Children's hospitals are reducing visits for asthma by building partnerships in the community and meeting families and patients where they live, learn and play.
By Amanda Bertholf
When a team at Children's Health in Dallas began looking closely at asthma visits in 2011, it noticed the same families would visit the emergency department (ED) week after week. These families had children with asthma, and they were in crisis mode. When the team talked to ED staff members and spent more time with families, it became clear that managing childhood asthma across a population or a community is a "wicked problem"—not just a complex problem, but one with many interdependencies.
Nationally, childhood asthma is the most common chronic conditions to affect children under the age of 18, and according to the Centers for Disease Control and Prevention (CDC), is most prevalent among African Americans. In 2010 and 2011, asthma was among the top five reasons for ED visits in most children's hospitals nationwide. And because the incidence of asthma is so high, it ranks as one of the top five costliest pediatric health conditions.
The complexity of the condition means it's difficult to identify a singular source of measurable impact. But using population health models, children's hospitals are working to improve the care experience for patients with asthma and the health of populations, and reduce costs. Here's a look at how two children's hospitals are tackling the issue.
Plan of action
To reduce ED admissions for asthma, team members at Children's Health knew they would need a system-wide solution and collaboration among community groups in different sectors. Of Dallas County's 650,000 children, about 60,000, or 9 percent, have asthma. And in 2012, nearly 1,500 children in the county visited the ED or were admitted to the hospital due to asthma. To shift these numbers, the goal was to move upstream from the ED and meet the families where they live, learn and play. Four areas of work began to emerge at Children's Health.
Focus on high-risk asthma patients. Grant-funded activities helped the Children's Health team focus on a small subset of the larger care management group. This group involved 170 children who were considered at high risk for asthma-related illness. The grant was used to mitigate environmental triggers for asthma discovered during individual visits to patients' homes.
Expand care management. A care management team retrospectively reviewed cases of 3,614 patients who had a primary or secondary diagnosis of asthma. In the six months prior to becoming involved in the program, 516 children (14 percent) had one or more visits to the ED. In the six months following the care management encounter, 332 children had one or more asthma-related visits, representing a 35 percent reduction in overall unique patient visits.
Expand the primary care network. State-administered federal health care reform incentives helped the hospital grow its primary care network from six to 17 clinics covering underserved ZIP codes in the hospital's primary service area. The team monitored the execution of best practices for asthma, including action planning, severity assessment and controller therapy. Additionally, physicians were incentivized to improve results. This work directly correlated with a reduction in ED visits.
Engage the Health and Wellness Alliance for Children. This group represents more than 70 community organizations focused on measurably affecting health and wellness for children. With childhood asthma its first priority, the group serves as a bridge between community and clinical partners, and brings together several active but fragmented internal clinical services at Children's Health. These clinical stakeholders are now able to move alongside other local health care partners.
Creating community partnerships
Children's Health formed partnerships with community groups, including joining efforts with Parkland Memorial Hospital, the local adult safety-net hospital. The two organizations developed evidence-based clinical guidelines for asthma and spread them across all the pediatric practitioners in Dallas. Then the group turned its attention to working with the city of Dallas to combat asthma-related environmental issues.
Knowing many asthma-related problems are caused by the environment and where people live, combining forces with the adult hospital helped Children's Health work with the city to change housing code. "Children's health became a criterion for the local housing inspectors to work with owners and landlords to resolve those issues," says Peter Roberts, now retired, who at the time this work got underway was executive vice president of population health and business development at Children's Health.
Nationally, the CDC estimates kids with asthma missed 13.8 million school days in 2013. To help keep kids in school, Children's Health partnered with school nurses. The hospital launched a telemedicine program in 60 schools and connected those schools with the hospital's electronic medical record system. With a parent or guardian's permission, the nurse can access the child's medical record and asthma action plan.
Roberts says the strategy for improving care is not to look for a single-point solution. "We address these problems in communities by aligning ourselves collaboratively behind a single problem," he says. And that alignment is getting results. From 2012 to 2015, the number of unique patients visiting Children's Health's EDs with a primary clinical diagnosis of asthma decreased by 49 percent, while overall volume remained relatively flat.
Into the home
While Children's Health in Dallas had success reducing asthma admissions by developing community partnerships, Le Bonheur Children's Hospital in Memphis successfully brought asthma education and programming into patients' homes.
When team members at Le Bonheur examined asthma-related ED visits and hospitalizations in Shelby County, they noticed the county had twice as many visits and hospitalizations than other areas—31 percent of all pediatric asthma visits in Tennessee occurred in Shelby County. "We knew asthma was a big problem here because we'd been in the trenches caring for these children," says Christie Michael, M.D., medical director. "But we were surprised by how much bigger of a problem it was." In Memphis, poor housing conditions with mold and mildew combined with few community resources were negatively affecting kids with asthma.
The majority of the children who present with asthma exacerbations are admitted to Le Bonheur, so the hospital had a large dataset to examine. The bottom line was patients were spending time in the ED or in the hospital for sick care rather than managing this chronic illness at home or school.
To reverse the trend, Le Bonheur set out to reduce ED visits, hospitalizations and observation days. "We also wanted to improve the patient and family experience with the medical system," says Susan Steppe, a licensed advanced practice social worker at Le Bonheur. "Many of our patients are not accustomed to being active in their own health care. They're used to being told what to do. They're treated acutely, and not involved as partners in care and educated in the tenants of self-management of their disease."
The hospital launched Changing High Risk Asthma in Memphis through Partnerships (CHAMP) in 2012, a program funded by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, to improve the health of children with high-risk asthma by improving self-management, reducing unplanned medical encounters and reducing health care costs. With 587 children currently enrolled, CHAMP was designed to affect as many areas of the community as possible. "We wanted to take down the walls of the clinic and build connections in the community and in the patients' and families' homes," says Steppe, who is also program director of CHAMP.
CHAMP serves asthma patients ages 2 to 18 who are Memphis residents and TennCare recipients (Tennessee's Medicaid Program). A majority of the children participating in CHAMP live in single-parent households where resources fall below the poverty line. Seventy percent of CHAMP patients live in rental properties with mold, mildew or cockroaches, which exacerbate asthma episodes. And many of these families move frequently or spend time in more than one residence over the course of a week or a month.
How it works
Providers in the hospital consult with the CHAMP team for children who are admitted to the intensive care unit. CHAMP also has a 24/7 call line staffed by two Le Bonheur EMTs. They evaluate the severity of asthma and can give advice about whether the patient needs to visit the ED or begin treatment at home. If needed, the EMTs can contact one of the doctors on call.
To help manage the population, the CHAMP team receives monthly downloads of TennCare encounters and claims data on all CHAMP-enrolled patients. "For asthma management, you can't follow the guidelines appropriately if physicians don't know how often a patient is going to the ED or filling albuterol," Steppe says. This data becomes a powerful tool for individual case management and for tracking outcomes, including costs.
CHAMP also has a group of community health workers and educators who enroll and engage families in their homes. To capitalize on their ability to connect with patients and families, they can track medication refills and make referrals as needed. "We can be that hub for other community-based efforts that support these families," Steppe says. "And even though we can't solve the problem, we can often provide information that will help the family access resources they need."
This team conducts home visits that include asthma education and environmental assessments using an Environmental Protection Agency tool, which is embedded in the CHAMP registry. After completing the assessment, the team provides families with basic cleaning supplies in buckets.
Helping with housing and schools
The CHAMP team plays a role in helping patient families communicate with their landlords. "Families struggle to communicate with the landlord, or they're scared to talk to him or her," Steppe says. CHAMP gives families tips on how they can make a service request. "Sometimes, we help a family get important improvements made to their residence just by supplying a letter on Le Bonheur letterhead that says, 'You have a high-risk asthma patient living here, we see mold, and we would appreciate your help in addressing a water leak,'" Steppe says. "First, we help families ask for help. Then we go with the letter." For complicated legal situations, Le Bonheur's medical-legal partnership can step in.
Like Children's Health, Le Bonheur established relationships with schools. The CHAMP team ensures every school or child care center where a CHAMP patient is enrolled has access to information and medication. "They know what to do if one of our children is wheezing," Steppe says. "And our parents tell us that's one of the things they like about the program. They feel like the schools and child care providers hear them when we speak on their behalf."
CHAMP started with a goal to reduce ED visits by 15 percent. Today, the program has helped reduce ED visits by about 36 percent and has reduced the number of patients who return to the hospital within 30 days of a previous admission to zero. The hospital also had a 50 percent reduction in actual cost of care per child per year.
By taking information and education directly to families and building partnerships with community organizations, children's hospitals are making strides in reducing asthma admissions and helping kids breathe easier.
For more information, view the webinar: "Attacking Childhood Asthma: Two Member Approaches to Chronic Care Management."
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