Collaborative Efforts in Systems Change in Reducing the Impact of Asthma

1
Collaborative Efforts in Systems Change in
Reducing the Impact of Asthma

• Steps to a Healthier Austin
• Meeting the Challenges of Chronic Disease at the
  Community Level
• June 11, 2009
• Rick Schwertfeger Justine Kaplan
• Austin/ Travis County Health and Human Services
  Department
• Steve Conti SETON and the Austin Asthma
  Coalition
• And the many partners of Steps to a Healthier
  Austin

2
Collaborators in the Austin Asthma Initiative

• American Lung Association (ALA)
• American Cancer Society (ACS)
• Amerigroup Insurance
• Austin Asthma Coalition
• Austin/Travis County Community Care Services
  Division (CCSD)
• Austin/Travis County Health and Human Services
  Department (HHSD)

• Carousel Pediatrics
• FamilyConnections
• Indigent Care Collaboration (ICC)
• Pflugerville Independent School District (PISD)
• Seton Asthma Center
• Steps to a Healthier Austin
• Superior Insurance

3
Steps to a Healthier Austin

• Over 460,000 residents
• 412 square miles
• 20 contiguous zip code area
• Racially Diverse
• 41 Hispanic
• 39 White
• 14 African-American
• Twice as many people living in poverty as rest of
  Travis County
• Median income is less than 60 that of the rest
  of Travis County
• 33 greater unemployment rate than rest of Travis
  County

4
Asthma in the Steps Intervention Area

• Between 38,183 - 72,686 asthmatics in the
  intervention area
• Inpatient hospitalizations for asthma are more
  than twice as high in the intervention area than
  in the rest of the County.
• 52 of asthmatics had an asthma attack or episode
  in the year 2006.
• Half of all asthmatics in the intervention area
  have not had a routine checkup for asthma in the
  past 12 months.
• Strong race/ethnicity and socioeconomic
  disparities exist in prevalence and
  hospitalization rates.

Data from BRFSS estimates Texas Hospital
Inpatient Discharge Public Use Data File 2002
BRFSS 2006 BRFSS 2006
5
Cost of Asthma in 2005

• Total Clinic 1.2 million
• Total ER 1.2 million
• Total Inpatient 7.8 million
• Grand Total 10.3 million
• Data based on Medicaid reimbursement
  payments for Indigent Care Collaboration member
  encounters

Indigent Care Collaboration, 2005, based on
Medicaid Payments for ICC member encounters
6
Concentration Map of Asthma ER Visits
Indigent Care Collaboration, 2005
7
Steps to a Healthier Austin Asthma Objectives

• Reduce the number of asthma hospitalizations
• Reduce the number of emergency department visits
  for asthma
• Increase the proportion of persons with asthma
  who receive formal patient education and who
  receive appropriate asthma care according to
  NAEPP guidelines
• Reduce adult smoking and increase cessation
  attempts
• Increase smoke-free and tobacco-free environments

8
HP2010 Asthma Goals Logic Model
Improve Asthma Screening
Population
People with Asthma
Improve Provider Practices
Coordinate Care
Improve Self-Mgmt Education
Improve Indoor Outdoor Air Quality
Improve Access to Healthcare
People with Self-Managed Asthma
Reduced ER Visits Hospitalizations
9
The Socioecological Model-A Community Impact
Model for Austin

• Key Considerations
• Reach
• Effective Strategies/ Evidence Based
  Strategies
• Cost
• Sustainability

10
Improve Asthma Screening
Improve Asthma Screening

• Austin Asthma Coalition launches annual Asthma
  Summit educating providers on NAEPP guidelines
  for diagnosing asthma
• CCSD implements continuing medical education
  seminars for physicians to help improve accuracy
  and consistency of asthma diagnoses

11
Improve Provider Practices
Improve Provider Practices

• CCSD offers Teaching the Asthma Patient
  Self-Management to increase physicians
  ability to educate patients in self-management
• Asthma Summit offers medical providers training
  in latest treatments and developing Asthma Action
  Plans.
• PISD works with ALA to train school nurses
  district wide in Asthma 101 to improve assessment
  and treatment of students
• CCSD standardizes practice of giving asthmatics
  vaccines for flu and pneumonia to prevent
  flare-ups

12
Coordinate Care
Coordinate Care

• ICC helps standardize reporting on asthma
  patients to help ensure consistent care for
  patients who are not seen by just one provider
• Seton Asthma Center works with patients to
  coordinate with
• Primary care physician or specialist to ensure
  treatment and follow-up meets NAEPP guidelines
• School (for youth) to ensure an Asthma Action
  Plan is in place
• Patient and family to ensure medication is being
  used correctly and triggers are managed

13
Improve Access to Healthcare
Improve Access to Healthcare

• ICC uses the Medicaider assessment tool to screen
  and register community members for any possible
  insurance for which they may qualify
• Seton Asthma Education Program is offered for any
  community member, regardless of insurance status
• Resource sheet created by CCSD and shared at
  Asthma Summit helps providers know where to refer
  patients to for services
• Mass media promotion of ACS Quitline leads to
  increases in cessation counseling utilization

14
Improve Indoor Outdoor Air Quality
Improve Indoor Outdoor Air Quality

• City-wide smoke-free ordinance passed, led by ACS
• ACS works with local employers to make their
  worksites smoke-free and to create incentives for
  employees to quit smoking
• ALA partners with Family Connections to educate
  childcare providers on asthma and how to remove
  asthma triggers from childcare centers

15
Improve Self-Management Education
Improve Self-Mgmt Education

• ALA partners with PISD to offer Open Airways in
  Schools for elementary
  students with asthma
• ALA expands Open Airways in Schools to include
  summer camps to increase
  reach
• ALA offers Asthma 101 to parents in faith-based
  organizations through the Search Your Heart
  Challenge of the AHA
• Seton Asthma Education Program provides case
  management on using medication, reduction of
  household triggers, and emergency response
• CCSD begins using peak flow meters with patients
  to help them learn to monitor their status
• CCSD implements Self-Management goal sheet to
  help patients reach behavioral goals like
  carrying rescue medication and quitting smoking

16
Improved Asthma Self-Management

• Miss fewer days at school/work
• Fewer ER visits
• Improved quality of life
• Recent Success
• Asthmatics who experienced no asthma symptoms in
  the past 30 days increased from 17 (2005) to 25
  (2006).
• Asthmatics who experienced symptoms once or twice
  per week decreased from 28 (2005) to 21 (2006).

BRFSS 2005-2006
17
Reduced ER Visits Hospitalizations

• Cost Savings
• Time savings to patient
• Ability for patients to be seen by their regular
  physician, ensuring more consistent care
• Recent Success
• During 2004-2006, through Setons Asthma Case
  Management Program, Seton realized a net savings
  of 775,000 in ER visit prevention

Seton Health Care Network, Asthma Care Coordinator
18
Systems at Work Case Study Maria
19
Where Are Asthma Activities Taking Place?

• Most Common
• Health/Healthcare 33
• Schools 22
• Business/Worksite 15
• Community Orgs. 7
• Childcare 6
• Faith-Based 6

Steps to a Healthier Online Documentation and
Support System Data, 9/1/2003-4/30/2007
20
Evaluating Our Success

• Focused on key objectives
• Extensive (and still increasing) partnership
  networks
• Using socioecological approach to expand reach
• Using effective, evidence-based strategies
• Expanding capacity of effective, evidence-based
  existing programs instead of creating new
  programs (more cost effective and sustainable)

21
Asthma Symptoms in the Past 30 Days
Goal 100
The goal is to move everyone to no symptoms
Goal 0
Source BRFSS 2004-2006
22
Percentage of Current Smokers
Source BRFSS 2004-2006
23
Room to Grow

• 21 of asthmatics in the intervention area still
  have symptoms once or twice per week
• 52 of asthmatics in the intervention area never
  use an inhaler to stop an asthma attack
• 36 of asthmatics in the intervention area never
  use controller medication to prevent asthma
  attacks
• Strong race/ethnicity and income disparities
• High rates among school-age children
• Still barriers to accessing care

BRFSS 2006
24
Lessons Learned

• Essential Elements
• Key Partnerships
• Framing Systems Work
• Replication within our Community
• Replication in Other Communities

25
Essential Elements for Systems Change

• Key representatives at the table
• Partners united by common goals
• Partners feel/see how they will benefit from the
  partnership
• Commitment to share
• Commitment to use best practices
• Understanding of framework/model for change
• Dedicated leadership
• Needs and strengths assessment
• Evaluation of progress
• Use of evaluation to build motivation and drive
  efforts

26
Key Partnerships for Asthma Work

• Health Departments
• Clinics
• Hospitals
• Medical Providers
• Pharmacists
• Allied Health Providers
• Care Managers

• Community Agencies
• Community Groups
• Data/Evaluation Sources
• Insurance Providers
• School Personnel
• Community Members

27
Framing Systems Work for Partners

• Teach the socioecological model (SEM) as a
  framework for success
• Ensure partners see where their work fits
• Ensure partners see what SEM level they have the
  potential to impact
• Look at issue at the population-based level
• Break down sub-issues to see where each fits
  within the SEM
• Tailor changes to affect the target level within
  the SEM
• Use SEM when considering adopting new practices
  and goals
• Use SEM when evaluating progress

28
Replication within Our Communities
Goal Improve asthma objectives throughout Steps
intervention area using a sustainable stage-based
method
one of the 6 core components of the asthma
goals logic model (slide 9) is being implemented
29
Replication in Other Communities

• Many similar potential partner agencies
• Communities and partners that share similar goals
• Ability to assess strengths and needs
• Ability to access to data
• Frameworks/models accessible from trusted sources
• Best practice information easily accessible from
  trusted sources
• People with passion and dedication for improving
  community health

30
Replication in Other Communities, Cont.

• First Steps
• Establish framework/model as foundation
• Establish linkages between partners
• Assess strengths and needs (community, medical
  providers, schools, etc.)
• Use assessments and data to shape goals
• Use framework/model to determine methods for
  reaching goals

31
Photo courtesy of the New York City Department of
Health and Mental Hygiene