Comprehensive approach includes educating docs

Decreases asthma-related admits, ED visits

Blue Cross of California State Sponsored Business takes a comprehensive approach to asthma management, partnering with the Fresno Valley Air Quality Board on ways to improve air quality in Fresno County, piloting a project to help physician practices improve their asthma treatment methods, and developing a three-tiered approach to managing members' asthma.

The health plan experienced a 60% decrease in asthma-related hospital admissions and a 46% decrease among members enrolled in its comprehensive asthma interventional program, according to an evaluation of claims for services performed between 2004 and 2006.

In an effort to reduce asthma attacks among its members, Blue Cross of California State Sponsored Business went beyond the standard asthma management programs and created a unique private-public partnership to deal with air quality issues that precipitate asthma attacks.

The health plan received the 2006 National Environmental Leadership Award in Asthma Management from the U.S. Environmental Protection Agency for its asthma intervention program.

The health plan compiled information on hospitalizations, emergency department visits, and physician's office visits related to asthma among its members residing in Fresno County. It shared the information with the local air quality board, Fresno Public Health Department, and researchers at California State University, Fresno, to see if there was a correlation between asthma attacks and air quality issues in the community, according to Dawn Wood, MD, vice president, medical director of the health plan, an operating subsidiary of WellPoint Inc. with headquarters in Thousand Oaks, CA.

The data showed that asthma attacks increased during the time that landfill fires were burning out of control in Fresno County.

"At the time we did the study, there were periodic fires in county landfills that burned out of control. Our data helped the county and other community partners take steps to get the fires under better control," Wood reports.

The health plan is continuing to work with the air quality board on ongoing air quality management, Wood adds.

"The landfill fires are not as much of an issue now, so the project is working to identify other air quality factors that contribute to asthma attacks," she says.

Practice improvement project

As part of its initiatives to find better ways to control asthma, the health plan is piloting a practice improvement project with five physician practices in San Francisco, says Margot Lisa Miglins, PhD, clinical research manager.

"We are helping physicians and their staff learn what they can do to educate the patient and family about environmental toxins, pollutants, and asthma triggers in the home, the school, and the work environment," she says.

The insurer provides the physician practices with asthma education materials to share with the members, along with pillow covers and mattress covers that the physicians can give to the patients whose asthma is triggered by allergies.

The health plan's health promotion consultant in San Francisco makes periodic visits to the physician offices, bringing them materials and working with them on practice modifications.

The project has resulted in four practice modifications that have made a big difference in improving services to asthma patients, Miglins says.

The clinics have begun to use registries for asthma patients. These are computerized databases that allow physicians to immediately identify who has asthma, how severe it is, and when the patient was last seen.

Instead of taking patient encounter notes on a blank piece of paper, the physicians in the pilot project have begun using guided, structured progress notes that prompt them with questions to ask and procedures to implement.

At least one person in each physician practice has taken a comprehensive training program and become certified to be an asthma educator. The asthma educators work with the members with asthma and those involved in their care, including schools and day care centers.

All of the practices have revitalized their procedures for involving families in the management of the member's asthma.

The health plan's asthma intervention program takes a three-pronged approach to asthma management, intensifying the interventions based on the severity of the member's asthma.

When members are identified as having made an asthma-related ED visit, they are enrolled in the asthma program and screened for case management.

"Some of our members go to the emergency room two or three times during the high season when their allergies are the worse. These members most likely end up being case-managed by a nurse who helps them learn to manage their environmental triggers," says Thi Montalvo, MHA, senior health services analyst.

Members who have been to the emergency department receive additional interventions, including more educational material and an easy-to-read handbook covering 200 conditions and how to manage them.

Members are encouraged to call the insurer's 24-hour nurse information line if they have questions about their condition and are unable to reach their physician.

"If members are repeatedly going to the emergency room and not to the primary care physician, this tells us the member has not established a medical home. These are the kinds of members that we know interventions will help," Montalvo says.

Using claims and pharmacy data, the health plan stratifies members with asthma by risk level. There are about 47,000 members with asthma.

All members who are identified with asthma are enrolled in the asthma disease management program and receive an educational package. The materials include an offer to send members an inhaler case, a pillowcase cover, or other asthma-related items if the members send in a form indicating that they have seen their doctor.

The plan's proactive case management and/or clinical operations specialists call patients who are at moderate risk if they have not been to the primary care physician for an office visit and encourage them to work with their doctors to develop an asthma action plan.

High-risk members go through an intensive screening process to see if they are appropriate for the asthma case management program.

"After our annual sweep of claims data, all moderate and high-risk members with asthma are mailed educational materials that focus on how to manage asthma, how to reduce exposure to environmental triggers, and the importance of going to the doctor and working with him to develop an asthma action plan," Montalvo says.

Low-risk members are eligible to receive the asthma education packet upon request. All identified members are put into the asthma registry, which tracks and trends each member's asthma condition over the years, she adds.

The case management nurse works with the physician and patient to manage the disease, prompts the patient to go for office visits, and works with him or her on taking controller medication regularly and relying less on the rescue medicines.

The plan provides physicians with triplicate copies of the asthma action plan — one for its medical files, one for the patients, and one to forward to the specialist if the patient is referred to an allergist or pulmonologist.

The health plan provides primary care physicians with a member-specific asthma fact sheet to insert into the medical record.

The fact sheet includes information on emergency department visits, inpatient hospital stays, specialist visits, primary care visits, the number of times the controller medicine and rescue medicine were refilled, and any comorbidities the patient may have.

The pharmacy information helps the physicians understand how much medication their patients are using and if they are following the prescribed medication regimen.

"We encourage the physicians to utilize the information. For instance, if they see that the patient has had no primary care visits, we hope that they will take the next step and try to get the patient to come in for a visit," she says.