Each year, we spend more than $4.6 billion treating children’s asthma. Are we getting enough for our money?
Despite America’s outsized spending on care for children with asthma, it remains the leading chronic disease among American children, affecting more than six million of them. Every year, millions of children live without cohesive, long-term care for their asthma.They account for 700,000 emergency department visits, 200,000 hospitalizations, 14,000,000 missed school days and countless missed opportunities.
We can do better. There is no quick solution, but we can make a difference. Improving asthma outcomes is possible through education and outreach. While there is no single recipe for improving the lives of children with asthma, the programs highlighted within these pages—all supported by the Robert Wood Johnson Foundation—show that successful interventions share many common traits.To learn more about how communities, hospitals and health systems are changing the landscape of children’s asthma, visit www.pediatricasthma.org.
Lynval’s asthma has been under control since his grandmother called Philadelphia’s Asthma Link Line.
PediatricAsthma.org
Models for Advancing Asthma Care
Despite America’s outsized spending on care for children with asthma, it remains the leading chronic disease among American children, affecting more than six million of them. Every year, millions of children live without cohesive, long-term care for their asthma.They account for 700,000 emergency department visits, 200,000 hospitalizations, 14,000,000 missed school days and countless missed opportunities.
We can do better. There is no quick solution, but we can make a difference. Improving asthma outcomes is possible through education and outreach. While there is no single recipe for improving the lives of children with asthma, the programs highlighted within these pages—all supported by the Robert Wood Johnson Foundation—show that successful interventions share many common traits.To learn more about how communities, hospitals and health systems are changing the landscape of children’s asthma, visit www.pediatricasthma.org.
Lynval’s asthma has been under control since his grandmother called Philadelphia’s Asthma Link Line.
PediatricAsthma.org
Models for Advancing Asthma Care
Community Coalitions
Medicaid Managed Care
Strengthening the Continuum
Innovation in Action
“Coalitions bring together a variety of realms to make an impact.We have been able to show how important it is for a community to have physicians trained in the latest guidelines, universal asthma action plans and access to medications at school.We have evidence of their benefit.” —CYNTHIA KELLY, M.D., F.A.A.P., COALITION FOR INFANT AND CHILD HEALTH (CINCH), HAMPTON ROADS,VA
“More than 90 percent of persistent asthmatics in the Kansas City area now have controllers.That’s unheard of in other cities.” —JAY PORTNOY, M.D., FAMILY HEALTH PARTNERS, KANSAS CITY, MO Why Investing in Care Management Makes Sense INVESTING IN ASTHMA CARE management can improve asthma control and keep children out of emergency rooms and hospitals. By targeting children at risk for poor self-management and creating financial incentives to reward improved care management, health systems can achieve significant savings.
What can we do to strengthen our communities for children with asthma? SEVEN COMMUNITIES mobilized Allies Against Asthma coalitions to address children’s asthma with new and innovative approaches based on best practices in public health and deep and nuanced understanding of their locales. The coalitions— comprised of clinics, hospitals, public health agencies, health care plans, schools, parents, child-care providers, housing and environmental organizations, researchers and community-based organizations—combined clinical and public health approaches to control asthma in their communities.
• There is a strong business case for quality in comprehensive asthma case management: effective case management that
creates coordinated links among the plan, patient, and primary and specialty providers reduces costs. • Local collaboration among managed care organizations can help families better manage children’s asthma and improve the
quality of asthma care by standardizing provider and patient education, guidelines, asthma action plans and community outreach. • Incentives for provider and patient education (such as diagnostic and billing codes) can lead to better outcomes, decreased
utilization and increased satisfaction.
These coalitions have produced successful programs that can be replicated elsewhere, including:
New Voices for Environmental Justice
Affinity Health Plan Bronx, NY
• Standardization of asthma action plans within regions and across health
LONG BEACH, California, has some of the highest levels of particulate matter and ozone pollution in the country. While Long Beach Alliance for Children with Asthma (LBACA) outreach is multifaceted, its most dramatic efforts have involved empowering local residents— especially “LBACA Moms”—and bringing information about asthma and air pollution into public discourse. LBACA volunteers identify and test outdoor air pollution hot spots, monitor traffic patterns and test ultra-fine particles in the air. LBACA then uses the information to petition for clean air legislation for the Long Beach area. Their work has already identified serious air quality problems near several elementary schools.
BY IDENTIFYING members with asthma and referring them to asthma outreach and case management, Affinity Health Plan significantly reduced the cost of pediatric asthma care services and produced a significant return on investment:
systems • Access to care coordination and local asthma resources through a
telephone hotline • Outreach by community health workers in neighborhoods with high
rates of asthma • Policies that allow children to have access to asthma medications at school • Community education through events and seminars • Physician Asthma Care Education (PACE) training for professionals • In-home environmental remediation to reduce asthma triggers • Efforts to shape asthma policy at the state level.
Funding for coalitions can help:
ESTABLISH A NEUTRAL CONVENER ABLE TO BUILD AND MANAGE RELATIONSHIPS. In Philadelphia, Hampton Roads, and Washington, D.C., coalitions brought local managed care organizations together to standardize asthma action plans for their regions. FILL GAPS IN CARE. Across the country, community health workers reach out and tie isolated families to needed services and information. In Philadelphia, asthma resource coordinators are available through a telephone hotline. ENGENDER BROAD ENGAGEMENT. Engage the world beyond health care, from trade to education to the built environment.
• Inpatient utilization declined
threefold, and pediatric asthmarelated ED visits fell by more than 400 percent. • Per-member per-year costs for
both inpatient hospitalizations and emergency department visits fell by 50 percent. • Every $1 invested in the project
generated a $10 cost savings in childhood asthma care and a $3 in cost savings across the entire health plan.
Monroe Plan & ViaHealth Partnership Rochester, NY
Family Health Partners Kansas City, MO
AT A COST of $30 per asthma patient per month, this approach to patient outreach—including home visits, ongoing follow-ups and quality-of-life surveys, combined with extensive provider and staff education—resulted in:
THROUGH A program called KC CAMP, Family Health Partners standardized patient education and created incentives by offering providers reimbursement codes for time spent educating patients. The investment in education paid off with:
• A reduction in the percentage
• 40 percent reduction in
of patients categorized as moderate-to-severe from 51 to 26 percent • Improved quality of life for
participating children, including improvements in daytime symptoms, nighttime symptoms and functional limitations • Decreases in emergency
department and hospitalization costs that offset a rise in costs for asthma specialty services for moderate-to-severe patients.
asthma-related emergency department visits • 50 percent reduction in
asthma-related hospitalizations • 35 percent reduction in
asthma-related treatment costs. The approximate cost of the KC CAMP program is $0.43 per member per month, but the cost of caring for participating members has declined by about $2 per month, more than offsetting program costs.
PRODUCE SUSTAINABLE CHANGE. Many of these community-based coalitions have been able to impact local school medication policies, to improve the quality of care by training local providers to national standards, to standardize asthma action plans, and to become part of asthma planning within their states. PROGRAM NAME :
PROGRAM NAME :
SITES :
SITES :
Allies Against Asthma NATIONAL PROGRAM OFFICE : University of Michigan Center for Managing Chronic Disease Hampton Roads, VA • Long Beach, CA • Milwaukee, WI • Philadelphia, PA • San Juan, PR • Seattle, WA • Washington, DC
PediatricAsthma.org
Models for Advancing Asthma Care
Improving Asthma Care in Children Bronx, NY • Kansas City, MO • Rochester, NY
NATIONAL PROGRAM OFFICE :
Center for Healthcare Strategies
PediatricAsthma.org
Models for Advancing Asthma Care
Community Coalitions
Medicaid Managed Care
Strengthening the Continuum
Innovation in Action
“Coalitions bring together a variety of realms to make an impact.We have been able to show how important it is for a community to have physicians trained in the latest guidelines, universal asthma action plans and access to medications at school.We have evidence of their benefit.” —CYNTHIA KELLY, M.D., F.A.A.P., COALITION FOR INFANT AND CHILD HEALTH (CINCH), HAMPTON ROADS,VA
“More than 90 percent of persistent asthmatics in the Kansas City area now have controllers.That’s unheard of in other cities.” —JAY PORTNOY, M.D., FAMILY HEALTH PARTNERS, KANSAS CITY, MO Why Investing in Care Management Makes Sense INVESTING IN ASTHMA CARE management can improve asthma control and keep children out of emergency rooms and hospitals. By targeting children at risk for poor self-management and creating financial incentives to reward improved care management, health systems can achieve significant savings.
What can we do to strengthen our communities for children with asthma? SEVEN COMMUNITIES mobilized Allies Against Asthma coalitions to address children’s asthma with new and innovative approaches based on best practices in public health and deep and nuanced understanding of their locales. The coalitions— comprised of clinics, hospitals, public health agencies, health care plans, schools, parents, child-care providers, housing and environmental organizations, researchers and community-based organizations—combined clinical and public health approaches to control asthma in their communities.
• There is a strong business case for quality in comprehensive asthma case management: effective case management that
creates coordinated links among the plan, patient, and primary and specialty providers reduces costs. • Local collaboration among managed care organizations can help families better manage children’s asthma and improve the
quality of asthma care by standardizing provider and patient education, guidelines, asthma action plans and community outreach. • Incentives for provider and patient education (such as diagnostic and billing codes) can lead to better outcomes, decreased
utilization and increased satisfaction.
These coalitions have produced successful programs that can be replicated elsewhere, including:
New Voices for Environmental Justice
Affinity Health Plan Bronx, NY
• Standardization of asthma action plans within regions and across health
LONG BEACH, California, has some of the highest levels of particulate matter and ozone pollution in the country. While Long Beach Alliance for Children with Asthma (LBACA) outreach is multifaceted, its most dramatic efforts have involved empowering local residents— especially “LBACA Moms”—and bringing information about asthma and air pollution into public discourse. LBACA volunteers identify and test outdoor air pollution hot spots, monitor traffic patterns and test ultra-fine particles in the air. LBACA then uses the information to petition for clean air legislation for the Long Beach area. Their work has already identified serious air quality problems near several elementary schools.
BY IDENTIFYING members with asthma and referring them to asthma outreach and case management, Affinity Health Plan significantly reduced the cost of pediatric asthma care services and produced a significant return on investment:
systems • Access to care coordination and local asthma resources through a
telephone hotline • Outreach by community health workers in neighborhoods with high
rates of asthma • Policies that allow children to have access to asthma medications at school • Community education through events and seminars • Physician Asthma Care Education (PACE) training for professionals • In-home environmental remediation to reduce asthma triggers • Efforts to shape asthma policy at the state level.
Funding for coalitions can help:
ESTABLISH A NEUTRAL CONVENER ABLE TO BUILD AND MANAGE RELATIONSHIPS. In Philadelphia, Hampton Roads, and Washington, D.C., coalitions brought local managed care organizations together to standardize asthma action plans for their regions. FILL GAPS IN CARE. Across the country, community health workers reach out and tie isolated families to needed services and information. In Philadelphia, asthma resource coordinators are available through a telephone hotline. ENGENDER BROAD ENGAGEMENT. Engage the world beyond health care, from trade to education to the built environment.
• Inpatient utilization declined
threefold, and pediatric asthmarelated ED visits fell by more than 400 percent. • Per-member per-year costs for
both inpatient hospitalizations and emergency department visits fell by 50 percent. • Every $1 invested in the project
generated a $10 cost savings in childhood asthma care and a $3 in cost savings across the entire health plan.
Monroe Plan & ViaHealth Partnership Rochester, NY
Family Health Partners Kansas City, MO
AT A COST of $30 per asthma patient per month, this approach to patient outreach—including home visits, ongoing follow-ups and quality-of-life surveys, combined with extensive provider and staff education—resulted in:
THROUGH A program called KC CAMP, Family Health Partners standardized patient education and created incentives by offering providers reimbursement codes for time spent educating patients. The investment in education paid off with:
• A reduction in the percentage
• 40 percent reduction in
of patients categorized as moderate-to-severe from 51 to 26 percent • Improved quality of life for
participating children, including improvements in daytime symptoms, nighttime symptoms and functional limitations • Decreases in emergency
department and hospitalization costs that offset a rise in costs for asthma specialty services for moderate-to-severe patients.
asthma-related emergency department visits • 50 percent reduction in
asthma-related hospitalizations • 35 percent reduction in
asthma-related treatment costs. The approximate cost of the KC CAMP program is $0.43 per member per month, but the cost of caring for participating members has declined by about $2 per month, more than offsetting program costs.
PRODUCE SUSTAINABLE CHANGE. Many of these community-based coalitions have been able to impact local school medication policies, to improve the quality of care by training local providers to national standards, to standardize asthma action plans, and to become part of asthma planning within their states. PROGRAM NAME :
PROGRAM NAME :
SITES :
SITES :
Allies Against Asthma NATIONAL PROGRAM OFFICE : University of Michigan Center for Managing Chronic Disease Hampton Roads, VA • Long Beach, CA • Milwaukee, WI • Philadelphia, PA • San Juan, PR • Seattle, WA • Washington, DC
PediatricAsthma.org
Models for Advancing Asthma Care
Improving Asthma Care in Children Bronx, NY • Kansas City, MO • Rochester, NY
NATIONAL PROGRAM OFFICE :
Center for Healthcare Strategies
PediatricAsthma.org
Models for Advancing Asthma Care
Emergency Departments
PediatricAsthma.org
Challenging Assumptions
Models for Advancing Asthma Care
“Our studies challenged two assumptions.The first is the widely held belief that it is impossible to accurately address the chronic severity of a child’s asthma in the emergency department.The second is that children and families are too stressed and fatigued while they are in the emergency department to learn how to better manage asthma.”—CHARLES MACIAS, M.D., DIRECTOR,TEXAS EMERGENCY DEPARTMENT ASTHMA SURVEILLANCE (TEDAS) Enabling Emergency Departments to Drive System Change CAN EMERGENCY departments serve as drivers of system change, and not only impact how children’s asthma is treated locally, but how all emergency medicine professionals approach chronic disease therapy? • Uncontrolled asthma sends one out of every three children with asthma to the emergency department (ED) each year. • ED visits can cost up to five times more than a primary care visit. • IN WASHINGTON, D.C., a single follow-up visit to a comprehensive ED-based asthma clinic improved compliance with
a medical plan and inhaled corticosteroids, improved the quality of life for asthma patients, and decreased subsequent ED visits. • IN HOUSTON, individually tailored educational interventions, in combination with additional training for ED staff,
resulted in reduced ED visits and improved diagnostic skills.
About PediatricAsthma.org PEDIATRICASTHMA.ORG details the efforts of 14 research teams around the country to change the outlook for children with asthma. IMPROVING THE QUALITY OF CARE given to people suffering from chronic health conditions is an important goal of the Robert Wood Johnson Foundation. In 1998, RWJF staff considered how the Foundation might better focus its efforts on that objective. One recommendation was to explore one or two chronic diseases in depth, developing systems and interventions to improve the clinical care management and outcomes of people with those illnesses. The Foundation ultimately developed and supported the Pediatric Asthma Initiative, which used clinical and non-clinical approaches to improve the management of pediatric asthma among members of high-risk populations. Full details about these programs are available at www.pediatricasthma.org.
Allies Against Asthma sought to improve health outcomes for asthmatic children by supporting community coalitions.
Managing Pediatric Asthma: Emergency Department Demonstration Program used emergency department-based interventions to reduce ED visits and hospital admissions among asthmatic children.
Improving Asthma Care for Children tested new, publicly funded approaches to pediatric asthma management.
• IN MILWAUKEE, five hospitals developed a tracking system to follow emergency department care of children with
asthma. • IN HONOLULU, a local ED led the way in bringing primary care physicians up-to-date with the latest asthma
treatment guidelines.
Understanding—and Working With—Local Patterns SURVEILLANCE DATA from IMPACT DC clearly shows how poor access to primary pediatric care in Washington, D.C., is associated with fewer scheduled asthma visits. VISITS BY ZIP CODE, 2002
LOWEST RATE 3.9 / 1000
HIGHEST RATE 45.2 / 1000
Nearly 12-fold difference in rate VISITS / 1000 CHILDREN 0 – 12.5
25.1 – 37.5
12.6 – 26.1
37.5 – 50.0
“Our mapping demonstrates strong local racial, ethnic and economic disparities in asthma care and outcomes. ED visits are most common among children from areas marked by poverty, high concentrations of minority residents, and poor spatial access to primary care,” says the program’s medical director, Dr. Stephen Teach. In response, Dr. Teach created a model that meets parents and their children with asthma where they are—in the emergency department. Though he and his team emphasized linking to primary care providers, they also encouraged children and families to return to the emergency department two to 15 days after an acute visit for asthma for a single, 90-minute educational session aimed at helping them take charge of asthma. Seventy percent of 488 children followed through with their appointments. At six months, significantly more children in the intervention group reported use of asthma controller medications and no functional limitations on their quality of life due to asthma. In addition, they made 40 percent fewer ED visits for asthma during the follow-up period. The study was published in the May 2006 issue of Archives of Pediatrics & Adolescent Medicine.
PROGRAM NAME : Emergency Department Demonstration Program NATIONAL PROGRAM Immunology SITES : Honolulu, HI • Houston, TX • Milwaukee, WI • Washington, DC
PediatricAsthma.org
Models for Advancing Asthma Care
READ THE SITE’S CASE STUDIES and learn about the innovative, replicable models that will help improve quality of life and efficiency of treatment for children with asthma. Each profile tells the story of the program’s implementation, offering lessons learned and tips for future implementation. The site also offers links to many more resources, including asthma data, program sites and opportunities for continuing medical education.
OFFICE :
American Academy of Allergy, Asthma and
PediatricAsthma.org
Models for Advancing Asthma Care
Emergency Departments
PediatricAsthma.org
Challenging Assumptions
Models for Advancing Asthma Care
“Our studies challenged two assumptions.The first is the widely held belief that it is impossible to accurately address the chronic severity of a child’s asthma in the emergency department.The second is that children and families are too stressed and fatigued while they are in the emergency department to learn how to better manage asthma.”—CHARLES MACIAS, M.D., DIRECTOR,TEXAS EMERGENCY DEPARTMENT ASTHMA SURVEILLANCE (TEDAS) Enabling Emergency Departments to Drive System Change CAN EMERGENCY departments serve as drivers of system change, and not only impact how children’s asthma is treated locally, but how all emergency medicine professionals approach chronic disease therapy? • Uncontrolled asthma sends one out of every three children with asthma to the emergency department (ED) each year. • ED visits can cost up to five times more than a primary care visit. • IN WASHINGTON, D.C., a single follow-up visit to a comprehensive ED-based asthma clinic improved compliance with
a medical plan and inhaled corticosteroids, improved the quality of life for asthma patients, and decreased subsequent ED visits. • IN HOUSTON, individually tailored educational interventions, in combination with additional training for ED staff,
resulted in reduced ED visits and improved diagnostic skills.
About PediatricAsthma.org PEDIATRICASTHMA.ORG details the efforts of 14 research teams around the country to change the outlook for children with asthma. IMPROVING THE QUALITY OF CARE given to people suffering from chronic health conditions is an important goal of the Robert Wood Johnson Foundation. In 1998, RWJF staff considered how the Foundation might better focus its efforts on that objective. One recommendation was to explore one or two chronic diseases in depth, developing systems and interventions to improve the clinical care management and outcomes of people with those illnesses. The Foundation ultimately developed and supported the Pediatric Asthma Initiative, which used clinical and non-clinical approaches to improve the management of pediatric asthma among members of high-risk populations. Full details about these programs are available at www.pediatricasthma.org.
Allies Against Asthma sought to improve health outcomes for asthmatic children by supporting community coalitions.
Managing Pediatric Asthma: Emergency Department Demonstration Program used emergency department-based interventions to reduce ED visits and hospital admissions among asthmatic children.
Improving Asthma Care for Children tested new, publicly funded approaches to pediatric asthma management.
• IN MILWAUKEE, five hospitals developed a tracking system to follow emergency department care of children with
asthma. • IN HONOLULU, a local ED led the way in bringing primary care physicians up-to-date with the latest asthma
treatment guidelines.
Understanding—and Working With—Local Patterns SURVEILLANCE DATA from IMPACT DC clearly shows how poor access to primary pediatric care in Washington, D.C., is associated with fewer scheduled asthma visits. VISITS BY ZIP CODE, 2002
LOWEST RATE 3.9 / 1000
HIGHEST RATE 45.2 / 1000
Nearly 12-fold difference in rate VISITS / 1000 CHILDREN 0 – 12.5
25.1 – 37.5
12.6 – 26.1
37.5 – 50.0
“Our mapping demonstrates strong local racial, ethnic and economic disparities in asthma care and outcomes. ED visits are most common among children from areas marked by poverty, high concentrations of minority residents, and poor spatial access to primary care,” says the program’s medical director, Dr. Stephen Teach. In response, Dr. Teach created a model that meets parents and their children with asthma where they are—in the emergency department. Though he and his team emphasized linking to primary care providers, they also encouraged children and families to return to the emergency department two to 15 days after an acute visit for asthma for a single, 90-minute educational session aimed at helping them take charge of asthma. Seventy percent of 488 children followed through with their appointments. At six months, significantly more children in the intervention group reported use of asthma controller medications and no functional limitations on their quality of life due to asthma. In addition, they made 40 percent fewer ED visits for asthma during the follow-up period. The study was published in the May 2006 issue of Archives of Pediatrics & Adolescent Medicine.
PROGRAM NAME : Emergency Department Demonstration Program NATIONAL PROGRAM Immunology SITES : Honolulu, HI • Houston, TX • Milwaukee, WI • Washington, DC
PediatricAsthma.org
Models for Advancing Asthma Care
READ THE SITE’S CASE STUDIES and learn about the innovative, replicable models that will help improve quality of life and efficiency of treatment for children with asthma. Each profile tells the story of the program’s implementation, offering lessons learned and tips for future implementation. The site also offers links to many more resources, including asthma data, program sites and opportunities for continuing medical education.
OFFICE :
American Academy of Allergy, Asthma and
PediatricAsthma.org
Models for Advancing Asthma Care
PediatricAsthma.org
Models for Advancing Asthma Care
A Clearinghouse PediatricAsthma.org details the efforts of 14 research teams supported by the Robert Wood Johnson Foundation to change the outlook for children with asthma. About the Robert Wood Johnson Foundation The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with diverse groups of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 30 years, the Foundation has brought experience, commitment and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime.