Asthma Demonstration Project

State: NY Type: Model Practice Year: 2008

The Suffolk County Asthma Demonstration Project will reduce Medicaid expenditures in Suffolk County by reducing hospitalizations and emergency department (ED) visits and unscheduled doctor visits for those with a diagnosis of asthma who receive their primary healthcare at one of the county's network of Health Centers, with an emphasis on children. This will be accomplished by provider education and performance improvement initiatives; in-home environmental assessment and remediation; health education to asthmatics and their families; public health nursing in-home education; interdisciplinary team meetings; and hospital/health center coordination of care.
Since 1980, asthma prevalence, hospitalization, and mortality have been increasing in New York State. The incidence varies according to racial/ethnic and other demographics. Six percent of Mexican Americans, 8 percent of Hispanics, 13 percent of African American non Hispanic, and 19 percent of Puerto Ricans have been diagnosed with Asthma (Centers for Disease Control and Prevention, 2007, The overall incidence of asthma in New York averages almost 10 percent of children (CDC, 2006), although low-income and ethnic minorities are disproportionately affected (National Institute for Healthcare Management [NIHCM], 2007) Incidence is higher for homeless children (40 percent); among that cohort only 15 percent are taking asthma controller medications. Emergency use for this cohort is 59 percent. A disproportionately higher burden of asthma falls on the disadvantaged ethnic minorities in the suburban population of Suffolk County, NY. Asthma is a major cost burden for Medicaid recipients in Suffolk County mostly due to ED use and in-patient hospital stays. The rate of hospital-related discharges for asthma in this population is 84.2 per 10,000, which is three times the Healthy People 2010 Objective (25.0/10,000), and almost three times the rate for the remainder of the County (30.5/10,000) (New York State Department of Health, 2006, Risk factors for increased asthma-related mortality and morbidity has been documented in this population, including poor and crowded living conditions, exposure to environmental pollutants, limited health insurance coverage, poor access to medical care, and lack of self-management skills. A multipronged approach is being taken to address the issue. An asthma coordinator has been hired and will oversee the components of the project. Eligibility is based on individuals risk for hospitalizations, ED visits, and unscheduled health center visits. Risk factors including but not limited to recent hospitalization, ED, or unscheduled clinic visits as well as age (asthma can be more problematic for younger children) and severity of asthma. Provider-focused interventions include multidisciplinary provider education. This includes state of the art asthma management and treatment, building cultural and linguistic competence skills and effective health education strategies for those with low literacy skills. Performance improvement initiatives include goals and benchmarks, provider performance improvement monitoring on a regular basis, and skill building based on the National Initiative for Children's Healthcare Quality (NICHQ). System coordination and collaboration includes the integration of a new SCDHS asthma policy based on the 2007 National Heart, Lung, and Blood Institute (NHLBI) Asthma Guidelines. It also includes interdisciplinary patient-focused team meetings and use of community partners such as the local Asthma Coalition. Individual and family-focused interventions include enhanced monitoring, referral to Public Health Nursing Breathing Easy Program, environmental remediation and patient education with low literacy printed materials.
Agency Community RolesSCDHS is the lead agency for the project, and all enrollees receive both their ambulatory care and public health nursing intervention through the department. The level of citizen participation in government programs was enhanced through the program’s partnership and collaboration with the community coalition, the Asthma Coalition of Long Island. The Asthma Coalition of Long Island: Is a multidisciplinary coalition that maximizes the use of resources to benefit children with asthma, has more than 80 community members, and members include healthcare providers, schools, community organizations, and individuals with asthma; Provides resources, such as computers (for Public Health Nurses to take into the home for educational purposes), design of computerized and print health educational materials, hardware and software, and technical assistance, expertise, and advocacy; Provided support and advocacy for public policy changes needed to implement program. Costs and ExpendituresInitial implementation in two health centers that are operated via a contractual agreement between Suffolk County Department of Health Services (SCDHS) and area hospitals: Elsie Owens Health Center in Coram, NY, and Martin Luther King, Jr. Health Center in Wyandanch, NY. Project will be implemented into the other county health centers after initial rollout at pilot sites. The reductions in hospitalizations, ED, or unscheduled health center visits will be measured. Anticipated costs components include required additional staff and other associated expenses: In-kind services are provided by: Community partnerships (e.g., the American Lung Association’s Asthma Coalition of Long Island, area hospitals); and, SCDHS (current professional and administrative staff time to implement project). Anticipated savings components include the reduction of hospitalizations, ED visits, and unscheduled doctor visits for the target population. Projected net savings will be measured by gathering pertinent current statistical data and then comparing that data against reductions projected after program implementation; savings are projected at $370,000 per year. ImplementationAll asthmatics are provided with this care. The intensity and level of interventions are based on risk factors: Recent hospitalization, ED visit, or unscheduled doctor visit; Age (more problematic for younger children); Asthma severity. Asthmatics are provided with one or more levels of intervention based on severity of disease, number of ED visits, unscheduled visits, or hospitalizations within a determined time frame. Level 1: Health Center Health Education – emphasis on strategies known to be effective with those with low literacy skills. There is reinforcement of training in self–management, the patient-specific asthma action plan, and case-management/review. Level 2: Public Health Nursing’s In-Home Asthma Education Program Increase in those receiving an in-home nurse-led asthma education and health monitoring program, including health education materials that are specifically designed for the target population. Use of these materials has demonstrated improvement in both asthma management and control. Provide information on the danger and impact of second-hand smoking on a child’s health and risk of exacerbating asthma; Supporting SCDHS Public Health Nursing Programmatic Initiative: After implementation of a smaller scale intervention program several years ago, an assessment of this program showed reduction of: Highly significant statistical reduction of ER visits, verified by statistical analysis (in the number of ED visits for asthma, comparing 1 year pre- with 1 year post-program completion); Reduction by 33% of hospitalizations, verified by statistical analysis (significant statistical reduction in the number of hospitalizations for asthma comparing 1 year pre- with 1-year post program completion). Level 3: Environmental Assessment and Remediation. Using public health staff for in home environment assessment and recommended environmental remediation in the home (e.g., mold remediation, pest management) in order to improve environmental quality and reduce exposure to indoor asthma triggers (especially in low-income households of children with asthma). Depending on results of assessment, referrals may be made to the appropriate housing authority for structural remediation of housing for conditions that increase exposure to asthma triggers (e.g., poor ventilation, mold-infiltrated surfaces, leaks, holes in walls, carpeting). Additional Program Enhancement Components: Provider Education – Professional staff, including Physicians, Nurse Practitioners, Physician Assistants, Nurses, and other staff. Provider Performance Improvement. Development of provider goals and benchmarks. Monitoring provider performance improvement on regular basis. Integration of "Asthma Action Plans". Interdisciplinary Patient-Focused Team Meetings. Mental health staff, Nurses, Physicians, Social Workers, DSS staff, etc. ED, In-Patient Hospital, and Community Coordination of Care. Referral system and coordination between hospital and health center network, coordinating care after ED visits and in-patient hospitalizations. The initial phase involved six months of team building and planning by team members. Subsequent to this phase, the implementation involves an additional three months of education and skill building for the requisite staff.
Improved public health. Reduction of Medicaid expenditures and associated costs to the taxpayer. Reduction in ED visits or unscheduled doctor visits. Reduction in hospitalizations. Increased knowledge and self-efficacy. Change in behaviors (e.g., improved medication use). Lowered risk to exposure of environmental threats and risk.
Reimbursement comes from third-party insurance sources and can easily be sustained. Available resources continue to be used with existing revenue streams. Existing revenue streams will be used in order to continue sustainability.