Seton Asthma Center Snapshot
Ensure Mission-Program Alignment
Seton's mission is to care for and improve the health of all it serves with a special concern for the sick and the poor. In line with that mission, the Center's overarching goal is to reduce asthma disparities in Seton's seven county service area. With a focus on its mission, the Center delivers all asthma care services free of charge. To identify as many clients in need of care as possible, the Center accepts referrals from local hospitals, Seton's clinical network, other providers throughout the service area and school nurses--AISD nurses are Seton employees. The school district underwrites their salaries and Seton covers all benefits and administrative costs. To date, the Center's clients have primarily been children under 17 (90%) and more than 85% of clients have been either uninsured or publicly funded.
When the Center first launched in 2004, it had a staff of two respiratory therapists who delivered in-patient asthma education and educated providers on the National Guidelines for the Diagnosis and Management of Asthma (EPR-3). Over time, the staff expanded to include a clinical manager and five respiratory case managers and the focus shifted to home and community-based education to promote patient self-management, control of environmental triggers and coordination of long-term clinical care. Today, the Center offers more than education: its comprehensive care model helps to deliver "funding, physicians, pharmacies and follow-up" through ongoing case management that helps equip clients with all the components of effective asthma care. For example, if at any point during the Center's twelve-month program, a client becomes ineligible for previous insurance coverage, the Center's staff will screen the family for funding eligibility and attempt to establish insurance coverage and a new medical home.
The Center's education and case management program is carried out through a series of one-hour sessions, where clients and their families complete a quality of life (QoL) survey to address key indicators, such as frequency of symptoms, medication usage, missed school and work days and others. Based on the results, case managers provide tailored education on medication usage, environmental trigger exposure and management and self-monitoring and self-management. When the education session is complete, case managers develop treatment recommendations based on the EPR-3. In conjunction with the provider, case managers complete or update asthma action plans (AAPs) to reinforce the learning. Patients and their parents receive a copy of the AAP and a copy is placed in the medical record.
Use Data to Demonstrate Your Program's Value
Based on 2008 data during which 569 enrolled patients completed at least one intervention visit with a case manager, the Center developed a return on investment estimate to demonstrate cost savings to the health care system from the asthma program. The Center estimated the benefit of the program by comparing the total charge for asthma ED visits and hospitalizations in the 12 months prior to enrollment to the total charge for utilization in the 12 months after enrollment and subtracting the total operating expenditures for the Center. This analysis results in an estimated savings of $1.2 million or a savings of $2,132 per patient.
Promote Institutional Change for Sustainability
The Center is currently conducting a pilot project with the local Federally Qualified Health Center (FQHC) where the FQHC has underwritten a portion of the Center's operating cost for managing Medicaid and managed-care funded children with asthma who receive primary care at the FQHC. The partnership delivers many benefits, including contributing to the Center's long-term sustainability. The FQHC's support reduces the hospital's financial commitment; delivers prompt access to primary care, which helps drive down recidivism to emergency care and inpatient admissions; and enhances the value proposition the Center can offer Seton's hospital operations. The Center plans to conduct an annual evaluation of the pilot partnership and to examine the viability of the partnership as a model for other stakeholders, such as Texas Medicaid Services, a partner that could potentially support the expansion of the asthma care network in Central Texas.
The Center has expanded to include operations in six community clinics. Two clinics are in Burnet and Caldwell counties, among the most economically challenged in the state. Case managers offer monthly education sessions in conjunction with local providers at the clinic sites. When transportation is a problem, they deliver sessions in clients' homes. In Burnet and Caldwell counties, the Center also operates a mobile caravan to make monthly visits to public schools to deliver asthma care to uninsured and indigent students who may not be served in the clinic system.
INTEGRATED HEALTH CARE SERVICES--FACILITATE COMMUNICATION ACROSS THE CARE TEAM
In clinical settings, case managers provide a copy of the completed AAP along with treatment recommendations to the provider at the end of the visit and the provider signs the AAP. When encounters occur outside of the clinical setting, case managers communicate the treatment recommendations and provide a copy of the AAP to providers within seven days. To indicate they have received and reviewed the recommendations, providers return signed copies of the AAP to the Center within 48 hours. When the Center receives signed AAPs from providers for school-aged children, staff fax a copy of the AAP to the child's school nurse.
The Center evaluates ED and hospital utilization and self-reported QoL measures. Utilization data includes the number of ED visits, number of hospital in-patient visits and total length of stay (LOS). The Center estimates the program's impact by comparing outcomes for enrolled patients in the 12 months prior to enrollment, to outcomes in the 12 months after enrollment. QoL measures include symptom-free days in the last 14 days, missed school or work days in the past 30 days and number of days symptoms affect the ability to engage in physical activity in the last 14 days. QoL data is reported at enrollment and through follow-up surveys conducted at quarterly intervals throughout the year-long intervention.
Utilization data demonstrates a significant decrease in ED visits, inpatient encounters and hospitalization days due to asthma: ED visits declined by 75%; in-patient visits declined by 85%; and the total hospital length of stay for patients admitted for asthma decreased from 162 days to 16 days in the 12 month period following the initial intervention.