Michigan Department of Community Health Asthma Prevention & Control Program

The Michigan Department of Community Health’s (MDCH) Asthma Prevention and Control Program (APCP) is a comprehensive program responsible for addressing asthma throughout the state of Michigan. APCP’s goal is to reduce the burden of asthma in Michigan by identifying and eliminating asthma disparities, assessing the asthma burden and response, supporting awareness of and partnerships to address asthma, improving systems of asthma care, reducing barriers to self-management in people with asthma, and reducing exposures to environmental factors that cause and/or exacerbate asthma.

This is accomplished by providing leadership, coordination of efforts, asthma expertise, and resources. Distinguishing program features include:
• Focus on systems change, integration and replication of successful programs
The APCP role is now to identify or develop the best asthma initiatives to solve a recognized problem, support and incubate them, and then work with partners to establish them in sustainable ways.
• Garner policy improvement through strategic partnerships
APCP has a diverse staff that works with many local, statewide and national strategic partners and asthma champions. Using these partnerships to accomplish mutual goals has resulted in sustainable policy improvement in schools and in-home programs.
• Using surveillance data to expand program reach and address disparities
Surveillance data allows APCP to continuously measure both the state’s and community’s needs and ensure that any changes in asthma burden results in adjusted programming.

MDCH APCP is committed to sustainability for its individual interventions and overall program. Major interventions are described below:

• MATCH Based on the in-home case management program developed by the Asthma Network of West Michigan (ANWM) in 1996, the MATCH (Managing Asthma Through Case-management in Homes) model of case management has been fostered to grow in three additional high asthma burden communities, with more planned. Standard program elements of the intervention include three or more home visits (including environmental assessments), social worker visit, physician care conference to create an asthma action plan, and visit to school or work as appropriate. Visits/care conferences are reimbursed by many health plans, which contract with MATCH programs. Preliminary outcomes from the MDCH MATCH evaluation of three of the established programs show significant decreases in: hospitalizations (71%), ED and urgent care visits (60%); use of quick-relief inhalers (78% reduction in daily use) and oral corticosteroids (40%); school and work days missed (44 and 33%, respectively).
• FLARE APCP convened asthma and ED experts to develop a set of standard discharge instructions for asthma patients following care in Michigan emergency departments (known as FLARE). The instructions were distributed in hard copy and several electronic formats to all hospital emergency departments (ED) in Michigan in 2006, and three national EMRs added FLARE to their systems.
• GIST The GIST program created simple, focused tools that help clinicians make decisions based on the EPR-3 guidelines, and incorporate these tools into their everyday practice to make optimal asthma care standard. Promotion and additional pilot practices in Michigan have been focused on safety net practices and those in the areas of highest burden. In the first six months of implementation in one pilot practice, the percent of patients on appropriate medications significantly increased, and the percent of patients with documented asthma action plans nearly doubled. National goals for this project include its use in accreditation projects for primary care physicians and inclusion in EMRs.
• Schools The APCP approach to helping schools address asthma has been successful because it is multi-faceted, supported by many partners, and helps schools change policies to make the improvements permanent. Using lessons learned in pilot schools, programs like the Healthy School Action Tool, school packets, and mini-grants emphasized a teamwork approach to the comprehensive assessments of the schools, and improvements that could be sustained through standardized staff education and building maintenance.
• HHU/ACE APCP has supported many in-home interventions for persons living with asthma that include indoor and outdoor trigger assessments, including the Healthy Homes University (HHU) program. HHU served low to moderate-income children with asthma, with both environmental education and visual inspection for indoor environmental triggers and installation of products to reduce trigger exposures. HHU evaluation results showed a significant decrease in asthma symptoms, emergency rooms visits, hospitalizations and missed school days as a result of the program. The APCP and HHU are now partnering to combine the comprehensive in-home asthma case management of MATCH and the home environmental assessment and product installation of HHU in a program known as Asthma Control through Education and Environment (ACE). This combination program should show even greater reward for participants – giving them the best, tailored asthma education and the environmental products and services that will help them better self-manage their asthma.

Evaluation
APCP conducts process, impact, and outcome evaluations to understand the utility and value of Michigan’s asthma interventions, surveillance system, and partnerships. This allows for a data driven approach to addressing asthma and to determine the long term impacts of state and local programming. Additional data systems were added to identify intervention points and evaluate changes in quality of care and self-management. For example, analyses of Medicaid claims data linked with the Michigan Asthma Mortality Review provided detailed information on coordination of asthma care and self-management, enabling the identification of populations of greatest need and the most crucial points of intervention and policy adjustment. This led to a focus on implementation of case management for people with high risk asthma (MATCH), to the development of standard asthma discharge instructions for emergency departments (FLARE), and targeting asthma education resources to schools in the poorest areas. State hospitalization and Medicaid claims data are also used to evaluate the impact of interventions and policy change on rates of hospitalization, emergency department visits, outpatient utilization, and short-acting and long term controller medication use.

Between 2000 and 2007, activities of APCP and our partners have contributed to a 24% reduction in the asthma mortality rate in Michigan (from 16.7 to 12.7 asthma deaths per million people), preventing an estimated 182 deaths. Similarly, pediatric asthma hospitalization rates in the state have dropped by 28% between 2000 and 2009. Children enrolled in Michigan Medicaid programs, a particular focus on APCP programs, experienced a 41% decrease in asthma hospitalization rates between 2005 and 2009.

Management and Structure
APCP provides leadership, coordination of efforts, asthma expertise, and resources. It is guided by the goals and objectives of the Michigan asthma strategic plan, developed by APCP and stakeholders from across the state. Oversight is provided by the Michigan Asthma Advisory Committee and its four subcommittees (Environmental Quality, Epidemiology & Surveillance, Asthma in Schools, and Quality Improvement in Asthma Care). The subcommittees are charged with facilitating implementation of specific activities in their content area, with help from Project Teams that carry out time limited activities, and involve subcommittee members and additional topic experts. APCP is responsible for addressing asthma throughout Michigan, and concentrates on communities with the highest asthma burden.