South Bronx Asthma Partnership, Bronx-Lebanon Hospital Center
Focus on the Resource Strategy at Every Step
BLHC-CAMP grew in stages as key leaders emerged, new partners were engaged and resources were allocated to support the delivery and expansion of comprehensive asthma services. Over time, partners established a framework for delivering comprehensive care through three principle domains—the clinical care component run by BLHC; the community education and intervention component run through the South Bronx Asthma Partnership (SOBRAP); and the hospital-community integrated programming component, which BLHC and SOBRAP collaborate to deliver.
Clinical care is delivered by the BLHC Department of Pediatrics in the pediatric ED and inpatient ward, the Pediatric Asthma Center, Pediatric Subspecialty Center and at five ambulatory care network sites located throughout the Bronx. SOBRAP, meanwhile, coordinates a wide range of community-based activities, including home visits, which include asthma education and environmental assessment; school and daycare-based asthma surveillance, education and multi-faceted environmental interventions; and the Annual “Asthma in the Bronx” Conference, among many other programs. Jointly, the hospital and SOBRAP deliver a large number of programs that reach out to the community and support asthma patients and their families through medical, social and environmental interventions. One such jointly run program is BEAM, “Bronx Emergency Asthma Management,” an intervention targeting patients who frequently visit the pediatric ED. BLHC helps identify the patients and SOBRAP invites them to an educational “BEAM brunch” where they learn the importance of adhering to medical management, the benefits of following a tailored Asthma Action Plan, strategies for reducing exposures to environmental triggers and the importance of regularly scheduled visits with a primary care provider. Following the BEAM brunch, SOBRAP staff coordinates follow-up care with clinical providers and helps BEAM families access home visits and social support services to improve their child’s asthma control.
Use Data to Demonstrate Your Program’s Value — Demonstrate Your Program’s Impact
BLHC-CAMP supports clinical services through third-party insurance payments. Most patients are covered by Medicaid Managed Care, which reimburses for standard clinical asthma services with primary care providers, as well as hospitalizations and ED visits when necessary. Because the vast majority of BLHC-CAMP’s patients are Medicaid-eligible, and Medicaid reimburses for the care BLHC provides, the clinical care component is largely self-sustaining through revenue. However, the actual costs of clinical asthma care are declining because BLHC is reducing the burden of asthma visits over time. Since 2004, the number of asthma-related hospitalizations has declined by 42% and the lengths-of-stay for asthma-related hospitalizations has declined. This improved care is yielding an annual average cost savings of about $431 per child. But the issue of cost-savings is complex because what constitutes a savings from a public health perspective actually results in a loss of revenue to the hospital system. Therefore, it has become increasingly important to BLHC’s organizational leadership to focus on leveraging other sources of financial support that promote the mission of BLHC-CAMP.
Be Visible: Funders Support What They Know
The program has leveraged the scope, visibility and diversity of its interventions to engage a wide variety of local, state and national funders, and has embedded many interventions within its partner organizations. In addition to NYSDOH, the primary funder of SOBRAP, several BLHC-CAMP initiatives receive support through grants and contracts. Funders include the New York City Department of Health and Mental Hygiene, which supports the Managing Asthma in Daycare program; the United Hospital Fund, which supported the Asthma Literacy Project, an initiative to recruit and train community volunteers to serve as “asthma literacy advocates” and teach parents of children with asthma self-management skills; the National Asthma Control Initiative, which supports the Asthma Passport, a palm-sized, wire-bound guide to help parents and clinical providers navigate the critical components of the Asthma Action Plan; Merck Pharmaceuticals, which supported the 2008 SOBRAP Annual “Asthma in the Bronx” conference; and the American Lung Association, which supported the development of an integrated pest management study in Bronx-based elementary schools. BLHC-CAMP’s wide scope has made it possible to access local, state and national funders and leverage public relations to receive funding for new projects, as well as support for small local events. By offering funders and partners many opportunities to support elements of a multi-faceted, comprehensive, partner-driven system for care, BLHC-CAMP has spread leadership, ownership and responsibility for the program across the community.
INTEGRATED HEALTH CARE SERVICES — SUPPORT CONTINUOUS CLINICAL IMPROVEMENT
BLHC-CAMP uses data to drive improved performance among providers. BLHC-CAMP delivers anonymous “report cards” to BLHC pediatric health care providers with peer comparisons at quarterly departmental meetings. This performance feedback motivates providers to improve their documentation compliance. Providers who perform in the lower 50% must attend a guidelines refresher course.
STRONG COMMUNITY TIES — ENGAGE YOUR COMMUNITY WHERE IT LIVES
To reach the target population, BLHC-CAMP locates care sites within the community and meets local needs with local people. Three of the ambulatory care network sites are street-side clinics on main thoroughfares, and BLHC-CAMP conducts health fairs at schools, daycares, community centers and clinics. BLHC’s Community Asthma Educator is a bi-lingual community resident who delivers culturally-appropriate asthma education to patients and their families in the pediatric emergency department (ED) and in-patient ward. Her education sessions in homes, schools, workplaces and clinics help to facilitate referrals to primary care, asthma specialists, environmental services and other resources.
HIGH-PERFORMING COLLABORATIONS — BUILD ON WHAT WORKS
BLHC-CAMP’s success has resulted from coordinated efforts across a team of clinicians, administrators, program managers and community educators. These leaders work together to advance the goal of delivering care consistent with the National Asthma Education and Prevention Program’s Expert Panel Report-3 (NAEPP EPR-3) guidelines for asthma care. BLHC’s Pediatric Department Chairman and other senior leaders promote provider and patient education, outreach, treatment and training. Experts in clinical management, environmental issues, policy, school and daycare health, health literacy, managed care and other areas serve as champions for environmental interventions, education and advocacy. Parents of children with asthma are active in SOBRAP activities. This combination of clinical, educational, community and parental leadership has amplified BLHC’s ability to address the diverse asthma needs of a disproportionately affected community. To organize the dispersed leadership across the asthma care system, BLHC-CAMP is led by a Steering Committee that guides program direction and encourages communication across the collaboration. Steering committee members include BLHC senior leaders and representatives from Morris Heights Health Center, Health People, Visiting Nurse Service of NY, DeFranco Pharmacy, Martin Luther King Jr. Health Center, Asthma Free School Zone (AFSZ), NYC Department of Education Region 1, the Bronx District Public Health Office, and For a Better Bronx.
Evaluate Program Implementation
BLHC-CAMP incorporates evaluation in the program design to track patient health outcomes, achieve program goals and improve adherence to clinical practice indicators. Evaluation results drive continuous program improvement and support long-term sustainability. Data collected include: provider compliance with asthma care documentation requirements, parental knowledge and confidence following self-management education, asthma prevalence in pre-school aged children across the Bronx, asthma-related health care utilization and much more.
BLHC employs a centralized, integrated, electronic medical record (EMR) system, which captures and produces reports on patient information, such as scheduled and missed appointments, ED visits and hospitalizations, medication history and refill data, diagnoses (i.e., asthma severity classification), specialty consultation reports, spirometry results, immunization records and allergy test results. This data supports planned care, such as influenza vaccine reminders or invitations to attend BLHC-CAMP educational activities. Asthma clinical practice recommendations are also incorporated into the EMR to improve entry-to-exit clinical care by prompting guidelines-based documentation for pediatric asthma visits. BLHC-CAMP also conducts structured, interactive provider education sessions on guidelines-based care while monitoring key quality of care indictors including: documentation of impairment, risk, severity, control, stepwise treatment, self-management education, appropriate referrals and administration of the influenza vaccine to all pediatric patients with asthma. This education and evaluation process has shown a 50% increase in appropriate asthma severity documentation across all ambulatory care network sites between 2005 and 2010, and a 33% increase in annual influenza vaccination for patients with asthma from 2006 to 2010.
BLHC-CAMP also serves a coordinating function to help partners manage, monitor and share information. For example, the program’s Community Asthma Educator receives stratified data on high-frequency ED utilizers every month and coordinates referrals to clinical providers, environmental services and other support services. Additionally, she frequently receives referrals from SOBRAP partners for patients or caregivers in need of further one-on-one education. In this way, patient information is shared across the partner network to facilitate care.