Transcript Tobacco Free Environments

CommunityCARE Quality Unit
Achieving Better Care for
Asthma
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Vested Interest
The Office of Public Health Nursing Services
Continuing Education Program and the Dept of
Health & Hospitals Quality Unit ensures
objectivity and non-bias in all of its activities.
Presenters have no financial interest or
relationship with manufacturer’s and /or
providers of commercial products and/or services
discussed in this educational activity. It is the
intent of this disclosure to ensure that listeners
are provided with information on which they can
make their own assessments.
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Presentation Objectives
By the end of this presentation, you should:
Acquire knowledge about the prevalence of
asthma in the Medicaid Population.
Understand how Louisiana’s Asthma HEDIS
measures compare to national average
Know the effects of direct and 2nd hand
tobacco smoke exposure on asthma
Be familiar with the Asthma Change
Package and the Chronic Care Model
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CommunityCARE
CommunityCARE, a primary care casemanagement program (PCCM), is a
comprehensive, community-based health
care delivery system with preventive and
primary health care at its foundation.
The CommunityCARE Program has an
established CommunityCARE Quality Unit
that conducts Quality Performance
Improvement (QPI) projects.
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CommunityCARE
789 CommunityCARE
Providers
1,519 physicians
319 physician
extenders
632, 972 linkages
678,751 eligible
population
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Goals of the Quality Unit
To conduct Quality Improvement Projects
To promote healthy behaviors in our Medicaid
population resulting in improved health outcomes.
Improve medical home management by providing
education, office management tools, and utilization
data to providers.
Develop patient self-care through education.
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QIP Structure
Identification
How do you identify
the relevant
population?
Stratification
How do you assign
risk within the
population?
Outreach
How do you reach the
target population?
Intervention
How do you improve
clinical outcomes?
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Why Asthma?
Asthma is the most common, chronic disease of
childhood.
Asthma can be controlled not cured.
Children living in poverty and/or inner cities have
higher rates of hospitalizations and mortality
from their asthma.
Proven best-practice models that demonstrate
improved health and cost savings.
(Pediatric Asthma: Promoting Best Practice Guide for Managing Asthma in Children)
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How Common is Asthma?
Approximately 20 million Americans have
asthma
Nine million U.S. children under 18 have
been diagnosed with asthma
There are approximately 5,000 deaths
from asthma annually
(American Academy of Allergy & Immunology)
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Asthma Prevalence in
Louisiana
An estimated 200,000 adults in Louisiana
currently suffer from asthma.
Louisiana falls within the top 25% of states
for asthma related deaths.
One in ten Louisiana households with
children have at least one child with
asthma.
Females have higher rates of asthma than
males in Louisiana.
( Bureau of Primary Care and Rural Health, LPHI, 2007)
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Asthma Prevalence in
Louisiana (cont’d)
African Americans in Louisiana are more
likely to report having asthma than
Caucasians.
Both asthma prevalence rates and asthma
death rates are increasing nationally.
A burden is placed on the health care
system, in the work place, and in schools in
Louisiana due to absenteeism.
(Bureau of Primary Care and Rural Health, 2007; MMWR, 1998)
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Prevalence of Asthma in
Louisiana
The rates of
asthma in Louisiana
increased from
4.9% to 6%
during the
four years
(1999-2002) for which
data was available on the
prevalence of asthma in
the state.
Louisiana Youth Tobacco Survey, 2000
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Asthma Initiatives:
Phase I
Individual and group education with targeted
persistent asthma patients ages 5-9
Phase II
Provider education: toolkits and CEU
presentation for staff
Phase III
Quality review tool based on Chronic Care
Model
Provider profiles based on HEDIS measures
Interventions include education and
educational tools
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Education as the Intervention
Works
LSU Shreveport
has demonstrated
that with asthma
education, we can
improve health
outcomes in
impoverished and
minority patients.
Healthcare Utilization Data
350
310
300
245
250
200
150
100
0
52
38
50
49
4
Missed Work/School
Days
Emergency Department
Visits
Hospitalizations
Initial Visit
310
245
49
Follow-up Visit
38
52
4
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Achieving Better Care for
Asthma
Identification
ID relevant population
Aim: identify 100% of the
persistent asthma patients
per HEDIS
Stratification
Assign risk
Aim: identify 100% of the
uncontrolled persistent
asthma patients age 5-15
Outreach
Reach the target
Aim: Contact 10/ top 15
providers per region who have
uncontrolled persistent
asthma patients
Intervention
Improve outcomes
Aim: Provider Education
10/10 per region by 12/31/05
(90providers)
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What is HEDIS?
Health Plan
Employer
Data &
Information
Set
HEDIS is an
evolving set of
standard
specifications
for measuring
health plan
performance.
©2004 by the National Committee
for Quality Assurance
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Asthma HEDIS Measure
Percentage of enrolled members 5-56 years of age
during the measurement year who were identified
as having persistent asthma patients and who were
appropriately prescribed medication during the
measurement year.
Numerator = dispensed at least one prescription
for inhaled corticosteroids, nedocromil, cromolyn
sodium, leukotriene modifirers or methylxanthines
during the measurement year
Denominator = the eligible population
©2004 by the National Committee
for Quality Assurance
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HEDIS Measure 2005
Denominator = 32,664
Numerator = 23,120
Percent on appropriate medications =
70.78%
©2004 by the National Committee
for Quality Assurance
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Patient Stratification:
Who are the Persistent Asthma
Patients?
We will identify your patients that meet the criteria for a diagnosis
of Persistent Asthma using HEDIS guidelines:
1. At least four asthma medication dispensing events.
2. At least one emergency department visit with asthma as the
principal diagnosis.
3. At least one acute inpatient discharge with asthma
as the principal diagnosis.
4. At least four outpatient visits with asthma as one of the
diagnoses AND at least two asthma medication dispensing
events.
HEDIS 2003, Volume 2, pp. 105 “Use of Appropriate Medications for People with Asthma”
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Louisiana
Persistent Asthma Patients
Pre-Hurricanes
Sep-06
12,000
10,000
8,000
6,000
4,000
2,000
0
I
II
III
IV
V
Regions
VI
VII
VIII
IX
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Appropriate Asthma Medications , Adjusted
denominator: HEDIS asthma denominator
1
.9
.8
.7
.6
.5
.4
.3
.2
.1
0
Graph shows only CC PCPs with 10+ patients
overall level = 61%, red = stat sig diff > .05 from overall level
symbol size proportional to # of patients, range 10 to 650
Green/dashed = national level/64.1%
What is Asthma?
A disease in which inflammation of
the airways causes airflow into and
out of the lungs to be restricted.
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What Happens During an
Asthma Episode?
1. Muscles tighten
around the airways
(brochoconstriction)
Normal Airway
2. The insides of the
airways swell and
make extra mucus
(inflammation)
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Common Asthma Symptoms
Coughing (most common symptom)
Wheezing
Tightness in Chest
SOB/ Trouble Breathing
Nasal Symptoms
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Cockroaches
Cold or Respiratory
Infection
Exercise
Strong Odors
& Fumes
Strong Emotion
Pets
Pollen & Weeds
Smoke
Changes in Weather…
Especially Cold
Dust
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Asthmatics and Smoking
According to the EPA, between 200,000 and
1,000,000 kids with asthma have their condition
worsened by second hand smoke every year. Also,
passive smoking may also be responsible for
thousands of new cases of asthma every year
Chronic respiratory symptoms such as cough and
wheezing may be attributed to second hand smoke.
Children who breathe in second hand smoke are
more likely to suffer from dental cavities, eye and
nose irritation, and irritability
* U. S. Environmental Protection Agency, 2004
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Health Risks to Children with
Asthma
Asthma is the most common chronic
childhood disease affecting 1 in 13 school
aged children on average.
Exposure to secondhand smoke can cause
new cases of asthma in children who have
not previously shown symptoms.
Exposure to secondhand smoke can trigger
asthma attacks and make asthma symptoms
more severe.
* U. S. Environmental Protection Agency, 2004
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Serious Health Risk to Children
Children are particularly vulnerable to the
effects of secondhand smoke because:
they are still developing physically
have higher breathing rates than adults
have little control over their indoor
environments.
* U. S. Environmental Protection Agency, 2004
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The Science Behind the Risk:
11% of children aged 6 years and under are
exposed to ETS in their homes on a regular basis
(4 or more days per week) compared to 20% in
the 1998 National Health Interview Survey
(NHIS).
Parents are responsible for 90% of children’s
exposure to ETS.
Exposure to ETS is higher and asthma prevalence
is more likely in households with low income and
low education levels.
Children with asthma have as much exposure to
ETS as children without asthma.
* U.S. Environmental Protection Agency, 2004
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CommunityCARE Quality Unit
Goal:
Improve medical home management
by providing education, office
management tools, and utilization
data to providers.
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Chronic Care Model
1. Community
Resources and Policies
2. Health System
Health Care Organization
6. Clinical
3. Self4. Delivery
5. Decision Information
Management
System
Systems
Support
Support
Design
Informed,
Activated
Patient
Prepared,
Proactive
Practice Team
* Effective Clinical Practice, 1998
Chronic Care Model in Practice
Treating the “whole patient” to empower
them to self manage their disease.
Identification of environmental needs,
family dynamics, economic needs, and
specific disease education individualized
for each patient/caregiver.
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Quality Reviews as part of
Intervention
Quality reviews of charts are completed in the PCP
offices using questions derived from the domains
of the Chronic Care Model
Medicaid claims data using a measurement period
of 1 year is used to complete reviews.
Purpose is to give meaningful feedback to the
provider about the quality of care they are
providing
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Interventions Continued
Intervention materials are given to the PCPs to help improve the
quality outcomes of their asthma programs.
Example of Interventions
Domain of Chronic Care Model
NHLBI guidelines/recommendations
Decision Support
Asthma Action Plan
Family and Self Management Support
Community Resources the provide
Smoking Cessation Programs
(1-800-Quit-Now, MYFSF)
Community Resources
Educational materials to be given to
patients/caregivers.
Family and Self Management Support
Asthma presentation (for CEUs) for PCP
and their staff.
Decision Support
Sample tracking forms
Sample asthma flow sheets and sample
tracking forms.
Clinical Information System
Decision Support
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Asthma Classifications
The NAEPP (National Asthma
Education and Prevention Program)
has classified asthma into four
categories.
These are based upon:
Frequency and severity of symptoms
Pulmonary functions
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NAEPP DAILY MEDICATION GUIDELINES
(FOR ADULTS AND CHILDREN >5 YEARS)
SEVERITY
SYMPTOMS
DAILY/CONTROL MEDS
Severe
Persistent
Continuous (Day)
and/or
Frequent (Night)
Preferred: ICS & LABA
AND, if needed oral steroids not to
exceed 60mg/day
Moderate
Persistent
Every day
and/or
>1 night/week
Preferred: ICS & LABA
Alternative: ^ ICS and/or add
leukotriene modifier or theophylline
Mild
Persistent
>2/week but <1x/day
and/or
>2 nights/month
Preferred: ICS
Alternative: Leukotriene modifier,
cromolyn, nedocromil or
theophylline
Mild
≤2 days/week
and/or
≤2 nights/month
No daily meds needed
Intermittent
ICS: Inhaled corticosteroid
LABA: Long-acting inhaled beta-agonist
*2002
* 2002 NAEPP Expert Panel Report
The Asthma
Action Plan
The Asthma
Maintenance
Form
* NICHQ National Initiative for Children’s Healthcare Quality, 2000
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Contact Information
Program Manager
Cindy French
(225) 342-9320
[email protected]
Region 1 Nurse
Kathy Carter
(504) 568-2827
[email protected]
Region 2 Nurse
Karen Adams
(225) 342-1851
[email protected]
Region 3 Nurse
Mary Scorsone
(985) 449-4722
[email protected]
Region 4 Nurse
Nina Fouke
(337) 262-1957
[email protected]
Region 5 Nurse
Jennifer Bruney
(337) 491-2600
[email protected]
Region 6 Nurse
Vetreese McCue
(318) 487-5655
[email protected]
Region 7 Nurse
Rhonda Baird
(318) 676-5159
[email protected]
Region 8 Nurse
Candice McVay
(318) 362-4263
[email protected]
Region 9 Nurse
Kathy Solis
(985) 543-4163
[email protected]
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Questions ????
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Websites
http://www.improvingchroniccare.org
/change/model/components.html
http://www.nichq.org/NICHQ/Topics
/ChronicConditions/Asthma/Changes/
www.lamedicaid.com
www.la-kidmed.com/communitycare/
commcare.html
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References
American Academy of Allergy, Asthma & Immunology (2004). Pediatric Asthma:
Promoting Best Practice. Guide for Managing Asthma in Children. Rochester, New
York.
American Academy of Allergy, Asthma & Immunology (2006). Media Resources: Media
Kit. Retrieved from
http://www.aaaai.org/media/resources/media_kit/asthma_statistics.stm
Baylor Health Care System (2001). Rules of Two®. Retrieved from
http://www.baylorhealth.com/medicalspecialties/asthma/asthmaprograms.htm#Rof2
Bureau of Primary Care and Rural Health. Chronic Disease and Prevention Control.
Asthma Initiative PowerPoint.
HEDIS (2006). Use of Appropriate Medications for People with Asthma. Volume 2, pp.
105.
Louisiana Public Health Institute (2007). Asthma. Retrieved from
http://www.lphi.org/home/health/asthma/
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References
Louisiana Youth Tobacco Survey (2000). Retrieved from http://www.lcltfb.org/CCPlan/YTS_LAYOUT1.4.pdf
Morbidity and Mortality Weekly Report (1998). Forecasted State-Specific Estimates
of Self-Reported Asthma Prevalence -- United States, 1998, 47: 1022-1025.
National Initiative for Children’s Healthcare Quality (2000). Retrieved from
http://www.nichq.org/NICHQ/Topics/ChronicConditions/Asthma/Tools/
asthmamaintenanceform.htm.
National Heart, Lung, and Blood Institute (NHLBI) National Asthma Education and
Prevention Program, Expert Panel Report 2 (1997). Guidelines for the diagnosis and
management of asthma. (NIH Publication No. 97-4051). Bethesda, MD: US
Department of Health and Human Services.
National Heart, Lung, and Blood Institute (NHLBI) National Asthma Education and
Prevention Program, Expert Panel Report (2003). Guidelines for the diagnosis and
management of asthma: Update on selected topics 2002. (NIH Publication No. 025074). Bethesda, MD: US Department of Health and Human Services.
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References
U. S. Environmental Protection Agency (2005). National Survey on Environmental
Management of Asthma and Children’s Exposure to Environmental Tobacco Smoke.
Retrieved from http://www.epa.gov/smokefre/pdfs/survey_fact_sheet.pdf
Wagner, E.H. (1998). Chronic Disease Management: What Will It Take to Improve
Care for Chronic Illness? Effective Clinical Practice (1), 2-4.
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