Demonstrating Positive Asthma Outcomes

By Adem Lewis / in , , /

Tracey Mitchell: Good afternoon, everyone. My name is Tracey Mitchell. I’m a registered respiratory therapist and
certified asthma educator at the U.S. Environmental Protection Agency in Washington, D.C. EPA
is pleased to host you today for an important and exciting webinar presentation, Demonstrating
Positive Asthma Outcomes: Collecting and Analyzing Data to Make Your Case. Our esteemed and very knowledgeable presenters
today are Kevin Kennedy, Program Director of the Environmental Health Program at Children’s
Mercy Kansas City. Mr. Kennedy has been involved in environmental
health science and healthy housing advocacy and industrial hygiene chemistry consulting
for over 30 years. He teaches courses in environmental health
assessment and investigation, environmental measurement and sampling, building science,
and safe and healthy housing. He received his Master’s degree in public
health from the University of Kansas Medical School. Kevin is a certified Indoor Environmental
Consultant and previously worked as an environmental analytical chemist and research scientist. Next, you’ll hear from Dr. Ben Francisco,
Professor of Pulmonary Medicine and Allergy in the Department of Child Health at the University
of Missouri School of Medicine. He is founder and Director of Asthma Ready®
Communities, a statewide initiative for improving asthma care and outcomes. He is the past President of the Association
of Asthma Educators and author of Interactive Multimedia Program for Asthma Control and
Tracking, or IMPACT Asthma Kids. Dr. Francisco is a practicing pediatric nurse
practitioner providing specialty asthma care to infants, children and young adults. He has served as a contractor for the CDC-funded
Missouri Asthma Prevention and Control Program for 15 years. EPA is proud and eager to support and shine
a spotlight on these partners so that they can share their information and stories in
order to teach us all about how data can be used to improve asthma care and how to move
whole systems to bring the best care to the people who need it most, particularly children. Thank you for joining us for this important
discussion today. As a reminder, after today’s presentation,
our question-and-answer session will take place on the discussion forum of This is a great opportunity for you to interact
with today’s presenters. The directions to access the discussion forum
are on your screen right now. You do have to be a member of Asthma Community
Network to take part in the discussion forum, so if you’re not a member, please take a
moment to join. It’s quick and easy, and you’ll be able
to interact with our presenters after the presentation. Also, this webinar and the question-and-answers
will be archived on, so you’ll definitely want to be a member
so you’ll have access to this information in the future. So now that we’ve introduced our presenters,
I’d like you to introduce yourselves by telling us what type of organization you represent. I’d like to open the poll, and please choose
the option that best describes your organization. Great. We have a wide variety of disciplines represented,
a diverse audience, and I’m excited that we can learn and share from each other. Our next polling question, just to get an
idea of how you’re currently using data in your program, please choose the answer
that best reflects your current data use. You’re collecting basic data but not really
demonstrating results? Are you using data to show positive outcomes
or return on investment? Are you targeting high-risk patients through
the use of data? Are you translating complex data to improve
asthma care? Great. About a third of you are just collecting basic
data at this point. I think we have a lot of information for you
today to help you with turning that into demonstrating results. There’ll be some information on all of these
topics, ROI and at-risk populations. You’ve come to the right place. Learning objectives, as I said, we’re going
to learn about the basic framework for data, what you’ll need to show positive outcomes
for your program. You’re going to learn how to use data to
help your program provide in-home services, assessments and education. You’ll hear how complex data can be translated
to help clinicians improve their care for asthma patients, and you’re going to hear
best practices for reviewing data to identify high-risk individuals. I just want to take a moment to talk about
EPA’s role in asthma care. We all know that the environment plays a critical
role in asthma, and at EPA, science informs policy and forms the foundation of our program
approaches. Science tells us that along with medical
management, there’s strong evidence and supporting national guidelines that recognize
the role of environmental triggers and their remediation as an important part of
comprehensive care. We know that eliminating common indoor triggers
like tobacco smoke, pet dander, molds, cockroaches and dust mites results in decreased symptoms
in asthma episodes and improved outcomes for people with asthma. We also know the importance of home visits
as a critical component of asthma care, particularly for at-risk populations. Home visits provide one-on-one time to educate
families, assess their environment and help them remediate triggers. As technical experts on the built environment
and health, EPA has led the federal nonregulatory strategies that enable communities to deliver
and sustain in-home environmental asthma care aimed at ensuring access. So how does EPA’s program support programs
at the state and local level? These five cogs represents the five basic
program elements of EPA’s program. First, we host learning spaces. We’ve talked about,
which connects over 1,000 programs across the country. We provide technical assistance through cooperative
partners and cooperative agreements. We recognize and leverage excellence through
our competitive National Environmental Leadership Award in Asthma Management. EPA is working to advance policy on the national
level through collaboration with Asthma Disparities Working Group federal partners and locally
through regional asthma summits. Finally, we synthesize and spread the learning
in a variety of ways, and one example is today’s webinar. So here we are today to talk about one of
the central pieces of asthma programs: data collection and analysis. We hear from many community-based programs
that this is an issue of importance. Some programs are much further along in developing
sophisticated data practices, and others are just starting out. I think we saw that reflected in the poll…the
second question we asked today. It’s important to collect the right information. I think we can all agree on that. But how will this information be used? Who are the decision makers we need to target,
and what data will be most compelling to them? For example, health plans may want to hear
about cost savings, but Medicaid may also want to hear about the high utilizers and
the services provided. Using data is necessary to build the evidence
base and to make your case, and you’ll hear a lot about this from today’s presenters. Also, on Asthma Community Network there’s
information about building the evidence base. Using data to develop your value proposition
is also important. A value proposition is an analysis and quantified
review of the benefits, cost and value that an organization can deliver to customers or
funders and other stakeholders. It’s a succinct statement that clearly describes
the tangible results a customer gets from your program. It’s a way to get support for your program
and to draw interest and share success, and we have more information on that in this webinar
and on Asthma Community Network. We also know it’s important to move from
collecting data to showing impact. Given our shared goal of advocating for sustainable
financing, what data supports that goal? That’s what are speakers are going to talk
about today, using examples from their work in Missouri and with the groups they worked
with around the country, so without further delay, I’d like to turn it over to Kevin
Kennedy for our first presentation. Kevin Kennedy: Alright. Well, thank you very much. Thank you for inviting me. It’s an honor to be here. It’s an honor to participate with Asthma
Community Network. I’ve been involved actively for a long time. I’m particularly honored to be part of the
webinar with Dr. Francisco. I’ve worked with him for many years and
consider him a true expert in data analysis, and really a great opportunity to hear what
he has to say. I do not consider myself an expert per se
related to data, but I am part of a team here at Children’s Mercy Kansas City that has
used data in evaluating our program and to measure our successes and our challenges along
the way. So I’ll provide one perspective, and then
we’ll hear another one from Dr. Francisco. The goal of our program—we’ve been going
to homes since 1995. I’ve been fortunate to be here at Children’s
Mercy Kansas City for about 20 years, where we have built a home-visit program related
to a variety of health conditions. We started out focused on asthma and developing
a practice for offering effective assessments and effective interventions for children with
such a significant environmental disease. But you have to understand the success of
your program or where your challenges are, and being able to use data helps you understand
what kind of successes there are, what kind of challenges there are and how to make your
program better. Really, the point is how we help Jeremy, how
we help kids with asthma feel better, be able to do the things they want to do with their
lives. The ability is there. The disease management strategies are there. The medicines exist. It’s just effective teaching of families,
both about how to manage the disease and how to manage their home to make their lives easy
to do, easy to participate in. There’s lots of great information, fortunately,
in this field, so much so that I was wonderfully surprised to see this report from the National
Governor’s Association, this white paper from our governors for our states, pointing
out that health investments related to asthma, to addressing asthma in children, is well
worth the investment. The paper specifically describes this tiered
approach of focusing on using the disease management guidelines, of teaching self-management
education, and then ultimately including home visits as part of that comprehensive asthma
care service. At the same time, this Governor’s Association
report also talks about the importance of stratification, the importance of analyzing
data, the importance of understanding some concept called the return on investment for
your program that we’ll talk more about. So, how do we evaluate our programs? How do we understand the quality of our effort
in trying to help patients? There are some key components that, over the
years, we’ve learned and others have learned are particularly valuable. What we want to know is ultimately the impact
of the program. What kind of outcome is there for the patients? Are they feeling better? Are they managing their disease better through
that process? If they are managing their disease better,
we should see a reduction in their health care costs. We should see a reduction in their utilization
of urgent care services. We should be able to track that and see what
that kind of impact is, and there’s certainly a method and a structure to that. It’s identifying what kind of data we want,
and then ultimately calculating what we call the return on investment, which is basically
the input or investment of service and care delivery, and then ultimately what kind of
savings do we see in return and what kind of health improvement we do. And for those of you that have a program that
is trying to figure this out, one strategy is ultimately to have some kind of pilot project. Select a group of patients or a population
that you might want to work with, a smaller set, and use that to test a certain model
to see what kind of return on your investment you might have. To be clear about this then, return on
investment is specifically a process for using data about the health care service costs related
to implementing a program, and then simply comparing that to the savings from the program
as you deliver it for the patients. Having a mechanism or a process for collecting
that data and managing that information so that you can look at it periodically and understand
what the data is telling you about the success of your program, and we’ll talk more about
that. There are key components to that. It helps you identify the population that
you’re trying to serve. It helps you identify what—for your program
maybe, or for programs in general—what are the cost drivers for your program? What are the challenges? What are your expenses? It helps you understand opportunities for
improving quality while trying to reduce your overall expenses for managing the program
to make it more efficient and cost-effective. It’s also useful in understanding how your
program is designed or how to design a program. I think if you go through a process of knowing
what your ROI is, it’s a way of organizing your program and knowing what resources you
need, and then how to evaluate those resources and whether you are using them effectively,
and then the cost associated with those resources. Ultimately, and probably most importantly,
it’s a great tool for knowing what you believe your program is doing and ultimately computing
and understanding if it is, in fact, doing what you hoped. I think that’s often the thing that people
don’t realize. You can be an idealist like me and dream up
what you think would be an ideal program, but there are so many realities and challenges
that make it difficult. It’s important to try to develop the program,
and then along the way, use effective tools for evaluating what’s working and what’s
not working. You’re always adjusting the quality of the
services or connecting with new partners to offer new services. It’s an ongoing tool that you use all the
time. These are some of the components of the data
you might select, and if you’re going to do a pilot program, it would be a good idea
to select a population or a size of a target population, or if you have a whole program
you’re working with, knowing what the size of that population is. I’m a big advocate for the idea of risk
stratification, stratifying patients based on that utilization, we’ll talk a little
more about that; having some sense of the enrollment rate, how often and frequent you
are enrolling new cases and cases from different geographic regions, for example; what is the
actual duration of the program; knowing what your baseline costs are; and then any additional
services. Those are all components you’re going to
want to have in evaluating your return on investment. Different kinds of data, fundamentally, health
utilization, the ones we know of, related to hospital costs and ED costs of medication
and procedures, but also just the labor of staff, the effort of staff, in staying in
touch with individual patients and their families. Routine communication: What kind of effort
occurs at the home? What kind of effort occurs at the clinic or
at a school setting, all of your education materials? If you do home interventions, which I recommend,
what are the cost of those interventions? What are the cost of the services of hiring
programs or housing programs or partnering with them to provide home intervention services? Fortunately, there are some excellent tools,
excellent research publications out there to support your work. This Center for Health Care Strategies tool
for forecasting return on investment is an excellent tool, even if you use it just to
frame how you might organize your program and how you might evaluate your program. It’s intended…original intent was for
understanding the value of patient-centered health homes or medical homes as that model
of care is adopted across the country. But it actually is an excellent tool for understanding
a specific component of a program, and they use it, turns out, for some other examples—
asthma programs. So it becomes a good way, and a good example,
for understanding how to evaluate the components of an asthma program. Just touching on some of the components, you
put in your target population here. You develop some kind of method or mechanism
for deciding what your risk stratification might be, who might be participating in the
particular program that you want to analyze— whether it’s the high-risk or all of them,
high-, medium- and low-risk, whatever that is, what that enrollment rate is. Then, putting in some specific costs, and
these are just projections based on what you know, either from your own information or
from what you found that’s been published using that information. Based on a certain number of patients, you
can come up with a model for how much care cost you think it might be per individual
patient. And then you can set up what your goals are for
decreasing utilization, for reducing some of those health care costs, and ultimately
allow you to build a summary of what kind of impact you would project for what your program
might do. It’s a great tool for trying to understand—and
not maybe your whole program—but what kind of data you might want to collect and track,
and how are you going to collect that information? Is it coming from electronic health record? Is it coming from partnerships with clinics? Is it data that you track in your own data
system? Are you doing it on a hardcopy form? Do you have mobile tools that you can use
to collect data in the field and have that populate into a database? It helps you to guide and understand what
kind of data you need and what kind of questions you want to ask as you develop the program. There’s also excellent reviews of what programs
have done and what kind of ROI they have reported. This is an excellent review by Joy Hsu and
her colleagues about the economic evidence for asthma self-management education programs
and home-based interventions. It came out in 2016, and they looked at 42
individual programs that they were able to find across the country, nine of them specifically
asthma self-management education programs, 17 of them being home-based, so they had both
the asthma self-management education and a home-based component. Then they looked more deeply at specifically
at what each of these programs did as a service, and then what kind of…if they did any kind
of study. Was it a randomized control trial? Was it a pre-post analysis? Then, what kind of outcomes did they see,
and did they report any kind of return on investment data? In this case these programs all reported some
kind of positive ROI, and interestingly many programs observed a positive return on investment
when they focused on the higher health utilizers. And that makes perfect sense; those are the
ones that are costing our health care system the most, those are the ones who are struggling
to manage their disease, and where we might want to target some of our efforts and services. At the same time, they found one of the challenges
with trying to do a uniform analysis of programs across the country is there was a lot of variety
in the kinds of services that programs offered, and that made it difficult to have a consistent
measure for what return on investment might be. Personally, I think that’s OK, because geographically
around the country you’re going to find that it takes different partnerships, different
collaborations and different strategies to try to help families improve their asthma
disease management. Just a brief look at some of the tables, and
that’s the nice thing about this study, is they do a really nice review of these and
specifically tell you what the interventions were, what health care utilization was evaluated
and then what the economic outcome was—specifically what the return on investment was. Was it, as in this case, a $6.35 per dollar
of investment, or was it less? It’s a really nice summary of what these
programs did, and it gives you an opportunity to really look at different approaches that
programs have taken across the country. Here’s another look at some of the additional
components that are included in there where they specifically describe many of the services
that different programs offer, so it’s really nice detail. Here’s just some more of those. Our program was identified in here—so we
had a program that ran from 2001 to 2010, that’s analyzed in here, and you can see
here the reduction in ED and hospitalization that was looked at, and then the net savings
based on $0.43 per member per month cost and a gross savings of $2 per member per month
for this program and our successes. We’ve been at this a while and have seen
things go up and down as we’ve tried to implement various strategies in our program. In 2016, in trying to better identify patients
and do a better job of stratifying risk, we looked specifically at the data from our hospital
system and used that data to predict health care use of children with asthma. We took a population of 28,000 outpatient
visits representing 10,800 patients over the years 2009 to 2013, and we looked at their
data from a particular point in time for an outpatient visit, and we looked at their data
in the past 12 months and wanted to understand how predictive that was of an acute care visit
in the next 12 months. What we found was the more acute care visits
that a patient had in the past, the greater the likelihood of a future acute care visit
in the next 12 months. Here, looking at two historic acute care visits,
we find right about a 45 to 50 percent likelihood of a future acute care visit. With three, we saw about a 60 percent likelihood;
four, about a 75 to 80 percent likelihood; and five acute care visits, you saw up to
a 90 percent likelihood of a future acute care visit. We used this analysis of the data to develop
a high-risk asthma protocol within our electronic health care system, so when a patient is touched
by one of our clinics or hospitals or inpatient or ED, we can look at and do this quick analysis
to identify who the high-risk patients are. They’re automatically enrolled by the system
in the high-risk asthma protocol. They are automatically referred for social
work. They’re automatically referred for an environmental health referral, and then
they’re given the opportunity to connect with different outpatient elements but in
particular the opportunity for an environmental assessment. They don’t automatically get a home visit,
but we certainly talk with the family and try to determine what their needs might be. Then our asthma-friendly home program does
a further risk stratification using that health care utilization as a representative of past
utilization in combination with their current asthma status using the Asthma Control Test,
and then a simple survey we’ve developed that we call “Tell Us About Your Home,” which
is a quick survey of current environmental exposures that the family is experiencing
and trying to manage. We use all of this to determine their total
asthma risk, and then based on that they’re stratified into different levels of service, so those who are lower risk are given the opportunity
for a basic home assessment; those that are higher risk, typically more complicated health
problems, much higher utilizers, but also often a more complicated environment that
they’re trying to manage to try to reduce exposure to different types of environmental
triggers. We’ve been in many, many homes over the
last 20 years. We provide focus on healthy home education,
we do a visual assessment, and then for those advanced or high-risk patients, we might do
a little bit deeper dive into the home and understanding and diagnosing potential exposure
risks to help us target our interventions to address specific environmental risks and
hazards that we might identify in the home. Like many programs, we have a multi-visit
management model, so multiple touches and visits with the family. That’s been shown by many programs to be
very important to maintain continuity of service, maintain education. We use this opportunity for the phone surveys
to use the ACT score, once again, check in with the family and see how things are going
in the management of their disease. We stratify the number of visits provided
as well, based on what they’re…whether they’re high risk or low or medium risk. Through our process, we do a home assessment,
we identify and make recommendations for healthy home actions that both the family can do. We provide healthy home supplies. We provide specific interventions. We have funding to support that or we
refer families to housing partners who can make fixes to a home, try to reduce the potential
for exposure to specific environmental triggers, and openly try to improve the indoor environment
of their home so that it’s easier to manage their child’s asthma. There are lots of great resources. I highly
recommend if you can—or if you are interested in knowing what some programs have been doing—
the National Center for Healthy Housing has these excellent case studies and resources
here at this website that will be made available to you. Here’s just one of the examples of a program
that they describe in one of those case studies. Looking at their total cost, it was roughly
$1.3 million in total cost, and then a net benefit of $2.5 million, so clearly a significant
improvement in savings and better care for those patients. You can see the reduction in utilization as
a result of participation in the program. But I want to point out that even though your
program might be looking at and focusing on a return on investment and making sure your
program is cost effective and efficient, it’s not that easy. So many patients are dealing with complex
challenges, have a host of comorbidities that makes it very difficult for them to manage
the disease. Many of them are dealing with a host of social
determinants, complexities in their community that lead to health disparities—overcoming
those challenges and barriers is always difficult. Ultimately, a part of any asthma management
program is the goal of improving the overall community health, so there’s an underlying
mission that’s more important in my mind than the return on investment. But having the ability to analyze the effectiveness
of your program provides you a constant opportunity for evaluating how you’re doing and just
trying to do better, and ultimately trying to do better in how you help Jeremy. I’ll stop there. Thank you very much for listening. Ben Francisco: Hi, this is Dr. Ben Francisco,
and I also appreciate very much the opportunity to speak to you today. I want to address data-driven approaches for
improving asthma care and control while lowering costs, and so the focus is to use data to
support and demonstrate real results in children with uncontrolled asthma and to talk a little bit about the importance and difference data makes in sustaining our programs for long-term success. This is really a story. I’m not going to speak to every slide in
detail, but I want to weave a story in the next 20 minutes that touches on how we establish
goals and focus on what we’re going to change. Which authoritative sources guide us? What are evidence-based drivers? Is their intervention based on a framework,
or a theory, or some cohesive model that others can use? Which outcomes do we believe show success,
and which data are required to show progress towards goals and then actual outcome differences? I think the most important is: Can this be
scaled? Can this really affect large numbers of people? Is there a business model to sustain it? We need strategic partners, and today we need
to show return on investment. I’m going to talk a little bit about two
different Missouri asthma improvement initiatives that illustrate these ideas, and I do have
an emphasis on administrative claims data. I hope I can share what we know and what we’re
learning on that topic. I also want to touch on, as Kevin has, an
integrated model for assessing asthma status, not just based on clinical information, but
based on self-report, community assessment, clinical, but also claims data. Finally, I think this moves us towards a population-based
approach that asks for us to match workforce development and service delivery to meet local
asthma burden. I do believe in the triple-aim—better care,
better health and lower cost, and we see that that is possible with childhood asthma. The first project…piece of work here in
Missouri that I want to share with you was funded by the CDC, and it’s called Teaming
Up for Asthma Control. We had great evidence that school nurses needed
additional support if they did not have the things they needed to address the needs of
students. They lacked training, they lacked equipment,
they didn’t even have quick-relief medications on campus for the students who were having
difficulty breathing. They had no educational materials and lacked
uniform policies. We fortunately have great evidence—the EPR 3 guidelines clearly are authoritative—but we also have school-specific initiatives—the
National Asthma Control Initiative from Heart, Lung and Blood, as well as the American School
of Health Association—had delineated the possible roles of school nurses improving
asthma control. Our project really focused on promoting school
nurse competency, and that would allow the school nurse to collect clinically relevant
data around impairment—the ways in which asthma limited children—but to also monitor
and report asthma control status, so plans could be adjusted, and particularly to focus
on improving student self-care and to promote family awareness of the importance of healthy
homes and environmental factors. I think our evidence-based drivers came straight
really from GIP—the Guidelines Implementation Plan—which really said, these are the big
drivers. If we’re successful implementing these in
clinical care, in school, in home , in community settings, then we’re very likely to see
a big impact. That potential impact had been described in
2010 in Chest Physician. The cost savings that were reported for families
as well as for insurers were substantial as asthma control moved into a well-controlled
status. Our other goal addresses data gaps. In Missouri, children with Medicaid have on
average about one outpatient visit for the management of asthma per year, and many visits
that are acute care visits because they’re sick. We felt that the school visit would be an
opportunity to obtain assessment and monitoring data at an affordable cost that would support
clinical decision-making. This fits the framework of collective impact,
which basically says, we can’t do all the work in the clinic or the hospital, but many
other settings have benefits. We took our focus on school to do as much
as we could in the school setting to complement other settings where children’s needs were
being addressed. We looked at the expert guidelines, and we
translated those for the school setting and found four key messages. You must measure airflow, FEV1 being the preferred
measure in home and community settings. Inhaler identification and training for optimal
inhalation technique was critical because inhaled corticosteroids absolutely improve
control and reduce acute care and morbidity, but that triggers also have to be avoided. Families need to know what those are as well
as the other disease conditions like gastroesophageal reflux that impact children. So, we were able to train school nurses first
to identify children who have had persistent asthma so that they could recruit those children
to participate in three school nurse encounters. There were 176 children in this study, and
each child had a measurement of the FEV1 at each of the three visits. We used Children’s Health Survey for Asthma—Child
Version, which, unlike the ACT, does not require parental input and is valid for children 6
and above. We used the same survey to assess psychosocial
well-being related to asthma. We determined the adequacy of ICS inhaler
technique, measuring inspiratory flow rate and time using a device called the In-Check
DIAL, and we used inhaler charts to help children identify what the red inhaler or the orange
inhaler actually is and how they should be using it. We used Childhood Asthma Risk Assessment Tool
to assess environmental tobacco smoke exposure as well as other environmental factors in
the home that children can recognize. Importantly, we did deliver asthma self-management
education using an evidence-based program that we developed here called IMPACT Asthma Kids. That program is driven by self-regulation
theory, and I know some people don’t like to talk about theory, but self-regulation
is terribly important for the individual, but it’s also important for the clinician,
and it’s also important for the health system and insurer. In this model, we’re vigilant. We’re looking for data or evidence that there’s
a problem and then we have ways of acting to address the problem. Then when we’re in a steady state, we go
back to a state of vigilance. We’ve actually applied this to children, to
clinicians and to health systems and insurers effectively. We did publish a randomized control trial
of the asthma self-management program, 228 children. We are listed in the EPR 3 guidelines as one
of three computer-based programs that showed significant positive health outcomes. We relied heavily on the NIH investment in developing CARAT—Childhood Asthma Risk Assessment Tool— across the 25-year period of time where
we were really trying to understand why are so many people struggling with asthma control. What are the barriers in the home? That tool is very important to us and was
integrated into the school-based program. There were a number of very positive outcomes
that we have published, and that included about a 12 percent increase in FEV1, a significant
decline in impairment, a marked increase in ICS consumption by the child, and a very important
improvement in the adequacy of the inhalation effort measured objectively. We were thrilled to see that children’s psychosocial
functioning improved, that there was significant reduction in frustration, isolation, sadness,
anger, embarrassment. Students self-reported that their tobacco
smoke exposure declined significantly after education of families as well as teaching
children simple avoidance methods. The program was well received by parents and
students, and we were fortunate to have approval from Missouri Medicaid to analyze cost using
claims data. This all occurred in a period of time, 2009
to 2014, where there were significant annual increases in the cost of asthma in our state. We invested about $150 per student in the
delivery of this program, and we saw about…more than a $1,300 decrease in the cost per child,
so the ROI was about 7 to 1 in the first year, and we would certainly expect—but have not
analyzed—savings that would occur in the second and third year. I think there’s a variety of data that were
involved here, but these helped us to successfully show a reduction in the rate of uncontrolled
asthma and about a 30 percent reduction in Medicaid costs. If you google “Teaming Up for Asthma Control,”
you can readily find that article, and I hope you will and send us your comments after reviewing
it. What about an integrated model for assessing
asthma status of individuals, meaning that data from different sources and different
types are brought together? This suggests that it’s really the person
that should be the center, like Jeremy that Kevin mentioned, the person in the family
at the center, and then the medical home and community partners, the insurer, the government,
all others really are around them helping. We particularly believe that community interventions
like home environmental assessments, home asthma education—when they’re coupled with
standardized assessments and when those data can be then joined to claims data—are very
powerful ways and cost-effective ways to improve outcomes. We think of four critical data sources that
really need to be integrated. That’s what patients say and their families
about their asthma, that’s what clinicians are doing and trying, believing about the
asthma. But certainly what insurers pay for. Administrative
claims tell us a lot. Then we want our community partners to be
linked in this analysis: pharmacists, school nurses, educators, in-home services like environmental
and asthma education. This is consistent with expert guidelines
for how to deliver to them the highest standard of asthma care. In this case, this is a diagram talking about
when you should step up therapy. You should first check adherence, and claims
is the best way to do that. You should check inhaler technique, not just
once but in multiple settings to know that the person has the skills needed, and you
need to consider environmental control because environmental drivers are often behind a worsening
pattern of asthma. In Missouri, for more than a decade we’ve
had access to Medicaid claims data through a program called CyberAccess. That gives you a look at what’s being dispensed
from all the pharmacies the patient might be using and from all of the providers who
might be prescribing medication. And it gives us quite a bit of power in looking
at the individual patient by sorting the types of medications and so forth. It also allows ready identification of medication-related
problems, or MRPs, that might be addressed by pharmacists or asthma educators and others
in the community— things like low rate of ICS refills, excess
dispensing of albuterol, no evidence of having had spirometry in 3 years or more, ER visits
and so forth. Finally, I want to kind of put this together
with a population-based approach that would really I think empower us to get better outcomes and
lower cost. This is consistent with the National Academy
for State Health Policy, who suggest that Medicaid claims data and encounter data are
key to moving forward with value-based health care. So, we have a second project in the state of Missouri. We have about 55,000 children with asthma
that have Medicaid; 20 percent of them have uncontrolled asthma at any point and time. What we discovered is health care providers
as a group have a low adoption rate of best practices, which means if you take the expert
guidelines and you say, “Are you doing this every day in your clinical care of children
with asthma?”, we find that on average, out of about 32 best practices, only about
30 percent are commonly used in our health homes. That’s prior to engagement around asthma
improvement and training. We’ve been fortunate to have a program here
in the state called ECHO—Extension for Community Healthcare Outcomes—and we’ve been fortunate
to have new policies over the last decade that clearly support appropriate asthma care,
including a state plan amendment to reimburse providers for delivering in-home asthma education
and environmental assessment for trigger reduction. We have specific CPT codes now that do appear
in claims data, so it’s possible to see which patients are receiving those. Our project currently is called Promoting
Asthma Best Practices—or the subtitle, that is The Asthma Care Accelerator—meaning
that we’re putting together dynamic features that allow us to make progress together faster. This falls under the rubric of the Learning Health Systems framework; it relies on the ECHO platform, which is video teleconferencing. We’ve already connected over 1,200 health
care providers and over 100 clinical sites and agencies in the 4 years that we have been
working on this. We provide Continuing Education credits, CME,
Advanced Pharmacology credit and Maintenance of Certification Part 2 and 4, which I will
explain briefly. The local clinic does their own run charts
over a 6-month period during this engagement to document implementation of best practices. They choose what they want to add to their
practice, and they document the percent of patients with asthma care…receiving asthma
care who do have those services, such as measurement of FEV1 or coaching for improved inhalation
technique. We’re able to provide them claims data for
the year before and the year after participation. This is supported by the evidence—there’s
an article published by Mold and group called Implementing Asthma Guidelines Using Practice
Facilitation and Local Learning Collaboratives: A Randomized Controlled Trial, and they’re
basically for movers, for drivers for improving care. We’ve been able to integrate all four of
those in the Asthma Care Accelerator Program. This is in many ways not a new concept. In 2004 an article titled “Asthma Days”
was published that provides us a model for how to stand alongside practicing health care
providers and help them be more effective and have better outcomes. This is our forum for assessing asthma best
practices. Again, there’s 32 items, and most people
are starting at about 30 percent of those best practices being routine. We’re able to look at claims data to validate
or question some of these findings in the survey. Of our participants, about 70 percent say
that they use specific J-codes to indicate the level of asthma, but the claims analysis
says only about 30 percent of children consistently have a J-code that reflects the specific level
of asthma. Of course, the significance is, if you don’t
call it right, you can’t treat it right. So, again, we use learning health systems, we use ECHO,
we have an amazing team of local and national folks that are on those video calls and that
actually travel out to clinic sites and help us. We have wide distribution across the state
of clinical practices, and we’re really trying to drill down and use geo mapping to
get specific about where the kids are. The red dots are 13,000 children, the blue
dots are primary care health homes, and the color gradation tells you how far it is for
the patient to reach a place where we’re working to improve asthma care. We are also looking at burden by school district. These are red circles showing large groups
of children with uncontrolled asthma, over 400 on those largest dots per district. And we are working at the level of creating community
hubs where there is engaged clinical practices, engaged schools and home-visitor workforce
to do environmental assessment. We’re really focused on what is high-impact
but low-cost, and there are a number of things that are clear standouts that don’t take
a lot money but seem to have a very large impact. We are spending a lot of time trying to translate
these data in a way that’s easy to act on or actionable. Red means this patient’s got a lot of problems
in this arena, yellow means it’s a problem, and green means were pretty much where we
need to be. Environmental interventions are integrated
into this claims analysis and report. This is an individual provider’s report
who has 172 patients with asthma. Almost 30 percent are uncontrolled, 69 percent
of their care is outpatient or preventive, but 31 percent of the care is still happening
in the emergency room. We give them a summary of their ICS use, we
look at the business model of how many missed outpatient appointments or opportunities you
would have expected for that population. Then the last item on this list:
What services can I offer? We do have an algorithm for predicting which
patients need a home environmental assessment based on ICS use and morbidity. So summing it up, we really focused on better
care, better outcomes, but also greater professional satisfaction with increased clinical revenue. One inpatient day equals about 20 outpatient
days financially, so we want to increase the outpatient and preventive care and lower the
overall insurer cost and total health care cost. We very much appreciate our sponsors who have
helped us reach this point. Thank you very much. Tracey Mitchell: Wow. Thank you, Kevin and Ben. Kevin, I think you said you didn’t consider
yourself an expert. I think you’re being very modest. Thank you for sharing your expertise and the
fabulous information and practical information on collecting and analyzing data. Before we close, I’d like to do one final
polling question. For folks on the phone, if you wouldn’t mind:
Based on what you heard today, what will you do next to improve your asthma data collection…or use data to improve asthma control? Please select all that apply, so you can select
more than one at this point. Great. Fabulous. Many of you will be working to collect better
data and analyze those data. You will be working with community partners,
and we have lots of information on Asthma Community Network as well as ways to connect
with community partners. And then hopefully you’ll all visit Asthma Community
Network…the resources there. Like I said, there’s information on business
case development, on sustainable financing. We have the sustainable financing microsite,
so many, many resources to help programs that are at any level of development or in the
process of seeking reimbursement and sustainability. So, at this point, I’d like remind you that
we will be closing the webinar and we will be going to Asthma Community Network for the
next 30 minutes with our speakers, so you will have an opportunity to ask them questions
and interact with them through the discussion forum. Here’s a reminder on how to access the discussion
forum on Asthma Community Network, and as I said, look for the webinar to be archived
there for your future reference as well as the question and answers. We are right at the top of the hour. I’d like to thank Kevin and Ben again, and
at this point that concludes today’s webinar. Thank you.

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