Health Care Service Corporation (HCSC), the nation’s largest customer-owned health insurer, in partnership with the American Lung Association of the Upper Midwest (ALAUM), has implemented comprehensive, community-based asthma quality improvement programs in more than 120 health care clinics in Illinois, Montana, New Mexico, Oklahoma and Texas. The program have served an estimated 435,545 individuals across these states, including low-income, Latino, and Native American populations. The ongoing effort works directly with providers to improve the quality of care being delivered to patients with asthma, in addition to direct engagement with individuals through home environmental assessments that include asthma education and providing allergen-reducing and remediation products. The company leverages its own medical claims data to identify providers serving the highest-risk children with asthma and the ALAUM invites these clinics to take part in a year-long learning collaborative and training program based on the National Asthma Education Prevention Program developed by the National Heart, Lung, and Blood Institute. Overall, hospitalizations for children years 18 and younger have reduced by 59 percent and emergency department (ED) visits have been reduced by 54 percent. For individuals older than 18 years, results showed a 52 percent reduction in hospital stays and a 56 percent reduction in ED visits for this population. The program has also realized a positive return on investment – a savings of $2.40 per dollar spent. Not only are patients able to better manage their asthma, but significant reductions in avoidable medical utilization drives down the cost of care for all and allows the company to play a vital role in making the health care system work.
AmeriHealth Caritas, through a local affiliate, implemented a comprehensive asthma management program serving Medicaid recipients in southeastern Pennsylvania’s five counties, including Philadelphia. This multifaceted program applies a sustainable approach based on population health, guiding members through a continuum of care that is built on solid evidence and works within AmeriHealth Caritas’ integrated health care management system. Members and network providers can participate in several unique, award-winning initiatives that support the delivery of asthma medication and supplies, asthma education, and home environmental surveys. Since 2012, AmeriHealth Caritas has incorporated asthma-specific measures into its Annual Operating Plan’s Managed Care and Quality goals.
In 2015, Philadelphia was ranked the third-worst city for asthma in the United States, with 16,000 children visiting emergency rooms each year for asthma-related causes. The asthma management program serves residents of culturally diverse inner-city environments such as west and northwest Philadelphia, where one out of four children has physician-diagnosed asthma or was admitted to the hospital for wheezing.
AmeriHealth Caritas works with local network providers and community-based organizations to deliver a range of services that reach members in their physicians’ offices, homes and communities to enhance existing care management efforts. Simultaneously, AmeriHealth Caritas continuously improves its capability to monitor, assess and refine its offerings based on member, staff and provider feedback.
Care managers and support staff guide members by telephone or in person across the continuum of care to (1) identify members with a primary diagnosis of asthma; (2) perform asthma management assessments; (3) categorize patients into risk strata and high-need population groups; (4) implement tailored interventions based on risk profile and social determinants of health; (5) perform reassessments as needed; and (6) monitor outcomes to quantify program effectiveness and financial sustainability. Low-risk members receive general and asthma-focused education through member mailings and are invited to AmeriHealth Caritas-led programs and events. High-risk members receive individual care management assessments, care planning and interventions focused on priority areas (i.e., asthma control action plan, sick day plan, medication management, behavioral risk management and asthma self-management). The asthma action plan incorporates environmental management protocols and helps members contact public and private entities, supporting members’ overall health. Member material—which can be translated into 200 languages on request—is written at a sixth-grade reading level and keeps patients’ cultural needs in mind to help members with limited English proficiency understand medical content.
AmeriHealth Caritas partners with the local affiliate’s high-volume network providers, which have led to distinct provider-specific community health worker (CHW) models in northeast Philadelphia, west Philadelphia and Chester tailored to the local demographic and fiscal environments. Trained CHWs, supervised by a medical director, cooperate with the practice- and telephone-based care management system to provide face-to-face care coordination, home health and environmental surveys, and asthma-related education for members and their families while addressing the social determinants impacting members’ health. When environmental asthma triggers are identified, the CHW suggests such actions as installing an air conditioner or new windows, removing carpet, and conducting mold remediation; in some instances, they even provide members with an “asthma home kit” (hypoallergenic mattress and pillowcase covers, storage bins, trash bags, cockroach bait stations and cleaning supplies). To help connect to cultural and health literacy barriers faced by members in their communities, CHWs often are hired from those same communities, and several are bilingual, primarily in Spanish and English.
Additional service offerings include provider-led dispensation of asthma medication and supplies and hands-on education during office visits (B.E.S.T. asthma program—Breathe Easy. Start Today.®); school-based clinic partnerships to address member care gaps in asthma medication adherence; and “edutainment” programming (Healthy Hoops®) for children with asthma and their families.
From 2013 through 2015, statistically significant improvements were observed in asthma controller medication adherence rates, acute hospitalizations and hospital readmissions. Increases in pharmacy expenditures for asthma medication were more than offset by significant decreases in hospital admission rates. Dozens of provider practices and thousands of members have participated in these asthma-focused initiatives, leading to 327 CHW-led home visits and environmental surveys, as well as the distribution of more than 13,000 asthma medications and supplies and 875 asthma home kits. During this time, hundreds of children with asthma and their families in the community attended Healthy Hoops® programs in the Philadelphia area, where pediatric participants received health screenings (including spirometry, peak flow and spacer education). Asthma action plan consultation stations provided participants with a clinical summary and a blank asthma action plan template to assist their providers in completing an individualized asthma action plan.
Peach State Health Plan in Atlanta, Georgia, is a statewide Medicaid managed care organization that delivers a customized asthma program for teenagers. The Plan is part of the Centene Corporation, an integrated health enterprise that delivers Medicaid services in 19 states. Peach State Health Plan has a targeted asthma improvement program focused on their teen members with asthma because almost 20 percent of teens in the Plan have an asthma diagnosis (13,159 members with asthma out of 66,138 members ages 13–19.) Peach State's innovative program has successfully engaged teens with asthma—a notoriously hard group to engage—and has demonstrated success in improving teens' ability to understand their asthma, improve their asthma, and address the environmental and social factors that can make asthma worse.
Peach State's Asthma Team seeks to reduce teens' asthma healthcare utilization, improve their asthma status (i.e., functional severity), ensure appropriate medication regimens per NIH EPR-3 Asthma Program Guidelines and promote self-management. They pursue these goals by facilitating relationships between teens, caregivers, primary care physicians and medical homes, providing access to specialists, delivering tailored education and addressing social issues, such as environmental exposures at home and school.
The Plan delivers stratified asthma management services, including health coaches and environmental, medical and social interventions in clinic, at home and at school. The Asthma Team includes health plan case managers, medical directors, pharmacists, a disease manager/ health coach and respiratory health coaches, who serve as the primary contact for teens, their families, the care team and partners.
Teens with an asthma diagnosis in the Plan's information system are stratified into three intervention groups—low, moderate and high risk—based on a multi-stage and validated initial health assessment. Sixty percent (60%) are in the low-risk intervention group and receive education materials by mail. The moderate group receives telephonic and mail outreach and can receive home visits if appropriate. The high-risk group, which includes about 700 members per year, receives telephonic and mail outreach and in-home visits. Peach State uses an innovative and award-winning incentive program, CentAccount, to motivate teens (and others) to take preventive care actions. For example, when a healthy activity, such as a preventive well visit, is completed, members receive money on a debit card they can use to purchase healthy items. This has encouraged teens with asthma to get well visits, thus helping to identify previously undiagnosed teens with asthma. In fact, teenage members in the asthma program have increased their attendance at regular wellness visits by more than 500% compared to a control group. This increased and proactive interaction with primary care providers at scheduled visits has helped teens with asthma to stay healthy and to stay ahead of their asthma rather than having them interact with their providers only after a serious asthma attack.
All teen members in Peach State's asthma program receive award winning, age-appropriate educational materials, including the multilingual and multimedia, "Off the Chain—It's All About Asthma" and "On Target with Your Asthma." These materials promote understanding of asthma, environmental triggers and appropriate medication use. Members in the low-risk group receive education by mail and can also receive peak flow meters, spacers, and masks as indicated.
Members in the moderate-risk group receive mailed education materials and telephonic counseling by health coaches to identify medical, environmental and social needs and to provide asthma education and self-management support. During calls, coaches collect self-reported asthma symptom data, review individualized treatment plans and self-management guides, and discuss environmental triggers; they also teach teens signs and symptoms that merit rapid intervention. The health coaches communicate back to the medical home and cooperating community organizations, such as schools and churches.
High-risk members receive everything the moderate group receives—education, barrier assessment, coordination of care and additional support—and in-home visits by a licensed Respiratory Care Practitioner. Home visits include disease education, medication counseling and an environmental assessment, which, according to Peach State, occurs in "the ideal setting to… assess all of the factors that impact the severity of the patient's condition…and [to facilitate] patient specific education." During visits, health coaches conduct spirometry screening and pulse oximetry, measure vital signs, review medications, demonstrate how to use spacers and peak flow meters, and discuss barriers to effective asthma control. During home visits, teens also receive counseling from a respiratory therapist about environmental factors in the home environment and their impact on asthma to take advantage of the 'teachable moment' that a home visit provides. The home visit team also identifies environmental factors in the home that may be contributing to the members' asthma and reviews in detail the teen-focused asthma education materials that address allergens and irritants.
In addition to the tailored interventions stratified by risk, Peach State's Asthma Team also bolsters clinical providers' abilities to care for teen asthma patients. The Asthma Team functions as an extension of the physician's practice by reinforcing the individual asthma management plan and providing up-to-the minute documentation on functional status, barriers and recommendations for future treatment based on the assessment.
Using clinical and financial data (i.e., medical and pharmacy claims), the Plan was able to model the health improvements and cost savings generated by the teen-focused asthma program. Compared to a control group, teens in the program had nine percent fewer respiratory-related unplanned healthcare utilization incidences and a shorter average length of stay when unplanned hospitalizations did occur. They were more likely to visit their primary care physicians as planned and to receive recommended flu vaccines, a critical self-management step as people with asthma are at increased risk of severe disease and complications from the flu because influenza can cause further inflammation of the airways and lungs. Peak flow meter use and controller medication use both improved at higher rates for program participants compared to a control group, while rescue inhaler use declined, indicating better overall asthma medication management and compliance. Peach State estimates the program saves approximately $320 per member per month. Recognizing the importance of environmental management of asthma, particularly for its Medicaid population, and the impact on the quality of care and patient outcomes that their program is achieving, Peach State Health Plan, Centene and Nurtur intend to continue funding the asthma disease management program.