Parkview Health System (Asthma Education and Management Program)

Program: 
Parkview Health Comprehensive Asthma Education and Care Navigation
Winner Blurb: 

Parkview Health System is a nonprofit health care provider that delivers care to more than 875,000 people in a five-county area in northeast Indiana. Parkview’s community consists of urban, suburban and rural populations that have seen increasing asthma prevalence over the past 15 years. In response to data indicating that asthma is a frequent cause for emergency health care services, particularly among low-income communities served by Parkview, as well as input from community partners, the hospital developed a comprehensive Asthma Education and Management Program in 2004.

 

Parkview’s Asthma Education and Management Program identifies children and adults with asthma and improves their ability to self-manage by providing support services, resources and age-appropriate education. The program is run by the hospital’s Integrated Community Nursing Program and relies on Parkview’s partnerships with local school districts and social service agencies to enroll patients and deliver program services. Parkview also partners with the Fort Wayne-Allen County Department of Health and Indiana State Department of Health (ISDH) to provide environmental home visits and to evaluate the Asthma Education and Management Program’s impact. With its partners, Parkview also educates school staff, including school nurses, teachers, coaches and bus drivers on the signs and symptoms of asthma and instruction on how to address a severe asthma attack. Parkview also works with the county’s Healthy Homes Program to provide environmental home visits and in-home asthma/allergy education.

 

One important program component is the Emergency Department (ED) Asthma Call Back Program, which began in 2009 and serves over 1,200 individuals annually. The Call Back Program equips people who have visited the ED with the knowledge and tools they need to manage their asthma and avoid future ED visits. All patients who visit the ED for asthma-related illnesses receive calls from an asthma educator after they are discharged to discuss asthma control and access to and appropriate use of medications. Where indicated, nurses can order home visits to provide environmental asthma trigger assessment and mitigation. Home visitors typically provide supplies, including bedding encasements, HEPA vacuums and green cleaning supplies, at no-cost, and they provide asthma education. Qualified patients who cannot afford their asthma medications or do not have a medical home are enrolled in Parkview’s Medication Assistance Program and referred to a physician in the Parkview system, a federally qualified health clinic, or a free clinic.

 

Through its partnership with ISDH, Parkview has access to evaluation data that demonstrate the impact of its asthma program. Surveillance data show improved asthma outcomes over time in counties served by Parkview as compared to demographically similar counties within the state. ISDH’s evaluation of the ED Call Back Program found that it is effective at reducing ED readmissions: ED recidivism dropped to 15.04 percent in the intervention group compared to 21.95 percent in the baseline group. The ED Asthma Call Back Program also demonstrated an impact on school and work attendance and quality of life, with nearly 59 percent of participants reporting they had missed zero school or work days since involvement in the program. The program has also demonstrated a positive impact on increasing access to medical homes and controller medication with 11.2 percent of participants acting on physician referrals and 16.4 percent receiving prescription support services. Finally, Parkview’s own data demonstrate a reduction in inpatient visits for asthma over time and reduced average costs per patient encounter. Parkview has been able to demonstrate a steadily improving return on investment (ROI) from the ED Asthma Call Back Program – from $20 saved for every $1 invested in the baseline year to $23.75 saved per dollar invested in 2012. These ROI data helped Parkview’s leadership decide to expand the ED Asthma Call Back Program to all six campuses within the health system.

Winnner Photo: 
Winner Photo Caption: 

Pictured l-r: Deb Lulling and Jan Moore

Award Winner Category: 
Health Care Provider
Award Year: 
2013

Greenville Health System (Asthma Action Team)

Community Program: 
Center for Pediatric Medicine Asthma Action Team
Location: 
Greenville, SC
Type: 
Public, Not-for-Profit Hospital-Based Program
Service Area: 
Greenville County and surrounding areas
Population Served: 
Largely Medicaid, multiethnic population from urban, suburban and rural communities
Key Players: 
Family Connection of South Carolina’s Project Breathe Easy, South Carolina Asthma Alliance, Greenville Pediatric Asthma Community Collaborative, Greenville Health System Children’s Hospital, Greenville County School District, United Way of Greenville County Child Care Resource and Referral, South Carolina Offering Prescribing Excellence, Decision Dynamic Inc.’s Disease Management Coordination Network
Results: 
Data from the Asthma Action Team’s (AAT) partnership to deliver environmental home visits demonstrate a 71% decrease in urgent health care utilization, a 21% decrease in unscheduled clinical care visits, a 51% decrease in missed school days and a 41% decrease in missed work days for parents post-intervention.

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. 

Building The System: 

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.

Key Driver: 

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.

Getting Results - Evaluating The System: 

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.

Sustaining The System: 

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.

Program Profile Top Link: 
2013 U.S. EPA National Environmental Leadership Award in Asthma Management Winner
Program Profile Bottom Link: 
view award-winning strategies

Parkview Health System (Asthma Education and Management Program)

Community Program: 
Parkview Health Comprehensive Asthma Education and Care Navigation
Location: 
Fort Wayne, IN
Type: 
Not-for-Profit Health System
Service Area: 
Northeast Indiana and Northwest Ohio
Population Served: 
875,000 people from urban, suburban and rural communities
Key Players: 
East Allen, Northwest Allen and Fort Wayne Community School Districts; Central, West and East Noble County School Districts; Fort Wayne-Allen County Department of Health; Indiana State Department of Health
Results: 
Emergency Department (ED) Asthma Call Back Program reduced ED recidivism for asthma from 21.95% at baseline to 15.04% in the intervention year, and demonstrated a positive impact on increasing access to medical homes and access to controller medication. Return on investment for the ED Asthma Call Back Program improved from $20 saved for every $1 invested in the baseline year to $23.75 saved per dollar invested in 2012.

Since 2004, Parkview’s Asthma Education and Management Program has worked with community partners to identify children and adults with asthma and to deliver support services, resources and age-appropriate education to improve their ability to self-manage their asthma. Since 2009, Parkview has expanded its program to also deliver an ED Asthma Call Back Program that provides ED patients with a primary diagnosis of asthma with knowledge and resources to improve their self-management of asthma and reduce future use of the ED and hospitalizations for asthma. The Asthma Education and Management Program is run by the hospital’s award-winning Integrated Community Nursing Program and relies on Parkview’s strong partnerships with local school districts and social service agencies to enroll patients and deliver the program. Parkview also partners with the Fort Wayne-Allen County Department of Health’s Healthy Homes Program and Indiana State Department of Health (ISDH) to provide environmental home visits and to evaluate the Asthma Education and Management Program’s impact, respectively. 

Building The System: 

Let the Data Guide the Program
Parkview’s Asthma Education and Management Program was developed to address the growing incidence and impact of asthma-related illness in Parkview’s service area. Data demonstrating the need for the program were compiled from multiple sources including the Centers for Disease Control and Prevention, ISDH and county health department asthma surveillance data, local school districts, physicians and ED staff, and two community health assessment surveys. One of the community health assessment surveys gathered general health status information, and the other focused on the needs of low-income individuals. The data showed that asthma prevalence was increasing, particularly among Parkview’s lowest-income service areas, which include a federally-designated Medically Underserved Population. The data also indicated asthma was a major self-reported health concern for Parkview’s population and that asthma-related symptoms were one of the most frequent reasons for ED visits and the leading cause of school absenteeism. Discussions with community partners further revealed that people with asthma needed more information and support in order to self-manage their asthma and that many ED visits for asthma resulted from a lack of regular medical care, lack of appropriate controller medication use, and/or the inability to effectively self-manage.

Conduct Needs-Based Planning
In response to both the community health needs assessment and needs of partner agencies, Parkview, in conjunction with numerous community partners, developed strategies to target the identified needs. The program’s goals were to help patients manage and control their asthma, reduce asthma-related ED visits, establish a medical home, provide financial assistance for medication as needed, support effective asthma trigger management and improve quality of life.

Start Small to Get Big
Today, Parkview’s Asthma Education and Management Program is a multi-component initiative that identifies people with asthma through local schools, social service agencies and the ED. The program delivers self-management education and resources, as well as environmental asthma management services to those identified through the initiative. When the program launched in 2004, it focused on delivering age-appropriate educational materials to school children and adults; supporting school nurses in asthma care planning and case management; educating teachers, coaches, bus drivers, social service agency staff and nursing students on asthma symptoms and attacks; and working through the county Healthy Homes Program to deliver environmental home assessments. Five years later, Parkview added the ED component to its program to further support people whose asthma may not be under control.

Every year, Parkview and its partners provide asthma education to people including young children, adolescents, adult caregivers, school nurses, teachers, coaches, bus drivers and other school staff. They receive tailored comprehensive asthma disease management education, including counseling on environmental asthma triggers and how to avoid them. They also receive asthma management resources, such as spacers for inhalers and back-to-school asthma checklists. As needed, they receive referrals for home visits, treatment of comorbid conditions, financial support for medication and assistance in establishing a relationship with a primary care provider. The ED Asthma Call Back Program serves over 1,200 individuals on an annual basis and recruits patients after asthma-related ED visits rather than through schools and social service agencies. This program delivers the same education, support services and resources as described above.

Key Driver: 

STRONG COMMUNITY TIES: Make It Easy to Accept Services
All home visits for patients include asthma and allergy education, trigger assessment and management assistance. Visits also include smoking cessation information and referrals for management of comorbid diseases. During visits, smoking cessation resources and information on financial assistance for medication and making a connection to a medical home are provided. Staff follow up at two-month, six-month and one-year intervals to monitor compliance and retained understanding of asthma management.

INTEGRATED HEALTH CARE SERVICES: PROMOTE ROBUST PATIENT/PROVIDER INTERACTION
Through group classes, home visits, educational materials and other communications with people with asthma and their families, Parkview’s Asthma Program makes clear the importance of appropriate controller medication use and regular contact with a primary or specialty care physician for ongoing asthma monitoring and management. Qualified patients who cannot afford asthma controller medication are enrolled in Parkview’s Medication Assistance Program. Those without a medical home are referred to a physician within Parkview’s system, a Federally Qualified Health Clinic, or a free community clinic.

Getting Results - Evaluating The System: 

Evaluate Program Impact
In addition to cost-per-visit and visit reoccurrence data, Parkview’s main source of data to assess the impact of its community-wide Asthma Education and Management Program is ISDH asthma surveillance data. ISDH’s county-stratified data indicate that Indiana counties that are demographically similar to those served by Parkview have experienced significantly higher rates of asthma-related hospitalizations and ED visits than seen in Parkview’s service community since Parkview initiated its Asthma Education and Management Program.

Use Evaluation Data to Demonstrate the Business Case
Parkview can compare data from before the ED Asthma Call Back Program’s implementation (baseline) to post-intervention results. ISDH analyzed Parkview’s data and found the intervention group had lower rates of repeat ED visits for asthma than did the baseline group (15.04% to 21.95%, respectively). Also, 11.2% of the intervention group had acted on referrals to find a medical home, and 16.4% had acted on referrals for prescription services. ISDH also determined that the average cost per asthma patient encounter has decreased continuously from the baseline year. The number of inpatient visits per year has decreased since baseline, and the average cost per inpatient visit has decreased (from $35,668 in the baseline year to $12,105 in the most recent year (2011-2012)). The ISDH concluded that the program is successful and provides a cost-efficient method for reducing the burden of asthma.

Sustaining The System: 

Use Data to Demonstrate Your Program’s Value
Parkview is philosophically and organizationally committed to improving the health of its community. Parkview’s leadership has stated that a program that provides as much benefit to the community as the Asthma Education and Management Program merits a commitment to continuing it. To ensure the translation of beliefs into practice, each hospital within the Parkview system allocates a portion of its net income to the Community Health Improvement Program, which includes the Asthma Education and Management Program, contributing an average of $3.5 million annually over the last three years.

The return on investment that the ISDH evaluation of the ED Asthma Call Back Program demonstrates has also helped to sustain the program. In the program’s first year, it returned $20 in avoided health care savings for every $1 invested in the program. In 2012, the program returned $23.75 for every $1 invested. Because of the success of the ED Asthma Call Back Program, it was recently expanded to all six campuses within the Parkview Health System. It is also being used as a model in the health system to help develop additional navigation programs for patients with other chronic diseases.

Program Profile Top Link: 
2013 U.S. EPA National Environmental Leadership Award in Asthma Management Winner
Program Profile Bottom Link: 
view award-winning strategies

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