Promote Institutional Change for Sustainability
New York State's Medicaid program offers financial incentives to Medicaid managed care programs that perform well on a number of measures. Monroe Plan has consistently achieved high scores in these measures resulting in quality incentive payments from the state. Monroe Plan's Board has committed to reinvest these funds into quality improvement, which has sustained quality initiatives, including the Improving Asthma Care for Children program.
Rochester, NY, faces significant challenges in children's health care. A 1998 study ranked the area near the bottom of 216 cities in child quality of life and the city's school district has the state's highest poverty rate (78%) and a large minority population. Monroe Plan saw trends in pediatric asthma and noticed high admission rates and that minorities were particularly affected. In the fall of 2001, in partnership with ViaHealth, a health care delivery system, Monroe Plan launched a program to shift asthma care away from emergency services and inpatient care toward improved patient self management. Because of the program's success, Monroe Plan has expanded the program to include all of its members with pediatric asthma.
Ensure Mission-Program Alignment
Monroe Plan's mission focused on improving health outcomes and reducing health disparities. Consequently, to be consistent with that mission, Monroe Plan's leadership knew that it had to improve asthma care for its children. Monroe Plan adopted the Center for Health Care Strategies' Best Clinical and Administrative Practices (BCAP) Quality Framework to support the development of the program. Monroe Plan and ViaHealth recognized that they could do more to better serve children by working together and determined that asthma patients needed more education if they were to become fully engaged in their own care. Monroe Plan and ViaHealth received a grant from the Robert Wood Johnson Foundation (RWJF) to support asthma educators and outreach workers; used plan data to identify children with asthma with multiple visits to primary care providers (PCP), emergency department (ED) visits or inpatient stays; made sure that all children with an asthma diagnosis were linked to a PCP; provided improved data for PCPs to support their asthma care delivery (e.g., make sure PCPs know when patients go to the ED); engaged patients in specialty care services; provided home visits to enhance asthma management understanding; and improved administrative processes to support these interventions.
In addition to providing the data to support providers, Monroe Plan also responded to providers calls for education. "We found out our providers didn't know as much about asthma as they wanted to know--assessment, management, using equipment--they were honest about the information they were missing. They also said that they had limited time for patient education." Monroe Plan designed a program to address the providers' needs.
To develop provider education, Monroe Plan borrowed, with permission, content from Family Health Partners and Children's Mercy Hospitals, American Lung Association and Denver Jewish Hospital provider curricula for asthma. Monroe Plan developed a five-hour program for which providers and their staff may receive continuing medical education credits. Monroe Plan partnered with other payers in their market to create a set of uniform codes that allow providers to bill for patient education once they have completed the training. "It became easy for offices to provide asthma education, particularly once they only had to worry about one code set." Monroe Plan trained Asthma Education Counselors at every site, created a registry of Asthma Education Counselors and shared the registry with the other payers. Monroe Plan also changed their benefits structure to make it easy for providers to deliver high quality asthma care: they began paying for spacers and nebulizers and removed the specialty referral requirement so that children could easily get allergy skin testing.
STRONG COMMUNITY TIES--ENGAGE YOUR COMMUNITY 'WHERE IT LIVES'
Monroe Plan heard from providers that they had limited time to deliver asthma education, so they decided to augment clinical education with home visits. To reach their diverse population, Monroe Plan hired a dedicated Asthma Outreach Representative, Neil Padraza, who is from the community he serves. Neil has lived in the Rochester area for 20 years. He is bilingual and understands the cultural background of Monroe Plan's Hispanic members. When Neil conducts home visits to educate children with asthma and their families, people recognize him, understand him and welcome his help.
Evaluate Program Implementation
Monroe Plan's Dr. Stankaitis, the Chief Medical Officer and Howard Brill, PhD, Director of Medical Informatics, led a team to develop an evaluation strategy involving quality of life, care management process, medical claims and qualitative interview data. "We do the survey twice a year (seasonally) to catch people when they are more aware of their asthma. We want to know how our program is impacting them and whether we were delivering the kind of care we want to be providing," said Deb Peartree, the Plan's Director of Clinical Services.
Use Evaluation Data to Demonstrate the Business Case
According to Deb Peartree, being able to demonstrate the quality of life impacts and collect utilization information from the pilot program was a driving force in Monroe Plan's program sustainability. "We were able to build an initial business case that enabled the Board to support expanding it to the entire population because we were achieving improved quality of life and demonstrating a shift in costs from ED and inpatient utilization to primary and specialty care. Our survey results showed that our program had improved patient's lives and that was a slam-dunk for our Board. We are fortunate to have a committed Board that is dedicated to quality of care and it is easy for them to support us when we have good data to put in front of them."
When Monroe Plan began its efforts, 51% of children in the ViaHealth system were categorized as having moderate-to-severe asthma based on their utilization of higher level services. After efforts to coordinate better care, the percentage dropped to 25%. The results of Monroe Plan's Integrated Therapeutics Group Asthma for Children Survey showed that the plan achieved significant improvements in all of the relevant measures for asthma: daytime and nighttime symptoms, functional limitations, inhaler adherence and family-life adjustment. In addition, hospitalization and ED visit rates demonstrated a downward cost trend.