High-Performing Collaborations and Partnerships in ... · PDF fileTotal 153 18.91 23.19 4.28 0.63 • 100% improvement in perceived health • Reduction of 59% in ER visits. ... Organization

High-Performing Collaborations and Partnerships in Providing Asthma Care Services

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2014 National Award Winners Share Successful Asthma Management Strategies

Moderator:• Tracey Mitchell, U.S. Environmental Protection AgencyPresenters:• Kim Tierney, Multnomah County Health Department• Dr. Steven Dziabis and Allen Frommelt, PhD, Peach State Health Plan• May Chin and Sherry Dong, Tufts Medical Center

Welcome to the Webinar




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Introduction

Tracey MitchellU.S. Environmental Protection Agency




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Poll 1What type of organization do you represent?

Government Agency 41%

School Program 7%

Health Care Provider 14%

Community Asthma Program 28%

Health Insurer 10%




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Poll 2Are you currently involved with an asthma

management program?

Yes, my main role is to manage a local asthma program24%

Yes, part of my role is to support a

local asthma program25%

Yes, I partner with a local asthma management program21%

No, but I want to learn more

28%

No, and I’m not considering it

2%




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Purpose of Webinar1. Learn about three exemplary asthma management

programs and how they accelerate improvements in asthma care through high-performing collaborations and partnerships.

2. Hear about a key achievement of each program that contributed to positive health outcomes.

3. Learn about a challenge each program faced and the lessons learned in addressing the challenge.

4. Learn how to improve your asthma management program.




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Agenda 1. Introduce EPA’s National Environmental Leadership

Award in Asthma Management2. Hear from Speakers:

• Kim Tierney, Multnomah County Health Department• Dr. Steven Dziabis and Dr. Allen Frommelt, Peach

State Health Plan• May Chin and Sherry Dong, Tufts Medical Center




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About the Awards1. EPA has honored exceptional asthma management plans

for almost 10 years.2. Goal of the Awards program is to showcase the highest

standards in asthma care and management.3. Eligible Applicants

National Institutes of Health's (NIH's) Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma

4. Join the Hall of Fame by applying in 2015!




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The System for Delivering High Quality Asthma Care




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Connecting to the System

High Performing

Collaborations

High Performing

Collaborations




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Multnomah County Health Department

Kim Tierney, MPH, Program Supervisor




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Multnomah CountyHealthy Homes and Families

Program• Location – Portland, Oregon• Population served – Low-income families with

children with Asthma/Reactive Airway Disease• Geographic area served – Multnomah County• Key partners – City of Portland, Weatherization,

Community-Based Organizations, Multnomah County Clinics, WIC, HUD, Medicaid Program, Home Repair Agencies, Head Starts




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Three Programs• Healthy Homes Asthma Program

– 6 month nursing case management program serving low income children with asthma

– Nurse serves as case manager; Community Health Worker (CHW) provides environmental interventions

– Provide household supplies and refer to community services– Program originally 2005 HUD Demonstration Grant, now largely funded through

Targeted Case Management (Medicaid). • Community Asthma Inspection Referral Program (CAIR)

– Similar to Healthy Homes, but CHW is case manager, with nurse and EHS– Serving low-income children with asthma & other environmental health

conditions– 2010 HUD Healthy Homes Demonstration Grant, but Targeted Case

Management provided program income to expand grant– Partner funds paid for home repair

• AIR Program – One time in-home environmental assessment by EHS to identify asthma triggers




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CAIR Program

The CAIR program works with community partners to provide small home repairs, access to medical care, and linkages to social services, including relocation. The case manager is a Community Health Worker who refers to a nurse for health care concerns and an EHS for physical

home repair.




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CAIR Program Goals• 323 households enrolled in CAIR• 320 total environmental assessments• 160 housing units receiving physical remediation• 160 referrals to Nursing Case Management• 300 units completed• 16 community outreach & education presentations &

20 persons provided skills training

• All goals exceeded: 312 units completed




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Structural Components• Multidisciplinary Teams • Environmental Assessment and Intervention• Nursing Case Management• Physical Remediation• Web-based Database System and Mobile Access• Program Evaluation and Return on Investment• Targeted Case Management Medicaid Reimbursement • Policy Component and Strong Partnerships




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Partnership Success Story• CAIR Program

– Conducted Nursing Case Management. • Provided medical supplies. • Dust containment. • Mold and moisture mitigations, increase ventilation, monitor humidistat. • Childproofing, smoke alarms, and general home safety.

• Partner Support:– OHP Transportation

• Medical transportation

– Community Warehouse • Replaced moldy household furnishings

– SEI • Energy assistance

– REACH: Physical repairs• Replaced kitchen sink drain, bathtub and bath vanity lines.• Replaced old gutter to direct water to front yard.• Replaced foundation vent screens with 1/4" mesh.• Replaced broken vinyl window sash. Replaced window.




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Before and After Intervention




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CAIR Program’s OutcomesAsthma Control Test Scores of CAIR Participants

Students Sampled

Initial Score Mean

Final Score Mean

ACT Improved Mean

ACT Plus 3 Proportion

Asthma not in Control

76 14.87 22.47 7.60 0.92

Asthma in Control

77 22.90 23.91 1.01 0.34

Total 153 18.91 23.19 4.28 0.63

• 100% improvement in perceived health• Reduction of 59% in ER visits




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Multnomah County’s Lessons Learned

• Identify how each partner benefits from partnership.• Develop streamlined referrals between agencies.• Community Development Block Grant (CDBG) dollars may

be available for help with repairs, relocation, flexible use.• Not all partners have the same timelines.• Work together to eliminate leverage resources.• Job shadow when possible.• Sharing staff with CBOs increased access to resources and

referrals.• There was greater need for nursing and home repair than

anticipated.




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Peach State Health Plan Steve Dziabis, MD

Senior Medical Director, Peach State Health Plan

Allen Frommelt, PhDDirector of Measurement & Analytics,

Nurtur




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Peach State Specialty Companies

Total Solution Integration:• physical health

• behavioral health

• pharmacy services

• ancillary services

24‐Hour Nurseline

Individual & Uninsured Solutions

Vision Benefits

Case Management Software

HCBS for I/DD Populations

Pharmacy & Specialty Pharmacy Benefits

Health & Wellness,

Work‐Life, EAP

Behavioral Health & Specialty Therapies

Centurion is a correctional healthcare joint venture between Centene and MHM Services Inc. Currently has contracts in

MA, MN and TN.




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About Peach State Health Plan • Peach State Health Plan is a Care Management

Organization (CMO) that reports to the Department of Community Health and has been in operation since 2006.

• Based in Atlanta, Georgia, and currently serving nearly 314,000 CHIP and TANF members, including 66,138 members between the ages of 13 and 19.

• 13,159 of these teenage members have been diagnosed with asthma according to our clinical information systems.




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Our Asthma Story




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Background

• For this webinar, we will highlight our experience in Georgia with our teen asthma population managed by Peach State Health Plan.

• Teenagers present a unique challenge as they are often a difficult population to engage in the management of their chronic disease.

• Our experience in Georgia shows a need to align our clinical and business leadership, as well as parents, providers and community organizations to become champions for our asthmatic teen members resulting in better health outcomes.




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The NeedsOur identified needs for our teens with asthma are as follows:• Need to facilitate the relationship between the patient,

parent/guardian, primary care physician (medical home), and health plan

• Access to a specialist when indicated• Educational materials and outreach that engages and empowers

teenagers to be a part of the management of their chronic disease.• Help with compliance of maintenance medication for asthma control• Support with social issues such as adverse environmental factors in

the home, and school, interactions with peers and lack of transportation




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GoalsPeach State’s Teen Asthma Program has four primary goals:

1. Reduce healthcare utilization related to asthma.

2. Improve functional status through reduced symptom

severity and frequency.

3. Promote medication regimen recommendations of the

NIH EPR-3 Asthma Program Guidelines.

4. Promote participant self-management according to NIH

EPR-3 Guidelines.




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The Process

• The Plan delivers stratified asthma management services, including health coaches and environmental, medical and social interventions in clinic, at home and at school.

• The Asthma Team includes health plan case managers, medical directors, pharmacists, a disease manager/ health coach and respiratory health coaches, who serve as the primary contact for teens, their families, the care team and partners.




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Identification• Teens with an asthma diagnosis in the Plan’s information

system are stratified into three intervention groups—low, moderate and high risk—based on a multi-stage and validated initial health assessment.

• Sixty percent (60%) are in the low-risk intervention group and receive educational materials by mail. The moderate-risk group receives telephonic and mail outreach and can receive home visits if appropriate. The high-risk group, which includes about 700 members per year, receives telephone and mail outreach and in-home visits. Peach State uses an innovative and award-winning incentive program, CentAccount, to motivate teens (and others) to take preventive care actions.




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Engagement TechniquesAll teen members receive award-winning, age-appropriate educational materials, including the multilingual and multimedia, “Off the Chain—It’s All About Asthma” and “On Target with Your Asthma.” These materials promote understandingof asthma, environmental triggers and appropriate medication use.

• Low-risk: education by mail and can also receive peak flow meters, spacers, and masks as indicated

• Moderate: mailed education materials and telephone counseling by health coaches to identify medical, environmental and social needs and to provide asthma education and self-management support

• High: everything the moderate group receives and in-home visits by a Health Coach and a licensed Respiratory Care Practitioner.




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Engagement Techniques(cont’d)

• In addition to the tailored interventions stratified by risk, Peach State’s Asthma Team also bolsters clinical providers’ abilities to care for teen asthma patients. The Asthma Team functions as an extension of the physician’s practice by reinforcing the individual asthma management plan and providing up-to-the-minute documentation on functional status, barriers and recommendations for future treatment based on the assessment.




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Outcomes• Using clinical and financial data (i.e., medical and

pharmacy claims), the Plan was able to model the health improvements and cost savings generated by the teen-focused asthma program.

• Compared to a control group, teens in the program had 9% fewer respiratory-related unplanned healthcare utilization incidences and a shorter average length of stay when unplanned hospitalizations did occur. They were more likely to visit their primary care physicians as planned and to receive recommended flu vaccines, a critical self-management step as people with asthma are at increased risk of severe disease and complications from the flu because influenza can cause further inflammation of the airways and lungs.




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Outcomes (cont’d)

• Peak flow meter use and controller medication use both improved at higher rates for program participants compared to a control group, while rescue inhaler use declined, indicating better overall asthma medication management and compliance. Peach State estimates the program saves approximately $320 per member per month.




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Peach State’s Lessons Learned • Our program has successfully engaged teens with asthma—a

notoriously hard group to engage.• We have demonstrated success in improving teens’ ability to

understand and improve their asthma and in addressing the environmental and social factors that can make asthma worse.

• Collaboration was a key factor in the success of this program. Teams met regularly to discuss challenges and how to best address them. Open and ongoing communication was crucial.

• As a team, there’s a much higher likelihood of success. When working jointly with parents, providers, health plans, etc., the program is more likely to work.




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Asthma Prevention and Management Initiative (APMI)

Tufts Medical Center, Boston, MAMay Chin, Program Manager

Sherry Dong, Director, Community Health Improvement Programs




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Basic Facts About APMI• Type: Health Care Provider• Service Area: Boston’s South End and Chinatown district• Population Served: Asian immigrants with limited English

proficiency (2012-2013 Boston Public Schools profile report)– 60% students are Asian and 76% of their parents’ primary language is

not English.– 78% students are low income– 25% asthma prevalence of students vs. 10% for City of Boston vs. 9%

for MA– 83% immigrant males living in Chinatown smoke, vs. 15% Asian

Americans smoke (MA DPH 2002)

Who We Are: APMI is a culturally and linguistically appropriate educational, outreach and clinically oriented program that provides asthma self-management education and incorporates healthy habits to encourage growth and development.




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APMI Program Goals• Provide patient/family-centered asthma self-

management educational programs. • Provide culturally and linguistically appropriate education

and care to patients and families across the continuum.• Work with community-based organizations to facilitate

coordinated accessible services.• Work with advocacy groups and community leaders to

increase awareness of high asthma prevalence in the Chinatown community. Collaboratively identify improvement initiatives.




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APMI Program Components• Education in the Schools

– Develop materials and provide self-management education to students diagnosed with asthma

• Resources to Clinicians– Provide standardization of asthma education materials across the

continuum– Emergency, Inpatient and Outpatient Departments

• Home Visit Program– Collaborate with community-based agencies,

state agencies, housing management companies to address environmental triggers and the home environment

• Projects with City & State Organizations




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APMI Partnerships• Program Advisory Group

– Brought together school principals, school nurses, Tufts Medical Center administrators, a physician champion to gain buy-in and support

• Boston Public Health Commission– Collaborate to establish standards of care and documentation for the

medical community– Partner to address pest management in our healthy homes visit

• Boston Asthma Home Visit Collaborative– Founding members include: Boston academic medical centers, health

plan, EPA, researcher– Streamline asthma management in the community




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Boston Asthma Home Visit Collaborative

• Who We Are:A diverse group of clinical, community and advocacy partners who are dedicated to offering free, quality, effective home visiting services to support Boston residents manage their asthma and create healthy living environments that supports asthma prevention and control.

• Outcomes:• Share resources and best practices and coordinate activities• Avoid duplication of home visiting services• Standardize the CHW role (training and certification)

– Home Visit Progress Note• Share outcomes as a collaborative unit and an individual




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APMI’s Partnership Successes

• Build on strong pre-existing relationships. Identify a physician champion to provide clinician buy-in.

• Collaborate with partners on essential program work and to establish standards of care, training, and program evaluation and quality improvement.

• Partner with community-based agencies, state agencies, housing management companies to reduce environmental triggers.




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APMIA Partnership Success Story

• 80% of families in HV program still confused after participating in the teaching sessions and found reading materials unhelpful

• Established partnership with Emerson College to create the “Asthma Self-Management” and “Environmental Management & Control” DVDs, available in English, Mandarin, Cantonese, and Vietnamese. Adding Spanish, Portuguese, and Cambodian.

• Multilingual DVD used by patients, students, and caregiver/ parents as a starting point to dialogue about asthma management.

• DVD is in high demand. Review and give to families and staff in day care, after school and community centers, as more children coming to programs with asthma




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APMI’s Outcomes• Asthma Self-Management Education:

– School absences decreased by 1 day/school year– 35% increase in prescribed controller to poorly controlled

asthmatics

• Home Visiting Initiative: – Environmental Scores decreased from 1.860.5. – Greatest improvement was pest management and least

improvement was smoking, dust, and pets.– Asthma-related ED/Urgent Care Visits decreased from

24%3%

• Collaborations and Partnerships:– Expanded student education program to include broader health

classes




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APMI’s Lessons Learned • Establish a multidisciplinary Program Advisory Group

that includes physicians, nurses, administrators, community leaders.

• Identify information systems that will help build an asthma registry to identify and track patients with asthma.

• Know your strengths and weaknesses.• Build and maintain collaborative relations.• Regularly obtain feedback.




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Poll 3Based on this webinar, what program strategy

would you like to hear more about in an upcoming webinar?

Home visitation programs

4%

Interventions targeting hard

to reach populations

32%

Collaborating with healthy

home programs 12%

Establishing the program

infrastructure in preparation for reimbursement

28%

Engaging partners to provide

coordinated care 24%




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Conclusion of the WebinarHigh-Performing Collaborations and Partnerships in

Providing Asthma Care Services

Moderator:• Tracey Mitchell, U.S. Environmental Protection AgencyPresenters:• Kim Tierney, Multnomah County Health Department• Dr. Steven Dziabis and Allen Frommelt, PhD, Peach State Health Plan• May Chin and Sherry Dong, Tufts Medical Center

Documents

High-Performing Collaborations and Partnerships in ... · PDF fileTotal 153 18.91 23.19 4.28 0.63 • 100% improvement in perceived health • Reduction of 59% in ER visits. ... Organization