Health Plan

Health Care Service Corporation (HCSC), the nation’s largest customer-owned health insurer, in partnership with the American Lung Association of the Upper Midwest (ALAUM), has implemented comprehensive, community-based asthma quality improvement programs in more than 120 health care clinics in Illinois, Montana, New Mexico, Oklahoma and Texas. The program have served an estimated 435,545 individuals across these states, including low-income, Latino, and Native American populations. The ongoing effort works directly with providers to improve the quality of care being delivered to patients with asthma, in addition to direct engagement with individuals through home environmental assessments that include asthma education and providing allergen-reducing and remediation products. The company leverages its own medical claims data to  identify providers serving the highest-risk children with asthma and the ALAUM invites these clinics to take part in a year-long learning collaborative and training program based on the National Asthma Education Prevention Program developed by the National Heart, Lung, and Blood Institute. Overall, hospitalizations for children years 18 and younger have reduced by 59 percent and emergency department (ED) visits have been reduced by 54 percent. For individuals older than 18 years, results showed a 52 percent reduction in hospital stays and a 56 percent reduction in ED visits for this population. The program has also realized a positive return on investment – a savings of $2.40 per dollar spent. Not only are patients able to better manage their asthma, but significant reductions in avoidable medical utilization drives down the cost of care for all and allows the company to play a vital role in making the health care system work. 

AmeriHealth Caritas, through a local affiliate, implemented a comprehensive asthma management program serving Medicaid recipients in southeastern Pennsylvania’s five counties, including Philadelphia. This multifaceted program applies a sustainable approach based on population health, guiding members through a continuum of care that is built on solid evidence and works within AmeriHealth Caritas’ integrated health care management system. Members and network providers can participate in several unique, award-winning initiatives that support the delivery of asthma medication and supplies, asthma education, and home environmental surveys. Since 2012, AmeriHealth Caritas has incorporated asthma-specific measures into its Annual Operating Plan’s Managed Care and Quality goals.

In 2015, Philadelphia was ranked the third-worst city for asthma in the United States, with 16,000 children visiting emergency rooms each year for asthma-related causes. The asthma management program serves residents of culturally diverse inner-city environments such as west and northwest Philadelphia, where one out of four children has physician-diagnosed asthma or was admitted to the hospital for wheezing.

AmeriHealth Caritas works with local network providers and community-based organizations to deliver a range of services that reach members in their physicians’ offices, homes and communities to enhance existing care management efforts. Simultaneously, AmeriHealth Caritas continuously improves its capability to monitor, assess and refine its offerings based on member, staff and provider feedback.

Care managers and support staff guide members by telephone or in person across the continuum of care to (1) identify members with a primary diagnosis of asthma; (2) perform asthma management assessments; (3) categorize patients into risk strata and high-need population groups; (4) implement tailored interventions based on risk profile and social determinants of health; (5) perform reassessments as needed; and (6) monitor outcomes to quantify program effectiveness and financial sustainability. Low-risk members receive general and asthma-focused education through member mailings and are invited to AmeriHealth Caritas-led programs and events. High-risk members receive individual care management assessments, care planning and interventions focused on priority areas (i.e., asthma control action plan, sick day plan, medication management, behavioral risk management and asthma self-management). The asthma action plan incorporates environmental management protocols and helps members contact public and private entities, supporting members’ overall health. Member material—which can be translated into 200 languages on request—is written at a sixth-grade reading level and keeps patients’ cultural needs in mind to help members with limited English proficiency understand medical content.

AmeriHealth Caritas partners with the local affiliate’s high-volume network providers, which have led to distinct provider-specific community health worker (CHW) models in northeast Philadelphia, west Philadelphia and Chester tailored to the local demographic and fiscal environments. Trained CHWs, supervised by a medical director, cooperate with the practice- and telephone-based care management system to provide face-to-face care coordination, home health and environmental surveys, and asthma-related education for members and their families while addressing the social determinants impacting members’ health. When environmental asthma triggers are identified, the CHW suggests such actions as installing an air conditioner or new windows, removing carpet, and conducting mold remediation; in some instances, they even provide members with an “asthma home kit” (hypoallergenic mattress and pillowcase covers, storage bins, trash bags, cockroach bait stations and cleaning supplies). To help connect to cultural and health literacy barriers faced by members in their communities, CHWs often are hired from those same communities, and several are bilingual, primarily in Spanish and English.

Additional service offerings include provider-led dispensation of asthma medication and supplies and hands-on education during office visits (B.E.S.T. asthma program—Breathe Easy. Start Today.®); school-based clinic partnerships to address member care gaps in asthma medication adherence; and “edutainment” programming (Healthy Hoops®) for children with asthma and their families.

From 2013 through 2015, statistically significant improvements were observed in asthma controller medication adherence rates, acute hospitalizations and hospital readmissions. Increases in pharmacy expenditures for asthma medication were more than offset by significant decreases in hospital admission rates. Dozens of provider practices and thousands of members have participated in these asthma-focused initiatives, leading to 327 CHW-led home visits and environmental surveys, as well as the distribution of more than 13,000 asthma medications and supplies and 875 asthma home kits. During this time, hundreds of children with asthma and their families in the community attended Healthy Hoops® programs in the Philadelphia area, where pediatric participants received health screenings (including spirometry, peak flow and spacer education). Asthma action plan consultation stations provided participants with a clinical summary and a blank asthma action plan template to assist their providers in completing an individualized asthma action plan.

Peach State Health Plan in Atlanta, Georgia, is a statewide Medicaid managed care organization that delivers a customized asthma program for teenagers. The Plan is part of the Centene Corporation, an integrated health enterprise that delivers Medicaid services in 19 states. Peach State Health Plan has a targeted asthma improvement program focused on their teen members with asthma because almost 20 percent of teens in the Plan have an asthma diagnosis (13,159 members with asthma out of 66,138 members ages 13–19.) Peach State's innovative program has successfully engaged teens with asthma—a notoriously hard group to engage—and has demonstrated success in improving teens' ability to understand their asthma, improve their asthma, and address the environmental and social factors that can make asthma worse.

Peach State's Asthma Team seeks to reduce teens' asthma healthcare utilization, improve their asthma status (i.e., functional severity), ensure appropriate medication regimens per NIH EPR-3 Asthma Program Guidelines and promote self-management. They pursue these goals by facilitating relationships between teens, caregivers, primary care physicians and medical homes, providing access to specialists, delivering tailored education and addressing social issues, such as environmental exposures at home and school.

The Plan delivers stratified asthma management services, including health coaches and environmental, medical and social interventions in clinic, at home and at school. The Asthma Team includes health plan case managers, medical directors, pharmacists, a disease manager/ health coach and respiratory health coaches, who serve as the primary contact for teens, their families, the care team and partners.

Teens with an asthma diagnosis in the Plan's information system are stratified into three intervention groups—low, moderate and high risk—based on a multi-stage and validated initial health assessment. Sixty percent (60%) are in the low-risk intervention group and receive education materials by mail. The moderate group receives telephonic and mail outreach and can receive home visits if appropriate. The high-risk group, which includes about 700 members per year, receives telephonic and mail outreach and in-home visits. Peach State uses an innovative and award-winning incentive program, CentAccount, to motivate teens (and others) to take preventive care actions. For example, when a healthy activity, such as a preventive well visit, is completed, members receive money on a debit card they can use to purchase healthy items. This has encouraged teens with asthma to get well visits, thus helping to identify previously undiagnosed teens with asthma. In fact, teenage members in the asthma program have increased their attendance at regular wellness visits by more than 500% compared to a control group. This increased and proactive interaction with primary care providers at scheduled visits has helped teens with asthma to stay healthy and to stay ahead of their asthma rather than having them interact with their providers only after a serious asthma attack.

All teen members in Peach State's asthma program receive award winning, age-appropriate educational materials, including the multilingual and multimedia, "Off the Chain—It's All About Asthma" and "On Target with Your Asthma." These materials promote understanding of asthma, environmental triggers and appropriate medication use. Members in the low-risk group receive education by mail and can also receive peak flow meters, spacers, and masks as indicated.

Members in the moderate-risk group receive mailed education materials and telephonic counseling by health coaches to identify medical, environmental and social needs and to provide asthma education and self-management support. During calls, coaches collect self-reported asthma symptom data, review individualized treatment plans and self-management guides, and discuss environmental triggers; they also teach teens signs and symptoms that merit rapid intervention. The health coaches communicate back to the medical home and cooperating community organizations, such as schools and churches.

High-risk members receive everything the moderate group receives—education, barrier assessment, coordination of care and additional support—and in-home visits by a licensed Respiratory Care Practitioner. Home visits include disease education, medication counseling and an environmental assessment, which, according to Peach State, occurs in "the ideal setting to… assess all of the factors that impact the severity of the patient's condition…and [to facilitate] patient specific education." During visits, health coaches conduct spirometry screening and pulse oximetry, measure vital signs, review medications, demonstrate how to use spacers and peak flow meters, and discuss barriers to effective asthma control. During home visits, teens also receive counseling from a respiratory therapist about environmental factors in the home environment and their impact on asthma to take advantage of the 'teachable moment' that a home visit provides. The home visit team also identifies environmental factors in the home that may be contributing to the members' asthma and reviews in detail the teen-focused asthma education materials that address allergens and irritants.

In addition to the tailored interventions stratified by risk, Peach State's Asthma Team also bolsters clinical providers' abilities to care for teen asthma patients. The Asthma Team functions as an extension of the physician's practice by reinforcing the individual asthma management plan and providing up-to-the minute documentation on functional status, barriers and recommendations for future treatment based on the assessment.

Using clinical and financial data (i.e., medical and pharmacy claims), the Plan was able to model the health improvements and cost savings generated by the teen-focused asthma program. Compared to a control group, teens in the program had nine percent fewer respiratory-related unplanned healthcare utilization incidences and a shorter average length of stay when unplanned hospitalizations did occur. They were more likely to visit their primary care physicians as planned and to receive recommended flu vaccines, a critical self-management step as people with asthma are at increased risk of severe disease and complications from the flu because influenza can cause further inflammation of the airways and lungs. Peak flow meter use and controller medication use both improved at higher rates for program participants compared to a control group, while rescue inhaler use declined, indicating better overall asthma medication management and compliance. Peach State estimates the program saves approximately $320 per member per month. Recognizing the importance of environmental management of asthma, particularly for its Medicaid population, and the impact on the quality of care and patient outcomes that their program is achieving, Peach State Health Plan, Centene and Nurtur intend to continue funding the asthma disease management program.

L.A. Care Health Plan established the comprehensive disease management program LA Cares About Asthma® in 2003. L.A. Care selected asthma as a disease management focus because of the large number of members with asthma enrolled in L.A. Care and the success of programs like these in helping patients with chronic illness improve their health status over the course of the disease. LA Cares About Asthma ® is a collaborative program designed to improve member self-management through education, empowerment, monitoring and member input and communication.

On a monthly basis, LA Cares About Asthma® identifies health plan members with asthma and provides them with a variety of educational materials and tools to help them take control and manage their disease. To be inclusive to its community’s needs, the program ensures that linguistically and culturally appropriate materials are available for all potential enrollees.

LA Cares About Asthma® also partners with several community-based organizations to expand its reach and depth to serve individuals most in-need. An in-home visitation program with Long Beach Alliance for Children with Asthma in the Los Angeles South Bay area and specialist referrals with Harbor-UCLA Medical Foundation Inc., throughout Los Angeles County offered to high-risk members with asthma are just two examples of such successful partnerships.

Thanks to these efforts, LA Cares About Asthma® achieved a member satisfaction of 97.6 percent, which exceeded their 2011 goal. In particular, members reported great satisfaction with the program materials and felt the materials educated them on how to control their asthma.

As an experienced, comprehensive service provider, Managed Health Services, a Centene Corporation Medicaid health plan, understands the need to customize asthma solutions for diverse populations. As a result, in 2007 Managed Health Services and sister company, Nurtur, Centene life, a health and wellness company, established a comprehensive asthma program designed to address the needs of several specific target audiences; these include persons with asthma in addition to other complex chronic conditions, as well as pregnant women and children with asthma.

Medical records, pharmacy records and claims data are scanned by predictive modeling software to identify patients that meet these criteria, who are then referred to the Asthma Team. A case manager follows up with each patient to assess their level of need and recommends an appropriate asthma intervention. Educational materials for children and adults, trigger identification training, goal-setting exercises, home visits and barrier assessments are just some of the many tools used as a part of this holistic asthma care process. The patient’s treatment plan is also updated by the Asthma Team and sent to the physician for review.

Continuous monitoring and evaluation are integral to this program, and results from 2007 to 2009 indicate an incredible 17.3 percent decrease in emergency department visits for child participants and a 9.4 percent decrease for adult participants. In addition, visits to primary physicians for children and adults were up by 11.1 percent and 16.4 percent, respectively, indicating improved preventive care.

The staff at Optima Health Plan — the managed care division of Sentara Health Care that operates in southeastern Virginia — noticed a disturbing trend: despite pharmacological advances in asthma therapy, the number of emergency room visits, hospitalization rates, and medical costs for asthma patients continued to rise. The quality of life for the approximately 8,500 asthma patients enrolled in Optima's plan was not as high as Optima's staff thought it should be and staff was committed to helping their asthma patients understand everything they could do to prevent asthma attacks. Optima's staff also knew that education and management advice were often most effective when delivered at home so they developed an innovative "Asthma Life Coach" program that sends nurses and respiratory therapists to asthma patients' homes where they work with patients and their caregivers to identify environmental triggers, such as secondhand smoke, cockroaches, dust mites, mold, and other sources that can trigger asthma attacks. Optima's staff understood that many asthma patients simply don't know that things in their homes, schools, and other environments can trigger asthma attacks and that many asthma triggers can be eliminated through simple management techniques. The Asthma Life Coach program provided an easy way for Optima's asthma patients to learn about environmental asthma triggers and how to reduce exposure to them. Optima's staff visited patients at home where they surveyed their environments, reviewed their use of medicines, and developed individualized written asthma treatment plans incorporating medical and environmental components. Optima's Asthma Life Coaches serve as coordinators helping patients take action based on disease management suggestions and physician recommendations and ensuring that patients know how to use medical and environmental controls to manage their asthma. Since instituting the Asthma Life Coach program in 1999, Optima has seen a significant decrease in the number of hospitalizations and emergency room visits for their members with asthma.

Blue Cross of California, State Sponsored Business Unit (SSB), has designed a Comprehensive Asthma Intervention Program (CAIP) to improve care for California Medi-Cal and Healthy Families members with asthma. Because standard asthma management programs seldom address the needs of all members in a culturally and linguistically diverse, low-income population, like the Blue Cross SSB membership, who often face environmental health challenges, CAIP encompasses innovative partnerships with members, providers, academic institutions, public health organizations, and communities, to maximize opportunities for improved asthma outcomes. CAIP includes individual member outreach; resources and incentives for physicians and pharmacists to encourage improved asthma care; Plan/Practice Improvement Project (PPIP), a collaboration modeled after the Institute for Healthcare Improvement's Breakthrough Series, to enhance asthma chronic care through practice-specific redesign; Valley Air Quality Project, a county-specific partnership to improve community responses to environmental air pollution affecting the respiratory health of Fresno County, where asthma prevalence is high.

Priority Health is a non-profit health plan that serves more than 19,000 people with asthma in 43 Michigan counties. In the late 1990s, Priority Health recognized the need for home-based asthma care that includes environmental trigger management. To deliver effective home-based care, Priority Health formed a first-of-its-kind partnership with the Asthma Network of West Michigan (ANWM). Priority Health uses ANWM's case managers and social workers to increase its ability to effectively assess and educate its members. ANWM provides home-based education; home environmental assessments; and resources to reduce exposures to environmental asthma triggers. Today, all of the plan's members with moderate or high risk asthma within ANWM's service area receive intensive case management that integrates patient education, home-based environmental interventions, and evidence-based clinical care. Priority Health also reimburses ANWM for meeting with providers to develop individualized care plans. These plans are the cornerstone for determining appropriate interventions, monitoring, and follow-up. Priority Health provides incentives to their providers to ensure that members use asthma medications appropriately and to implement the Planned Care Model for asthma. The results of these programs include improved medication use and significant reduction in the number of emergency room visits and hospitalizations for asthma. Utilization data show that emergency room visits were reduced from 72 visits per thousand patients in 2002 to 40 in 2006 for commercial members, and from 250 to 189 for Medicaid members. Savings over time for members are estimated at $1.7 million, and the long-term return on investment (ROI) for Priority Health is 2.1:1.

The Monroe Plan for Medical Care is a managed care organization, located in the Rochester, New York area. The Monroe Plan covers 5,633 children with asthma in Monroe County and 12 neighboring rural counties. With a high asthma burden among children in the area, the Monroe Plan saw trends in pediatric asthma and noticed high admission rates that disproportionately affected minorities. Monroe Plan partnered with ViaHealth, a health care delivery system, to launch a program to shift asthma care toward improved patient self-management. The program now covers all of the plan’s members with moderate to severe pediatric asthma and includes assistance to providers in creating asthma action plans and comprehensive provider and member education. Home assessments are conducted by bilingual asthma outreach workers to identify and reduce environmental triggers. As a result of these interventions, ER visits decreased from 1.1 visits per person to .95 visits per person over the first three years of the program. Inpatient admissions decreased from 98.3 admissions per thousand to 84.15 per thousand in the first three years of the program.

Founded in the late 1980s, Neighborhood Health Plan (NHP) was one of the nation’s first health plans to comprehensively address the health care needs of underserved populations. As part of its commitment to improving the lives of its 200,000 members and in response to alarming rates of asthma among the Plan’s target population, NHP introduced its innovative Asthma Disease Management Program (ADMP) in 2000. NHP provides an Asthma Home Visitation Program (AHVP) to all members living with asthma in need of in-depth asthma education and/or home environmental assessment. NHP implemented an Enhanced Asthma Home Visit program in 2005 based on the positive outcomes of a one year Inner City Asthma Study (ICAS) of non-clinician home-based environmental intervention to reduce exposure to environmental triggers and allergens. The AHVP empowers patients to proactively manage their asthma by providing multilingual, low-literacy education to patients and their families during in-home environmental assessments and interventions. In addition, the ADMP helps primary care providers improve asthma care by enhancing programs at primary care sites; using a robust and comprehensive asthma registry; and increasing provider awareness and compliance with asthma treatment guidelines. To further address the appropriate management of asthma, NHP’s website provides access to several provider-focused resources. By collaborating with community-based initiatives, including the Boston Asthma Initiative, the Greater Brockton Asthma Coalition, and State and regional partners, the ADMP’s active leadership strengthens Massachusetts’ community-wide approach to asthma management. Over the past decade, the rates of annual asthma hospitalizations and emergency department visits for Neighborhood Health Plan’s asthma population have fallen by more than 30 percent.