Make It Easy to Support Your Program
The AAT is deeply partnered with organizations throughout GHS and across the community so that no single partner shoulders the entire financial burden for the program. The collaboration has allowed the program to keep delivery costs low while improving outcomes for a low-income population of children with asthma. The partners intend to continue to collaborate, each delivering the program component for which it is best suited – for example, PBE and GPACC will continue providing environmental asthma counseling in homes, schools and child care centers with referrals from the AAT.
The AAT’s collaboration with the GHS Children’s Hospital provides the AAT with the clinical capacity, staff and resources it needs to deliver the highest quality asthma care. For example, children with asthma and comorbid overweight and obesity can attend GHS’ weight loss program, with financial support from CPM if needed. GHS Children’s Hospital CPM also provides transportation support for medical visits on an as needed basis and support for medication access. Additionally, the clinical and administrative staff, equipment, supplies and training costs are paid for with CPM and GHS funding. GHS and CPM are largely self-sustaining through the revenue and reimbursement from patient visits. The reduction in hospital and ED charges for children seen by the AAT exceeds the costs associated with their case management.
The Greenville Health System Center for Pediatric Medicine (CPM) AAT is a partnership-driven, hospital-based program. The AAT delivers a consistent, evidence-based approach to pediatric asthma management to families of children with asthma, and it teaches medical residents, medical students, and other health care professionals to provide care that aligns with national guidelines-based asthma care. Through a strong network of partners, the AAT delivers medical care, case management, school and child care facility environmental asthma control support, and environmental home visits for children and adolescents with asthma. Over 4,338 children are currently in the asthma registry, many of whom are uninsured or underinsured. Asthma prevalence in the greater Greenville community is estimated at 12.8%, and asthma/bronchitis is the leading cause of hospitalization for children younger than 18.
Built upon the foundation of the existing Asthma Clinic in 1997, the Center for Pediatric Medical Home Asthma Initiative formed in 2008 collaboratively with representative members of CPM, GHS, and the South Carolina Asthma Alliance. The initiative developed in response to growing asthma prevalence, increasing urgent and unscheduled health care utilization for asthma (i.e., emergency department (ED) visits and hospitalizations), increasing rates of ED recidivism for asthma care, and significant disparities in pediatric asthma outcomes across the community. The AAT’s partnerships and services have changed over time based on the social, cultural, and economic needs of their patients, resources available within the community, and the clinics’ and hospital’s needs and resources. But the overarching mission has remained the same: to deliver standardized evidence-based outpatient care to prevent hospitalizations and emergency department (ED) visits and to improve patient quality of life.
Ensure Mission-Program Alignment
The AAT delivers and coordinates consistent patient education in the home, school, child care facility, physician’s office, and community in order to promote self-management and reduce unplanned health care utilization. The AAT manages a registry for its asthma patients and delivers integrated care through a network of partners who help to reinforce self-care education, promote the connection to a medical home, and deliver environmental asthma controls. The AAT and its partners deliver training on the National Guidelines for the Diagnosis and Management of Asthma (EPR-3) for GHS Children’s Hospital Pediatric Residency Program and GHS Children’s Hospital Medicine-Pediatric Residency Programs’ medical students and for CPM nurses. CPM’s asthma clinic delivers guidelines-based care, including regular updating and online storage of pictorial, multilingual asthma action plans (AAPs) where inpatient and outpatient GHS providers can access them, as well as regular monitoring of asthma classification (i.e., spirometry), medication use, and health care utilization. All of the information is collected in an electronic medical record (EMR) that is available to inpatient and outpatient care providers. Qualifying families may also receive intensive case management to deliver asthma education, home visits, office coordination, and school visits, with a certified asthma educator (AE-C) from CPM serving as case manager.
Focus on the Resource Strategy at Every Step
The AAT recognized the need to address social, economic, cultural and environmental factors that make it difficult for some families to bring their children’s asthma under control. In order to address the many risks and compounding factors that complicate asthma, the AAT sought partners early on who could help reinforce asthma care messages patients received in the clinical setting everywhere patients spend time. The AAT also needed partners who could help control environmental factors contributing to asthma, particularly in homes, schools and child care facilities, and who could share the costs of comprehensive asthma care delivery. The AAT found the partners it needed in the Family Connection of South Carolina (FCSC) Project Breathe Easy (PBE), and the Greenville Pediatric Asthma Community Collaborative (GPACC).
PBE assists and educates primarily low-income and minority families with children with asthma through a parent-to-parent education model. Trained parent educators visit schools, laundromats, child care centers, health fairs, physician offices and neighborhoods with low-income housing to deliver asthma education and provide referrals to FCSC to ensure that families have access to a medical home. CPM offers its families with children with asthma a referral to PBE. A referral results in enrollment in the PBE home visit program with constant contact for a six month period, including in-home review and counseling on asthma symptoms and triggers, education on effective communication with doctors and schools about a child’s asthma, and a mattress and pillow encasement for the child’s room provided with funds from the GHS Children’s Hospital.
INTEGRATED HEALTH CARE SERVICES: Educate and Support Clinical Care Teams
The Asthma Action Team (AAT) operates an asthma clinic four half-days per week. All visitors are assessed for disease severity and control. They are then stratified for case management. They receive asthma education, medication review and explanation and tailored environmental trigger counseling. GHS Children’s Hospital Pediatric and Medicine Pediatric Residents in addition to medical students from the nearby University of South Carolina’s School of Medicine rotate through the asthma clinic, where they learn guidelines-based asthma diagnosis and care practices. Nurses from CPM are also trained in the national guidelines for asthma care, and they help to coordinate asthma services across CPM. For example, nurses are trained to administer asthma control tests and to use pharmacy data and sick call data to identify children from across CPM for referral to the AAT asthma clinic.
TAILORED ENVIRONMENTAL INTERVENTIONS: Promote Environmental Triggers Management at Home, School and Work
In addition to PBE, the AAT also collaborates with GPACC to assist with intensive case management and to deliver environmental asthma counseling at home and school. GHS’s high-risk asthma patients – children who frequent the ED for asthma-related care or who have had an exacerbation extreme enough to require hospitalization – receive referrals to the GPACC which coordinates case management with the AAT and delivers home and school visits through an AE-C.
Evaluate Program Impact
Between 2007 and 2012, CPM’s population of children with asthma almost tripled. At the same time, the overall patient count at CPM doubled. Despite the growth in patients served and the percentage of them with asthma, the percentage of children seen at CPM who visited the ED for asthma care declined while visits for asthma case management increased.
For the sub-population of AAT patients who received referrals to PBE and the GPACC for environmental assessments and intensive case management, respectively, asthma health and quality of life outcomes have improved since enrollment in the program. For the 373 patients with initial home visits that PBE conducted based on referrals from CPM, data indicate a 71% decrease in asthma ED visits and hospitalizations, a 21% decrease in unscheduled office visits, a 51% decrease in self-reported missed school days and a 41% decrease in reported parents’ missed work days related to asthma. For the GPACC, a newer program that has conducted 72 initial home visits, early data indicate reductions in emergency health care utilization and improved quality of life. Program implementation data indicate that all families that received a home visit now have an up-to-date action plan and prescriptions for appropriate controller medications.
The AAT uses its EMR system not only to guide clinical encounters and identify and stratify asthma patients, but also to track asthma control test results over time, adherence to appropriate medication regimens, receipt of influenza vaccines and results of partner-led program components, such as home and school visit results. These real-time data allows the AAT to observe and respond to trends that point to disparities and to connect patient care data to Medicaid claims data to ensure the program is achieving the improvements it seeks.