AmeriHealth Caritas

Winner Blurb: 

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.

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Community health workers provide hands-on community outreach that complement and strengthen AmeriHealth Caritas’ efforts to support members with asthma and improve the quality of health care services they receive. This is accomplished through a range of activities that provide member education and access to health care screenings and innovative programs that improve asthma-related health measures.

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Public Health—Seattle & King County

Winner Blurb: 

During its 20-year history, the King County Asthma Program (KCAP) at Public Health—Seattle & King County has pioneered research and programs in asthma management. Under the guidance of Dr. Jim Krieger, KCAP developed its core programming: home visits with community health workers (CHWs) to reduce asthma triggers in homes and improve asthma outcomes. For 20 years, KCAP’s projects and research have helped build the solid evidence base for this model, which now informs asthma services offered across the nation. To build this program, KCAP program staff have worked with care providers in public health settings, hospital systems, community clinics, health plans, schools, housing agencies and community organizations. Since its original demonstration project began in 1997, KCAP has engaged more than 4,000 patients in programs to manage environmental asthma triggers and improve care delivery for better health outcomes.


Building on a deep history of providing asthma services to those most in need, KCAP’s current Guidelines to Practice (G2P) project focuses on coordinating care and services for low-income clients with poorly controlled or uncontrolled asthma, specifically for King County’s African American, Hispanic and Somali communities. These communities are disproportionately affected by asthma and more likely to live in housing that exposes them to asthma triggers. Funded through a grant from the Patient-Centered Outcomes Research Institute (PCORI), G2P is KCAP’s most robust program to date. The program coordinates care between the patient, the patient’s health care provider and the patient’s health plan. Experienced CHWs work with patients in their homes to reduce asthma triggers; they also provide case management, support, supplies and resources to help patients self-manage their asthma. Working with several clinics and health plans, KCAP has developed an enhanced electronic health record template that streamlines communication between CHWs, care providers and health plan managers, making it easier for patients to access care. The three care teams are now able to work from a shared asthma care plan.


KCAP’s four CHWs have extensive experience working with individuals to improve health outcomes. Some have backgrounds in social work, medical assistance and medical interpretation, but their strongest experience is their deep familiarity with the communities they serve. CHWs have social and cultural connections and shared life experiences with their clients, which helps ensure that KCAP’s care delivery is culturally relevant. The program currently enrolls clients, both adults and children, to receive up to three home visits from a CHW. Each home visit consists of a home environment assessment, assistance with the identification and management of asthma triggers, and a discussion about medication concerns and adherence. The CHW sets self-management goals and provides practical tools to reach those goals, including a free High-Efficiency Particulate Air (HEPA) vacuum; HEPA air filters for high-risk patients; allergen-control bed covers; food storage containers; green cleaning kits; and an asthma spacer, peak flow meter and medicine boxes.


Many clients face pressing stressors that overshadow asthma as a concern, such as poor housing conditions, housing instability and mental health issues. Although CHWs emphasize asthma management, they can coordinate additional services so that these patients can begin to focus on their asthma. CHWs can connect patients with KCAP’s partners and local agencies offering other clinical and social services. The CHWs’ ability to provide culturally competent, empathetic approaches to the many social and environmental causes of asthma have been a cornerstone of KCAP’s success in asthma care for the past 20 years. KCAP’s programming is expanding to include additional partners that can more directly offer clients asthma-related services. These programs include housing weatherization and repairs specific to respiratory disease, tenant advocacy and legal resources, child care consultation, and training for pharmacists on medication adjustment.


In addition to working with clients in their homes, KCAP’s current program works with care providers and health plans to change systems and improve delivery of services in the community. KCAP is working with 13 clinics and two health plans to improve clinical care guidelines; equip clinics with spirometry and allergy testing; and optimize electronic health records to improve communication and care coordination between care providers, patients, CHWs and health plans. It also is working with two health plans to improve their Medicaid Managed Care Plans, adding such components as enhanced case management, medication monitoring, and provider notification of emergency room visits or hospital discharge.


KCAP’s extensive body of work in environmental asthma management and care coordination is evident in the successful patient outcomes throughout the program’s history. KCAP’s pioneering efforts with the CHW model and care coordination have contributed to decreases in asthma-related hospitalizations and urgent care use, increases in patient and caregiver quality of life, and a greater overall return on investment when compared to standard care. KCAP continues to build the evidence base for the CHW model and patient-centered asthma care, and it serves as an exemplar for asthma care delivery across Washington state and nationwide.

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Winner Photo Caption: 

Over 20 years, King County Asthma Program’s (KCAP) Community Health Worker programs have reached over 4,000 patients in programs to manage environmental asthma triggers and improve care delivery for better health outcomes. Above, CHWs, program staff, and project partners from KCAP’s Guidelines to Practice project.

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Urban Health Plan(UHP)

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Urban Health Plan (UHP) is a network of nine community health centers and nine school-based health centers located in the South Bronx, NY—the poorest congressional district in the country—and in Corona, Queens, NY. Located within UHP’s catchment area, in Hunts Point, Bronx, is the largest food distribution center in the country. As a result of the traffic and pollution generated by the trucks used to distribute food, Hunts Point has one of the highest asthma rates in New York City. Due to the incidence and prevalence of asthma in this area, and because many of UHP’s patients are unaware that they have asthma, early diagnosis is critical. By integrating asthma care into primary care, all patients are screened for asthma every 6 months, including those with no history of asthma. In 2009, 1,000 patients were screened and 22 percent were diagnosed with asthma.


Asthma Relief Street, UHP’s asthma management program, cares for more than 12,000 people with asthma using a multidisciplinary program that is fully integrated into its primary care practice. The primary care provider, health educator and medical assistant (MA) work closely with UHP’s allergists, pulmonologists, social service workers and the integrated pest management program, as well as with New York City Asthma Intervention and Relief (a.i.r. nyc), to provide integrated health care services.


UHP has created long-lasting relationships with community organizations and has partnered with local hospitals and the neighborhood’s shelters to provide support and asthma education to their constituencies. UHP works closely with the New York City Department of Health’s New York City Asthma Partnership, a citywide coalition that brings together more than 400 community-based organizations and individuals to make recommendations to improve citywide policies and systems that affect people with asthma. This partnership is coordinated by the New York City Asthma Initiative.


UHP has developed a unique workflow algorithm to help identify patients and optimize appropriate treatment and followup. Any patient who visits UHP for primary health care services, whether he or she is an asthma patient or not, meets with an MA who ask a series of questions about asthma and asthma risks, following UHP’s asthma template or asthma-screening template. This visit with the MA is followed by a visit with the primary care provider, who reviews the patient’s responses to the MA’s questions about signs and symptoms and the Asthma Control Test, focusing on medication use; reviews and updates the patient’s Asthma Action Plan as needed; and answers any patient questions. Following the visit with the provider, a health educator holds a counseling session with the patient and reviews five asthma lesson plans: (1) definition of asthma (2) the signs symptoms of exacerbations (3) recommendations on remediation in the home to address environmental triggers (4) differences between "controller" and "rescue" medications (5) and understanding of spirometry and exhaled nitric oxide. Health educators also address any concerns the patient might have about asthma management. This process is repeated during all visits.


UHP’s goal is to empower patients and families to better manage their illness, so patients are encouraged to set self-management goals with the asthma health educator. The five-lesson asthma curriculum, which was developed by UHP clinicians, is used to educate both patients and their families. Using a self-management tool box that includes placebo medications, spacers, peak flow meters, masks, and sample Asthma Action Plans (AAPs), the health educator provides hands-on demonstrations on how to use the metered dose inhalers, dry powdered inhalers and nebulizers. Through an arrangement with various vendors, nebulizer compressors and aerochambers are provided to patients who need this equipment for treatment at home. This allows the health educator to provide hands-on demonstrations on how to use the machine and to provide cleaning and storage instructions to patients.


As of December 2015—

  • 89 percent of UHP’s patients have had a severity assessment.
  • 99 percent of patients with a severity assessment of “persistent asthma” are treated with anti inflammatory medications.
  • 50 percent of UHP’s patients have documented self-management goals.
  • 56 percent of UHP’s patients receive the influenza vaccine each year.
  • 3 percent of UHP’s patients had urgent care or emergency department visits in the previous 6 months and an average of 11 symptom-free days and 0.156 work/school days lost per month.
Winnner Photo: 
Winner Photo Caption: 

The Urban Health Plan Asthma team: Back row: Caridad Taura, health educator; Samuel DeLeon, MD, Chief Medical Officer and Senior Vice President for Medical Affairs. Front row: Health educators Grace Baez, Vanessa Montanez and Kelly Chacon; Acklema Mohammad, MD, Chair, Pediatrics and asthma physician champion; Christine Torres, health educator.

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Asthma Regional Council for their New England Asthma Innovation Collaborative

Winner Blurb: 

Health Resources in Action’s Asthma Regional Council (ARC) established the New England Asthma Innovation Collaborative (NEAIC) in 2012 with a Center for Medicare and Medicaid Innovation (the Innovation Center) Health Care Innovation Award. NEAIC’s goal is to improve asthma outcomes, quality of care, and health care costs, especially for Medicaid and State Children’s Health Insurance Program (CHIP)-enrolled children, by advancing asthma home visits and sustainable payment systems across four New England states: Connecticut, Massachusetts, Rhode Island and Vermont. This goal supports the Innovation Center's aim to achieve better care for patients, better health for communities, and lower costs through improvements to the health care system. NEAIC achieves this goal through asthma self-management education; home environmental assessments, including minor-to-moderate environmental intervention supplies to mitigate asthma triggers; and use of nonphysician providers shown to be cost-effective deliverers of this level of care, particularly community health workers (CHWs) and certified asthma educators (AE-Cs).


During NEAIC’s 3 years of Innovation Center funding, providers utilized CHWs and AE-Cs to provide evidence-based home visit assessments and interventions. The target population was pediatric patients (ages 2–17) with poorly controlled or uncontrolled asthma symptoms who had a history of using expensive urgent care, with a focus on high-cost Medicaid and CHIP patients. Patients were enrolled in the intervention for an average of 6 to 8 weeks, with followup at 6 and 12 months after the first home visit. Medicaid payers provided patient claims and encounter data to monitor costs and outcomes for their patient populations, and some will consider new reimbursement policies should the interventions demonstrate positive health and cost outcomes.


Broadly, NEAIC focuses on four components: (1) workforce development, (2) rapid service delivery expansion, (3) committed Medicaid payers, and (4) a Payer and Provider Learners Community. Each component builds in continuous quality improvement measures through rigorous data collection/analysis, strong partnerships, and commitments from interested payers and policymakers.


In support of a well-trained workforce, NEAIC has provided scholarships for individuals to attend an asthma training institute to increase the number of AE-Cs; they also sponsored core training (a 48-hour course) and asthma home visiting training (a 24-hour course) for CHWs. Both asthma educators and CHWs are considered qualified and cost-effective providers. NEAIC also explored payers’ attitudes, knowledge and beliefs about both asthma home visits and CHWs. These conversations led to recommendations for innovative CHW asthma-credentialing programs that payers and provider practices across New England have requested and can benefit from. These combined efforts should contribute to higher-quality and culturally competent care, and NEAIC believes that the demonstrated cost-effective outcomes will help support innovative Medicaid reimbursement.


NEAIC experienced rapid service delivery expansion and provided asthma home visits to 1,145 high-risk children with asthma in its four-state service area during its 3 years of Innovation Center funding. Self-reported data and observations during home interventions show improvements to several intermediate factors, including exposure to environmental triggers, which may explain the improved asthma control and reported decreases in the use of health care services. Findings point to improved quality of life for asthma patients and their caregivers, including a nearly 50-percent reduction in the number of days patients missed school because of asthma and a more than 60-percent reduction in their caregivers’ missed work days.


Since its inception, NEAIC has engaged Medicaid payers as partners to provide claims data, participate in regional meetings, and consider financing and policy changes should the service model results achieve the Innovation Center’s aims.


The Payer and Provider Learners Community exists to rapidly disseminate demonstrated improvements to the quality and cost of asthma care, share viable reimbursement systems developed, successfully incorporate CHWs into the asthma care team, and disseminate best practices across New England. The Learners Community builds on ARC’s existing networks and partnerships across the region to increase awareness about these successful models, with the goal of broader adoption across New England.


Through these four components, NEAIC establishes and promotes CHWs as strong health care delivery partners who address environmental conditions as part of the disease management program—with reimbursement by payers—making this an innovative model for broad dissemination and potential replication across the nation.


NEAIC’s Partners


Clinical Providers

  • Boston Children’s Hospital (Boston, MA)
  • Baystate Children’s Hospital (Springfield, MA)
  • Boston Medical Center (Boston, MA)
  • Children’s Medical Group (Hamden, CT)
  • Middlesex Hospital (Middletown, CT)
  • Rhode Island Hospital/Hasbro Children’s Hospital (Providence, RI)
  • Rutland Regional Medical Center (Rutland, VT)
  • St. Joseph’s Health Clinic (Providence, RI)
  • Thundermist (Woonsocket, RI)


Workforce Development Partners

  • Central Massachusetts Area Health Education Center, Outreach Worker Training Institute (Worcester, MA)
  • American Lung Association of the Northeast (Waltham, MA)
  • Boston Public Health Commission, Community Health Education Center (Boston, MA)
  • Massachusetts Association of Community Health Workers (Worcester, MA)


Medicaid Payers

  • BMC HealthNet Plan (Boston, MA)
  • Department of Vermont Health Access (VT State Medicaid)
  • Connecticut Department of Social Services (CT State Medicaid)
  • Health New England (Springfield, MA)
  • MassHealth (MA State Medicaid)
  • Neighborhood Health Plan of Massachusetts (Boston, MA)
  • Neighborhood Health Plan of Rhode Island (Providence, RI)


Winnner Photo: 
Winner Photo Caption: 

Marie Gilmond (Rutland Regional Medical Center, VT), Susan Sommer (Boston Children’s Hospital, MA), Veronica Mansfield (Middlesex Hospital, CT), Stacey Chacker (Health Resources in Action), Megan Sandel (Boston Medical Center, MA), Annie Rushman (Health Resources in Action), Elizabeth McQuaid (Hasbro Children’s Hospital, RI), June Tourangeau (St. Joseph Health Center, RI), Michael Corjulo (Children’s Medical Group, CT). Missing from this picture is Matthew Sadof (Baystate Medical Center, MA), Donna Needham (Thundermist Health Center, RI) and Heather Nelson (Health Resources in Action)

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