Asthma management program shows a 2-1 ROI

Program provides home visits for severely ill patients

Optima Health's asthma disease management program has generated $2.10 in savings for every dollar spent on members who have been continuously enrolled over a five-year period.

In addition, the Virginia Beach, VA-based program, which provides home visits by a respiratory therapist or a nurse for severely ill asthma patients, has resulted in a 20% decrease in emergency department visits.

About 10,000 of the health plan's 350,000 members have asthma. More than 60% of the members are part of Optima's Medicaid health plan.

Members are identified through claims and pharmacy data, primary care and specialist office visits for asthma, inpatient admissions, or home health care with a primary diagnosis of asthma, according to Janis Sabol, RRT, team coordinator for the asthma program.

Once members are identified, they are stratified into risk levels by their resource consumption and the number of interventions their asthma has required.

Members at highest risk are eligible for a home visit by a nurse or a respiratory therapist, who conducts one-on-one asthma education and does an environmental assessment of the home, looking for mold, dust, or other allergens and offering suggestions for how the member can remediate them.

The health plan contracts with a home care agency, which sends a nurse or respiratory therapist into the home as often as necessary and assumes responsibility for coordinating the care of the member for a one-year period.

The lowest-risk members, about 80% to 85% of members with asthma, receive educational brochures and a card with the name of a contact person they can call with questions or concerns.

The case managers concentrate on the moderate- to high-risk patients, those who don't access emergency department care but have the potential to have a severe asthma attack if they don't change the way they are managing their disease.

"We are aware that you can throw a lot of time and energy into the sickest individuals. With some of the more severely ill members, we tend to be spinning our wheels. Sometimes we think we make an impact and then they end up back in the emergency room or hospital again and again. It depends on the nature of their disease, their desire to treat the disease, and their attitude toward health care," Sabol says.

When members are identified as being at moderate to high risk, the case managers call them and discuss their disease.

"We find out what medications they are taking and when, whether they've seen their doctor, if they have identified their asthma triggers, and other asthma-specific information. We ask questions to get the total picture and to offer assistance in whatever area they need most," Sabol says.

The case managers periodically check back with the members, depending on their needs, and help them overcome any obstacles to care.

For instance, one patient who lives in a rural area was supposed to be getting injections for an allergy, but her pulmonologist died suddenly and she had not been able to find another physician. The case manager helped her find a doctor and checked on her frequently until her condition was stabilized.

To overcome the transportation barrier for its Medicaid population, Optima Health Plan has contracted with a transportation service that members can use to get to and from their physician appointments.