Breathe Easy

Published On 11/17/2014

Asthma program improves health, lowers health care costs

The attacks leave her helpless. Watching her big-eyed 4-year-old, Luis “Joveny,” struggle to breathe, Brianna Ramirez is lost. He slumps over and begins to cough. Sometimes, he can’t walk. It’s an all-too-familiar sight, one she can see coming. One she can’t stop.

And in a matter of minutes, the attack is upon him, and her world is collapsing.

The scene plays out for hundreds of Memphis families each year – some of the estimated 10,000 children living in the city with asthma. Many are able to manage their asthma well, but others make multiple trips to hospital Emergency Departments and Intensive Care Units, threatening their health and burdening the health care system. But since the inception of a new Le Bonheur Children’s program aimed at helping children with high-risk asthma, those numbers have decreased.

CHAMP, or Changing High-Risk Asthma in Memphis through Partnership, has reduced the number of avoidable asthma-related hospitalizations and Emergency Department visits for children enrolled in the program and significantly lowered their health care costs.

Changing the care model for these children is improving their health and quality of life.

The sickest and the neediest

In 2013, asthma specialists at Le Bonheur began developing new ways to care for the high-risk population of children who appeared and reappeared in the hospital Emergency Department and Intensive Care Unit. Asthma-related symptoms were the hospital’s No. 1 diagnosis and accounted for 3,500 visits each year. Finding a way to control asthma for those kids became a priority.

“If you look at the asthma statistics for Tennessee, we don’t have the highest prevalence of asthma in Shelby County (Memphis), but we clearly have the highest Emergency Department utilization and hospitalization for asthma,” said CHAMP Medical Director and Allergist and Immunologist Christie Michael, MD. “It’s particularly weighted among socio-economically disadvantaged and the African American inner-city population.”

Program leaders looked to new Health Care Innovation Awards from the Centers for Medicare and Medicaid (CMS) as an opportunity to create better ways to care for these children. They aligned CHAMP goals with the Institute of Healthcare Improvement’s (IHI) Triple Aim Framework. Chief among the program goals: improve the health and quality of life of children with high-risk asthma by reducing Emergency Department visits and hospitalizations, improve the health care experience for these kids and lower asthma-related health care costs.

“They are the sickest and the neediest,” Michael said. “These kids are my babies.”

Criteria for the program was designed to find children at greatest risk: those between the ages of 2-18 who had two or more hospital admissions, one Intensive Care Unit admission or two Emergency Department/Urgent Care visits in the past year. Children with two or more steroid bursts for asthma in the past year were also eligible. All must be enrolled in TennCare, Tennessee’s Medicaid program.

Leaders also assembled an unconventional care team of community health workers, asthma care educators, nurses and social workers to support families in their homes and communities, providing environmental interventions, reinforcing asthma education and helping to navigate psycho-social issues.

“We thought: we know what to do here, but how can we engage our families,” said Program Director Susan Steppe, MSW. “We had medical standards of care; there was no new medicine. We were trying to engage families and help them manage the disease.”

Eighteen months later, CHAMP has enrolled more than 400 children, seen significant reductions in their Emergency Department and inpatient visits, and estimates a cost saving of more than $4 million by June 2015.

Finding connections

TennCare data provides important information that helps CHAMP understand whether each enrollee’s asthma is under control. For example, how often does each family fill medications? Too often means the enrollee may need new medication, while not often enough means the child isn’t taking it daily. TennCare claims data also tells CHAMP providers how often enrollees have gone to an urgent care, Emergency Department or have even been hospitalized for asthma-related symptoms.

Key among Michael’s goals is to really understand access needs and improve health care navigation. That includes making sure a child’s primary care provider is always looped in when asthmatic episodes occur. Parents also participate in a CHAMP parent board that allows families to support each other and providers to hear feedback about what works – and doesn’t work – in the program.

CHAMP leaders have found that there’s no one solution – but one common denominator for success: community health workers trained to address individual needs for each family. They are asthma educators, advocates, counselors and intermediaries when families need to connect with other social agencies. Above all else, they are problem solvers and caregivers.

Brianna Ramirez and her family, for example, received support from community health worker Raisha Montgomery that they didn’t even know they needed. A new home, with fewer environmental triggers, helped control Luis’ asthma. But so did Raisha, who taught the Ramirez family how to properly clean Luis’ spacer, find better hypoallergenic cleaners for their home and even detergents that wouldn’t trigger his asthma. She also helped educate family members on the importance of daily medicine – every day, no matter Luis’ symptoms – and traditional family homeopathic medicines like herbs and honey were discouraged.

“You don’t know what you don’t know,” Brianna said.

Community health worker Kelli Holloway says the most rewarding part of her job is watching her clients blossom into healthy children. “I want them to be able to grow up to be healthy and happy,” Holloway said. “Asthma isn’t a disease that they asked for, and I want them to have a good quality of life.”

Measuring success

When each enrollee enters the program, leaders are able to develop a baseline for each individual child using previous TennCare claims data. Of those enrolled in the program, the number of children being hospitalized each quarter (or every three months) are down from an average 10 percent the year before enrollment to an average of 6 percent through the program’s 9th quarter. Fewer hospitalizations mean better health and lower health care costs, but it also allows the child to go to school and learn, Steppe points out.

“When children are able to reach developmental milestones, go to school, that helps our community,” Steppe said. “We want a health care system where our needs are met and funds are spent in the best possible way – not in ways that can be avoided.”

In addition to program goals – which include lowering the number of hospitalizations and ED visits children make – Steppe also points to the decreased health care costs these children experience in the program.

Statistical studies show before enrolling in CHAMP, the average enrollee had asthma-related TennCare costs of $3,812.34. After enrolling, the average cost to care for that child through CHAMP is $1,648.27 – a 56 percent reduction.

Steppe and her team are constantly collecting data to ensure they are optimizing efforts. Leaders regularly tweak strategies to adjust to client needs, and have adjusted roles as they look at ways to improve the program. Success of the program, Steppe knows, depends on sustainability and its continued viability. CHAMP is now in its third year of its three-year CMS Health Care Innovation Award.

“Innovation gives you the ability to generate great ideas, but at some point how do you integrate them into your total service delivery model,” Steppe said. “We know using community health workers makes a significant difference. Time and attention from the medical director makes a significant difference. Our patients have experienced a very personal level of care.”

CHAMP client Luis Ramirez, meanwhile, has experienced that better quality of life. After three serious hospitalizations before CHAMP, it’s been more than two months since his last attack, which was resolved and managed with albuterol at home. It’s welcome news to the Ramirez family, and offers hope for a future where his asthma is well-control.

The project described was supported by Grant Number 1C1CMS331046-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

The project described was supported by Grant Number 1C1CMS331046-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.

The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.