Filling the gap: A hospitals response

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Filling the gapA hospitals response

• Elizabeth R. Woods, MD, MPH,
• Urmi Bhaumik, MBBS, MS, DSc
• Susan J. Sommer, MSN, RNC
• Amy B. Burack, RN, MA, AE-C
• Alaina J. Kessler, BS, BA
• Lisa M. Mannix, BA
• Elizabeth M. Klements, MS, APRN, BC
• Ronald Wilkinson MA, MS
• Gareth Parry, PhD
• Shari Nethersole, MD

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Funding in Part From

• CDC REACH U.S. 1U58DP001055-01
• Healthy Tomorrows, HRSA grant H17MC06705
• Bank of America
• Anonymous Individual Donor
• Childrens Hospital Bostons Office of Child
  Advocacy
• Childrens Hospital Bostons Program for Patient
  Safety and Quality

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Partners

• Boston Public Health Commission
• Boston Medical Center
• City of Boston Inspectional Services and Breathe
  Easy At Home program
• Asthma Regional Council
• Boston Urban Asthma Coalition-public policy,
  advocacy
• Boston Housing Authority

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Community Needs Assessment

• Office of Child Advocacy (OCA) 2003-2005
• Contracted with John Snow, Inc. (JSI) engage
  community, comprehensive needs assessment, review
  of literature
• 50 interviews, 4 focus groups stakeholders and
  community residents
• Communities of Roxbury and Jamaica Plain
• Four focus areas (asthma, mental health, injury
  prevention, fitness/nutrition)

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Asthma Hospitalization Ratesin Boston at Program
Inception

• Leading cause of hospitalization at Childrens
  Hospital Boston
• 70 of children hospitalized for asthma at CHB
  come from Roxbury, Dorchester, Jamaica Plain,
  Roslindale and Hyde Park
• Asthma hospitalization rates for Latino and Black
  children in 2003 were 5 times the rate for white
  children (Health of Boston, 2005)

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Program Development

• Asthma working group formed
• Consultation with local partners, e.g. Boston
  Public Health Commission, Boston Medical Center
• Identified model programs
• Initial funding from Bank of America and Office
  of Child Advocacy, grant funding
• Enhanced care model
• Quality Improvement evaluation

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Goals of Community Asthma Initiative (CAI)

• Reduce asthma-related ER visits and hospital
  admissions
• Reduce racial and ethnic health disparities in
  asthma rates and outcomes
• Improve the quality of life of children with
  asthma and their familiesable to go to school,
  sleep through the night, and play parents able
  to work or study

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Identification of Patients for Pilot Program

• Four zip codes in Roxbury, Jamaica Plain and
  Mission Hill
• Patients identified for CAI by CHB Emergency Room
  visits and admissions (provider referral
  case-by-case basis)
• Patients are identified by both active visit logs
  and summaries from billing codes from hospital
  databases

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Components of CAI

• Individualized nurse
• case management
• (bilingual Spanish)
• Asthma education
• Home visits and
• environmental interventions
• by nurse and/or Boston Asthma Initiative home
  visitor (multicultural)
• Care coordination (PCP), resources
• Community-based educational workshops for parents
  providers

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Nurse Case Management

• Assessment of childs and familys needs
• Start with childs asthma controlfrequency of
  symptoms, ability to play, missed school-- and
  impact on quality of life for child and family.
  Extremely low expectations on part of families
• Identify barriers to adherence--health insurance,
  high co-pays, competing priorities, fear of
  medication side effects, in particular inhaled
  steroids
• Facilitate communication with PCP, empower
  parents as partners in asthma management

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Home Visits

• Individualized asthma education (case review,
  clinical support for home visitors by NP) based
  on childs AAP and asthma triggers
• Home environmental assessment and education
  interventions, as needed, including Integrated
  Pest Management
• SuppliesDust mite proof bedding encasements,
  HEPA vacuums, spacers, large plastic storage
  bins, Healthy Homes Homesafe kit (A/C,
  dehumidifier, HEPA air cleaner--case-by-case
  basis)
• Tobacco treatment and referrals

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Integrated Pest Management (IPM)Why?

• Definition of IPM A common sense strategy to
  reduce pests and pesticides by a combination of
  methods, including the reduction or elimination
  of the food, water and shelter pests need to
  survive. Standard pest extermination not
  effective
• Limits use of toxic pesticides, both legal and
  illegal
• Limits aerosolized pesticides, such as Raid
• Empowers residents through education

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Additional CollaborationBoston Inspectional
ServicesBreathe Easy At Home Program

• www.cityofboston.gov/isd/bmc

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QI Indicators Monitored every 6 months (summed to
12 months)

• Number of Emergency Room visits
• Number of hospitalizations
• Number of missed school days
• Number of missed work days
• Number of days with limitation of physical
  activity
• Number of children with an up-to-date Asthma
  Action Plan
• Average monthly cost of medications (or co-pays)

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Initial Data

• As of December 31, 2007
• 234 patients received services (approximately 50
  of all possible patients)
• 159 families agreed to home visits (67.9)
• 110 outreach and 146 nurse visits
• 26 families Intensive IPM (46 visits)
• Often multiple family members with
  asthmaincreased impact of program

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Race/Ethnicity of Asthma Patients (N234)
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Household Income(N234)
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Decrease in Any ED Visits due to Asthma (Y/N)
66 at 6 months (plt0.001) and 63 at 12 months
(plt0.001)
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Decrease in Any Hospital Admissions (Y/N) 79 at
6 months (plt0.001) and 85 at 12 months (plt0.001)
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Decrease in Any Missed School Days (Y/N) 48 at
6 months (plt0.001) and 41 at 12 months (plt0.001)
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Decrease in Parent/Guardian Missed Any Work Days
(Y/N) 59 at 6 months (plt0.001) and 52 at 12
months (plt0.001)
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Decrease in Limitation of Any Physical Activity
(Y/N) 53 at 6 months (plt0.001) and 47 at 12
months (p0.001)
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Increase in Asthma Action Plan (Y/N) 98 at 6
months (plt0.001) and 95.8 at 12 months (plt0.001)
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Cost savings-preliminary data

• Of 120 patients enrolled from October
  2005-December 2006 the total hospital costs of ER
  visits and hospitalizations
• - 331,531 during the one year period prior to
  their enrollment,
• - 184,848 one year post enrollment
• (calculations do not yet include program
• cost, physician charges in ER or lost work
  time)
• Represents 44 cost reduction for 3rd party payer
  

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Next Steps--Sustainability

• Commitment to continue program, expand
• Currently no insurance reimbursement for visits,
  one payer (NHP) willing to reimburse for home
  visits
• Need to join other providers to negotiate with
  payers to reimburse for asthma education visits
  in office and home, supplies, case
  managementprecedents nationally

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Next Steps--Capacity-buildingTraining

• Trained workforce of asthma home visitors
• Culturally and linguistically competent
• Provide both asthma education and home
  environmental assessments and interventions
• Community Health Workers, nurses, respiratory
  therapists, working closely with PCPs
• Certified asthma educators
• Other training/certification for CHWs?

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Next stepsCapacity-buildingInfrastructure

• Hospitals in position to play key role in
  developing/supporting effective, comprehensive
  asthma programs
• Often see patients with poorest control, least
  resources
• Need to develop programs in-house and/or in
  collaboration with community partners, local
  boards of health and other stakeholders
• Funding opportunities (EPA, HUD, CDC, state and
  local agencies, private foundations), future
  reimbursement by payers