Children's Hospital Boston Snapshot
CAI seeks to improve pediatric asthma outcomes for the most severely affected children in Boston. Asthma is the leading cause of hospitalization at Children's and the majority of Children's asthma patients come from Boston's poorest and most ethnically diverse neighborhoods. To ensure CAI reaches its target population, it enrolls children who have been hospitalized or admitted to the ED for asthma in a year-long case management program and gives priority enrollment to children who have had admissions or multiple ED visits.
As soon as CAI began assessing patients who frequented Children's for emergency asthma care, it became obvious that social and environmental issues were significant contributors to asthma severity within the program's target population. The neighborhoods clients are drawn from have a high percentage of older rental housing, significant mold, dust and pest allergen issues and high rates of poverty, unemployment, language barriers and low health literacy. In response, CAI designed a program that matches high-need children and their families with culturally appropriate case management that strengthens the connection to a medical home, helps families obtain insurance and affordable medications and facilitates access to community-based asthma care resources, such as home visits and housing advocacy assistance.
The CAI estimates its ROI by comparing hospital costs for asthma treatment for children in communities served by the CAI in the first two years of the program against costs for children from similarly affected communities that the CAI did not reach. The program has since expanded and now covers the comparison community. The program can estimate the costs of the clinical portion of the CAI because those costs are supported by Children's Hospital. Based on this data, the CAI calculates a ROI of 1.46.
The CAI is working with Children's Hospital's Office of Child Advocacy (OCA) to advocate for policy changes that would lead to reimbursement by private and public payers in Massachusetts for nurse case management and home visits for asthma. Such a change would allow Children's and other agencies throughout the city and state to deliver the CAI model to a wider population of children with asthma. Part of the argument that CAI and OCA present is the powerful cost benefit data that demonstrates considerable savings resulting from the intervention. The CAI leaders also tell a compelling quality story based on their health outcomes. Children's and other community partners have presented these findings to Medicaid and state legislators with some recent success. The preliminary state budget for fiscal year 2011 includes a provision establishing a bundled payment pilot for pediatric asthma that would enable providers to deliver tailored asthma interventions.
Institutional change that supports asthma program sustainability can occur within an organization, across a community coalition and at the policy level. CAI pursues all three approaches. CAI's leaders have collaborated with the Asthma Regional Council (ARC) of New England on a range of initiatives to promote changes to health plan reimbursement policies to support expanded asthma care services. For example, CAI and ARC worked together to develop a business case for health plans on comprehensive asthma care that includes environmental interventions. They also co-sponsored a policy forum for providers and plans, surveyed insurers to document current asthma benefits and gathered data to advocate for lower co-pays for asthma medications.
CAI is currently partnering with the Boston Public Health Commission, Boston Medical Center and other providers across the community in the Boston Asthma Home Visit Collaborative to develop a coordinated, sustainable, asthma home visit program for Boston. The effort seeks to achieve standardization of home visit protocols and link clinical providers to home service providers through a web-based referral and feedback system. It also will facilitate data sharing and evaluation; a city-wide asthma registry; demonstration of improved outcomes, such as reduced hospitalizations and ED visits and cost savings to strengthen the asthma business case; and negotiation as a single body with payers for insurance reimbursement.
The CAI is collaborating with a city-wide group of partners to develop a centralized system for collecting, managing and sharing data about asthma-related home visits. The partnership represents a large group of clinical asthma programs, local public health and housing agencies and others involved in home visit services. By bundling their efforts and data, the collaborative will demonstrate the significant health and cost impact of effective home visits for high-risk asthma patients. The partners plan to use the data to advocate for sustainable support from health plans for a city-wide home visit program.
CAI's case managers, both nurses and community health workers (CHWs) communicate with primary care providers (PCPs) after admission or ED visits, home visits and other interactions with enrolled children. They provide the PCPs with detailed assessments of the patients' asthma control and adherence to medications and findings of environmental home assessments and recommended actions to reduce trigger exposure. Home visitors have time to thoroughly assess patient needs and can judge and report back on the impact of the home environment and other social issues.
CAI delivers home visits to assess the medical and environmental needs of families, provide asthma education and deliver environmental interventions. During home visits, families receive one-on-one education on reduction of triggers, medication usage and the importance of ongoing asthma control. After an environmental assessment, families receive supplies, such as HEPA vacuums, bedding encasements, storage bins and Integrated Pest Management materials to address asthma triggers. When pest infestations, mold or structural issues pose a problem, home visitors advocate with landlords or housing authorities for improvements and refer families to the Breathe Easy at Home program, an initiative of the Boston Inspectional Services Department, the Boston Public Health Commission, health care providers and advocates, to identify sanitary code violations that must be corrected in order to eliminate or reduce asthma triggers in the home environment.
CAI tracks health outcomes for enrolled children at six and twelve months post-baseline. The program captures data provided by the families on health care utilization, missed school and work days and days with limitation in physical activity. Between October 1, 2005 and September 30, 2009, CAI provided case management services to 441 children. Of the total number of families enrolled, 315, or 71%, received one or more home visits.
Families enrolled in the year-long case management program reported a significant reduction in ED visits (65%), hospitalizations (81%), limitation in physical activity (37%), missed school days (39%) and missed work days (49%). In addition, there was a 71% increase in the number of children with up-to-date asthma action plans.
CAI's data also provide demographic and other information for the population the program is reaching. Of the 441 families enrolled in the program, 48% are African American, 45% Hispanic and 8% are other ethnicities; the majority (70.5%) use state Medicaid and, of those, 67% had household incomes of considerably less than $25,000 per year.