Maine AAP: Shared Vision for Asthma Quality Improvement:

We “Can” Get There from Here!

Amy Belisle, MD, CMMCBarbara Chilmoncyzk, MD, MMC

Michael Ross, MD , EMMC

I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME

activity.

State Quality Improvement Strategic Plan

• Connect Pediatric Practices together through the AAP to work on Quality Improvement

• Focus on collecting data to improve care• MYOC• Oral Health Risk Assessment Collaborative • Medical Home Partnership• Chapter Quality Network (CQN) Asthma

Pilot Project

CQN Asthma Pilot Sites MAINE

OHIO

OREGON

ALABAMA

Maine Sites

• Kennebec Pediatrics, Augusta• Franklin Health Pediatrics,

Farmington• Lake Region Pediatrics,

Windham• Maine Coast Pediatrics,

Ellsworth• Intermed Pediatrics, Portland

and Yarmouth• Bowdoin Pediatrics,

Brunswick• BBCH Pediatric Clinic,

Portland• CMMC Pediatrics, Lewiston

Medical Home Sites• Husson Pediatrics, Bangor• Winthrop Pediatrics• Westbrook Pediatrics

• Allergy and Asthma Associates of Maine

How Did I Get Here?

Lesson #1: Quality Improvement is like a Japanese

Adventure

Lesson #2: Follow the Tour buses

What is the Quality Gap?

The gap between the care we know is best and our ability to deliver it, every time, to every patient in the way they need it.

Pediatric Asthma Process CarePercent of Patients Receiving All Process Care

40.6%

28.0%28.2%

53.8%

18.9%

0%

20%

40%

60%

80%

100%

Jan04-Dec04 Jan05-Dec05 Jan06-Dec06 Jan07-Dec07 Jan08-Dec08

GAP

Defining the Gap: Asthma

• Affecting nine million children, childhood asthma is the most common serious pediatric chronic disease. The incidence of pediatric asthma continues to grow; it accounts for 14.7 million missed school days a year and 44% of all asthma hospitalizations[1]

• Maine asthma rate 14.6% lifetime

[1] American Academy of Allergy, Asthma and Immunology. http://www.aaaai.org/media/resources/media_kit/ asthma_statistics.stm

Asthma in Maine

• Asthma current prevalence in Maine1: – 128,000 persons; 28,000 children are currently affected

• Asthma Burden in Maine:– 8000 Emergency Department visits2 – Asthma remains the leading cause of school absenteeism.– Children with asthma are more likely to report being in fair

or poor health than those without asthma (27.9% vs. 6.9%).– Young children (<4 years) are the most likely to be

hospitalized – In 2007, approximately 30% of children with asthma in

Maine reported activity limitations, trouble sleeping and at least 1 emergency department visit for asthma.

– 40% of Maine’s kindergarten and 3rd grade students with asthma had not received an action plan1. The Burden of Asthma in New England a report by the Asthma Regional Council (ARC)2006

2. The Burden of Asthma in Maine 2008, Maine CDC/HHS

Socioeconomic and Racial/Ethnic Disparities

• Asthma rates are less in high school graduates than non-high school graduates (10.4% vs. 15.7%)

• Asthma increases in households with <$25,000 annual salary compared to those with >$25,000

• Maine Care recipients have higher rates of current asthma than those with other insurance (19% vs. 8%)

• Children Enrolled in Head Start were more likely to receive treatment for asthma than any other health condition

Burden of Asthma in Maine 2008 CDC/HHS

Out in the Woods

• In 2005, over 60% of Maine’s 1.3 million residents lived in a rural area compared to 21% in US

• Highest ED visits In Aroostook and Washington Counties

• Highest Hospitalizations are in Penobscot and Washington Counties

The Statewide Maine Asthma Plan, April 2009

Why is there a gap?

• Too busy, Too little time• Low reimbursement• Absence of systems of care• Reliance on memory• Poor guideline compliance• Etc…..

Asthma Fatigue

NHLBI Guidelines: 2007

• Update to Asthma Guidelines• Emphasizes the importance of asthma

control • Introduces new approaches for monitoring

asthma • The AAP trying to spread guidelines and

help with implementationDecrease gaps in care Help move towards optimal care for

children with asthma

Optimal Care

>90% of patients have “optimal” asthma care (all of the following)

• assessment of asthma control using a validated instrument

• stepwise approach to identify treatment options and adjust therapy

• use a structured encounter form• written asthma action plan • patients >6 mos. of age with flu

shot (or flu shot recommendation)

Global Aim

Specific Aim

Maine’s Aim Statement

Global AimWe will build a sustainable quality improvement infrastructure within our chapter to achieve measurable improvements in the health outcomes of children within our member practices.

Specific AimFrom April 2009 to November 2010, we will lead a quality improvement collaborative and achieve measurable improvements in asthma outcomes with the participating 10 to 15 practices by improving use of the NHLBI/NAEPP guidelines and the documentation of quality care.

Maine’s Aim Statement

Goal: 90% of practices will achieve 70% optimal care on patients seen by September 2010.

Goal: 90% of practices use a structured electronic or paper asthma encounter tool 80% of the time by September 2010.

Outcome Goal: 90% of practices will have at least a yearly ACT score documented in 50% of their patients > 4 years old by September 2010.

Maine’s Aim Statement: Long Term Goals

Goal: All practices involved in this collaborative will continue to use a population based registry beyond the time of this grant.

Goal: The AH! Asthma Health evidence based asthma tools will be used by member practices.

Goal: Certified asthma educators will be available to all member practices.

Goal: A committee of AAP members experienced in quality improvement will be charged with infrastructure development in the organization; this will include identifying funding sources for activities. We will have semiannual reporting of QI activities at Maine AAP Fall and Spring conferences for all of its members.

Goal: The Maine AAP will partner with MaineHealth, MaineCare, the Maine CDC, Maine based Health Insurers and other organizations interested in child health improvement (such as the Maine Lung Association, the Maine Immunization Collaborative or the Maine Children's Association) to develop a sustainable approach to quality improvement in our organization.

Change is good, butDon’t reinvent the wheel

Barbara Chilmoncyzk,MD MaineHealth AH! Asthma Health Program

Why should we be involved?

What is AH!• A MaineHealth multidisciplinary program started in

1998 designed to improve the diagnosis and management of asthma

• 4 Key components:– Public policy – Education – Public Awareness – Outreach

• The education focus:– Formation of Partnerships with patients and providers.– Standardization of patient care and education– 1:1 Self management training– Monitoring of outcomes.

• The defined measures:– Systems measures: hospital admissions, ED visits, LOS – Process measures: classification, controller meds, #’s seen,

hospital / ED visits, flu vaccines– Outcomes measures: missed work and school, QOL indicators

(e.g.ACT)

• Continual effort to improve / change (new guidelines, obesity, COPD)

AH! Program Model

Patient/Family

Primary CareProvider

AsthmaEducator

Ah! Program Model

School

Hospital

Public Health

Housing

Pharmacy

Specialists

Home Health

Business

EDUCATION

CCM

AH! Asthma Health tools

www.mainehealth.org/AH

Pediatric Population

Self-Reported ED Visits (in the last 6 months)

n = 193

0%10%

20%30%

40%50%

60%70%

80%90%

100%

Baseline (n=43) 6 Month (n=6)

Pre Education Post Education

22.2%

4.6%

Pediatric Population

Overnight Hospital Stay n = 193

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline (n=46) 6 Month (n=0)

Pre Education Post Education

23.8%

0.0%

Pediatric Population

Parent Missed Work (in the last 6 months and among those eligible)

n = 193

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline (n=78) 6 Month (n=6)

49.4%

9.8%

Pediatric Asthma Process CarePercent of Patients Receiving All Process Care

40.6%

28.0%28.2%

53.8%

18.9%

0%

20%

40%

60%

80%

100%

Jan04-Dec04 Jan05-Dec05 Jan06-Dec06 Jan07-Dec07 Jan08-Dec08

GAP

CIR All Process ComponentsOffice Visit 80% + 1%Severity Class 65% +15%Controller Med 95% + 1%Asthma Plan 59% + 4%Tobacco Doc. 93% + 4%

CIR

MaineHealth PHO Quality initiative

Pediatric Asthma Process CarePercent of Patients Receiving All Process Care

Practice Results (20 + Patients)

3045226

169

118

402

271

187

294

69 155

188

55 24 368

236

26 186

201

187

233

25 520%

20%

40%

60%

80%

100%

2007

2008

96% 97%

PHOMeans

EMMC/Husson Pediatrics Asthma Initiative:

A Story of Achievement

Michael A. Ross, MD, FAAP

Areas of focus

Improve to data collection: staff awareness BMI

EMR (Centricity) Protocol reminders: Asthma Management Plans Flu Vaccine Active/passive Smoke exposure ACT/other Asthma tools

• Roll-out of Asthma assessment tools (ACT)• Registry implementation

Centricity protocol form:

• Increased and streamlined data collected by empowering MA staff.

• Physician/Provider review.

Asthma Tools:

• Introduction of the ACT• For children unable to receive the ACT, development and

implementation of other asthma metrics:          -Number of symptom free days          -ED visits over the last year for asthma          -Admissions over the last year for asthma          -Use of SABA over the last month

Smoking Data Accuracy:

• Smoking status Observation term cleaned up via use of standard Centricity form.

• Previously, had utilized data from non-trackable Well-child care forms.

Immunizations:

• Review of immunization data, via custom Centricity form.

• Phone/mail follow-up through systematic review of “NPPS Asthma list” mid-season.

• Form still in Development

• Two Mass-patient Mailings so far.

• Provider-dependent outreach

• Currently Investigating use of mass-phone system

Asthma Action Plan

• NPPS asthma protocols prompt the printing of Asthma management plan.

• Form has gone through one revision to be interchangeable with State of Maine-endorsed Asthma-school plan.

Data: Old vs. New2007-2008 2008-2009 Delta

Total Number NPPS Asthmatics

847 1034 (+) 187 patients(+ 18.1%)

Does patient have a documented Asthma ed. Plan?

Not Done 68.2% (+) 68.2%

Has a measuring tool been used for persistent-asthmatics (ACT)?

Not Done 17.8% (+) 17.79%

Is there Passive smoke exposure

Not Done 85.6% (+) 85.6%

Is there active smoke exposure?

88%* 85% (-) 3%

Data: Old vs. New2007-2008 2008-2009 Delta

BMI 76.8% 84.5% (+) 7.7%

Documented use of Controller Meds for Persistent Asthmatics

94.5% 98% (+) 3.5%

Influenza 68% 65.7% * -2.3%*

Office visit/year 87.9% 94% (+) 6.1

Severity classification 80% 99.32% (+) 19.32%

Data –Practice Graph

Performance: '08 v. '09

0%10%20%30%40%50%60%70%80%90%

100%

Doc

umen

ted

Ast

hma

Pla

n?

Mea

surin

gto

ol (

AC

T)

Pas

sive

smok

e

Act

ive

smok

e

BM

I

Con

trol

ler

Med

s

Influ

enza

vacc

ine

Offi

cevi

sit/y

ear

Sev

erity

clas

sific

atio

n

metric

per

cen

tag

e

2007-2008

2008-2009

Data – Graph by provider

0

10

20

30

40

50

60

70

80

90

100

metric

per

cen

tag

e

Barrett MD, Amy

Burch MD, Melissa

Clough MD, Scott

Holmberg MD, Robert

Malmer MD, Teresa

Ross MD, Michael

Sabbagh MD, Colette

practice Average

0

10

20

30

40

50

60

70

80

90

100

metric

per

cen

tag

e

Barrett MD, Amy

Burch MD, Melissa

Clough MD, Scott

Holmberg MD, Robert

Malmer MD, Teresa

Ross MD, Michael

Sabbagh MD, Colette

practice Average

Data: Use of protocols

  NPPS: Protocols and Tools used

EMMC Other: Protocols and Tools not used

Total Number Asthmatics: 1034 Practice A: 39Practice B: 126Practice C: 174

Does patient have a documented Asthma ed. Plan?

68.2% Not trackable

Has a measuring tool been used for persistent-asthmatics?

17.79% Not trackable

Is there Passive smoke exposure? 85.6% Practice A: 61.5%Practice B: 31%Practice C: 44.8%

Is there active smoke exposure? 85% Practice A: 59%Practice B: 39%Practice C: 51.2%

Data: Use of protocols  Protocols and Tools used Protocols and Tools not used

BMI recorded? 84.5% Practice A: 88.6% Practice B: 77.78%Practice C: 75.82%

Documented use of Controller Meds for Persistent Asthmatics?

98% Practice A: 100%Practice B: 100%Practice C: 50%

Influenza vaccine given? 65.7% Practice A: 35.9%Practice B:19.8%Practice C: 26.4%

Office visit/year? 94% Practice A: 84.6%Practice B: 5.6%Practice C: 81.6%

Is there a Severity classification? 99.32% Practice A: 20.5%Practice B: 5.6%Practice C: 6.3%

Data – use of Protocols

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

metrics

per

cen

tiles

Practice A (39)

Practice B (126)

Practice C (174)

Husson Pediatrics (1034)

Assessment: Significant Improvement in Most

Areas Distribution of Asthma Action plan to patients Rollout of Asthma Assessment tools Determining values of Active and Passive smoke

status Obtaining patient BMI Use of appropriate controller Meds for persistent

asthmatics Ensuring at least 1 office visit/year for all

asthmatics Determining Asthma severity classification

Areas of future development

Increase flu vaccine frequency/track flu-vaccine refusals

Develop specific AAP-based asthma-encounter form

Roll-out Husson Pediatrics asthma program to other EMMC practices

Increase use of Asthma Control Test

Asthma Care a Year From Now

• Healthier patients and empowered families• Engaged providers and staff employing

asthma guidelines• Utilizing electronic records to improve

quality• Efficient office systems that benefit from

planned care• Reduced cost• The best care for every patient, every time