Neighborhood Health Plan of Massachusetts (NHP) Snapshot
Let the Data Guide Program Planning, Design and Implementation
Initially, NHP's ADMP focused on characterizing the asthma population in Massachusetts by developing a registry to house medical and pharmacy data that will help NHP assess clinics' effectiveness in controlling their members' asthma and allow NHP to identify potential areas for improvement. In response to its data collection efforts, the program has expanded and today, NHP delivers a tiered disease management approach. The interventions are based on risk stratification and include generalized educational mailings, personalized case management and telephonic outreach; intensive home visits; and close coordination between home visitors, asthma care managers and providers. Currently, NHP is expanding to its ADMP by helping 10 community health centers that serve some of the plan's most at-risk members with asthma to adopt routine spirometry by providing equipment, training staff to perform tests and teaching providers how to interpret results. This intervention will benefit NHP members with asthma and all health center clients in these underserved, diverse communities, who are often the last to benefit from advances in medical technology.
Ensure Mission-Program Alignment
NHP was one of the nation's first health plans created specifically to address the health care needs of the underserved. It grew from a few thousand members in the late 1980s to more than 200,000 members today. Asthma is the number one chronic disease among NHP's members, affecting over 10% of its members, and the prevalence of asthma is higher in Massachusetts than in most states. It is highest among minority populations, including African Americans and Hispanics and low-income residents. To help address the disproportionate impact of asthma on low-income and minority communities, who are frequently exposed to high levels of housing-based asthma triggers and often unable to address structural impediments to environmental trigger controls, NHP developed its EAHVP in 2005. The EAVHP targets pediatric and adult allergic asthma members who, despite using appropriate controller medications, are experiencing uncontrolled asthma due to significant environmental exposures. The EAHVP provides home assessments and materials to help control environmental triggers and connects members to counseling and institutional support, such as public housing management and tenants rights programs, to help reduce environmental exposures.
Build Evaluation in from the Start--Establish a Process to Collect the Data You Need
NHP's registry is a powerful tool to drive identification of patients with poor asthma control, target provider education to improve clinical care and ensure utilization of aspects of the ADMP to those members most in need. NHP runs quarterly reports from the registry to identify members who may benefit from the ADMP. ADMP also can identify members through screenings, in-patient or ED utilization, high recent use of rescue medications and direct referrals. NHP then uses the registry reports to improve clinical care by providing site-specific information on in-patient and pharmacy utilization over the previous 12 months. Most sites also receive bi-weekly trigger reports, which identifies patients with current poor asthma control. NHP sends about 1,200 letters with individualized treatment recommendations to primary care providers each month based on their patients' presence on the trigger report. These members whose names appear on the trigger reports, receive educational mailings. The mailings include low-literacy information that defines good asthma control and describes the steps members can take to improve their asthma control, and a multi-lingual DVD providing video instruction on proper use of asthma delivery devices.
Promote Institutional Change for Sustainability
NHP does not receive outside funding for its ADMP; the program is funded through NHP's medical management budget. The program's leaders believe that improved health outcomes do not necessarily need to yield a positive return on investment to be deemed successful, however, they should represent a cost-effective use of medical and administrative spending. Because NHP is committed to improve health outcomes while reducing health care disparities in its member population and in the communities it serves and because asthma is the leading chronic disease among NHP members, the plan's leaders believe the ADMP is a high-priority, proven intervention worth continued support.
INTEGRATED HEALTH CARE SERVICES--FACILITATE COMMUNICATION ACROSS THE CARE TEAM
NHP holds integrated care management rounds each week where care managers, including asthma care managers, meet to discuss high-risk complex members and develop collaborative care plans. The asthma care managers help coordinate care provided at clinical sites and through the home visit program and direct educational outreach to targeted plan members with asthma.
NHP offers an Enhanced Asthma Home Visit Program (EAHVP) for patients who are using appropriate controller medication, but continue to show signs of poorly controlled asthma. The EAHVP offers multiple in-home visits by specially trained respiratory therapists, nurses or asthma educators to: assess asthma control and current treatment; provide education on triggers and appropriate medication use; conduct an environmental home assessment; suggest interventions and provide materials at no charge, such as impermeable mattresses, box springs, bed covers, pillow cases, a HEPA vacuum, a HEPA air purifier and, as needed, referrals to smoking cessation and housing remediation supports; and in consultation with the primary care provider, develop and review a written care plan to address patients' individual medical and environmental issues.
HIGH-PERFORMING COLLABORATIONS--BUILD ON WHAT WORKS
NHP collaborates to address environmental and social factors that contribute to poor asthma control. Partners include: The Greater Brockton Asthma Coalition, a partnership of community, health and environmental providers, insurers, educators and parents whose focus is reducing the number of asthma-related hospital and ED visits; Massachusetts Asthma Advocacy Partnership, the only statewide asthma partnership that links community organizations to efforts to achieve statewide environmental changes; and Boston Asthma Home Visit Collaborative, which leads home visiting efforts, including environmental assessments and interventions.
NHP conducts an annual survey to measure the number of members with asthma who received educational materials and the number enrolled in more intensive care management activities. The survey also gauges members' satisfaction with educational materials and assess their quality of life (QoL) improvements. NHP augments these member-reported results with data on asthma-related hospitalization, ED visits and asthma medication use patterns to determine how outreach and interventions impact health care utilization. In the most recent results, all survey respondents reported that the education tools are helpful and 96% said that the ADMP had improved their QoL, which exceeded NHP's goal of 90%. The percentage of members with an asthma-related ED visit or hospitalization also have shown positive trends. During the past decade, both have declined by more than 30%.
NHP also uses its registry to track program indicators on a quarterly basis. Using a variety of measures captured in the registry and analyzing data trended over a three-year period, NHP follows site-specific and plan-wide asthma care indicators, including the percent of members receiving appropriate medications and the ratio of controller to reliever medication received in the past year. More than 90% of plan members with persistent asthma based on HEDIS criteria receive appropriate medication, a rate significantly higher than most Medicaid plans. NHP has seen an increase in the ratio of controller to reliever medication use over the 10 years of the ADMP (from 0.42 in 1999 to 0.71 in 2009).