.la.gov

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Questions ????

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Websites

http://www.improvingchroniccare.org/change/model/components.htmlhttp://www.nichq.org/NICHQ/Topics/ChronicConditions/Asthma/Changes/www.lamedicaid.comwww.la-kidmed.com/communitycare/

commcare.html

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ReferencesAmerican 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/

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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

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ReferencesU. 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.