By Melinda Young, Author
Le Bonheur Children’s Hospital in Memphis, TN, offers a pediatric asthma case management program that improves the health and outcomes of area children who have asthma and are on TennCare, the state’s Medicaid program.
Called Changing High-risk Asthma in Memphis through Partnership, or CHAMP, the program incorporates various best practices, including early identification of children who could most benefit from the case management intervention, says Susan Steppe, LAPSW, director of CHAMP and 38109 Population Health at Le Bonheur Children’s Hospital.
“The program promotes a strong asthma action plan for the child and works with schools and day cares to make sure asthma triggers are addressed,” says Frances Martini, BSN, MBA, vice president of population health at BlueCare of Chattanooga, TN. BlueCare is a partner in the program.
Martini and Steppe describe how the program works:
• Early identification. There were several options in identifying which children to target for the asthma case management program. With an estimated 12,000 children with asthma in the Memphis area, the program had to identify those who were most in need of an intervention.
“We have a high poverty population in Memphis,” Steppe says. “A lot of poor children frequently visit the hospital.”
The goal was to provide high-risk asthma patients with a multidisciplinary management approach. This reduces their hospital and ED visits, improves health, and saves Medicaid funding.
“High-risk asthma” as defined by the CHAMP program includes children who meet any one of the following criteria:
- three or more ED or urgent care visits for an asthma-related event within one year;
- two or more hospital admissions for asthma in the past year;
- one or more ICU admission within the past two years;
- a physician refers a child who is on the cusp of these guidelines or who has special circumstances.
Also, all of the children needed to be on Medicaid and live in Shelby County.
CHAMP receives a daily report that lists all asthma patients admitted or seen within the previous 24 hours for an asthma-related condition at a Methodist Le Bonheur hospital or facility.
The criteria recognize that these children are at the most risk of long-term health problems.
“The frequency and severity of those asthma exacerbations for a very young person can have the capacity to impact the growth of lungs,” Steppe explains. “Getting help for this population was something our physicians really wanted to do.”
• Ongoing screening. “Every day, we get a report from a hospital record system that tells the names of any child who came to the hospital with a diagnosis of asthma, and then we screen to see if the child meets criteria,” Steppe says.
The program measures a number of data points for the pediatric asthma population, Martini says. These include ED visits; inpatient use; prescriptions; medication management; and prescription rate refill.
“We look at the percentage of kids using rescue inhalers,” Martini adds. “What we found was a 20% improvement in quality scores for children in the asthma program over children who were not, and we want to improve quality for all children.”
The higher the percentage of asthma patients using their inhalers, the better they are managing their medication and asthma, she says.
Thanks to the program, the Shelby County medication adherence rates were so high that their outcomes positively affected the state’s overall adherence rate for BlueCare, Martini says.
• Community health educators. The CHAMP community team reaches out to patients to see if their families agree to enrollment in the program. Three community health educators (CHEs), who are peer educators without a medical degree, work with the enrolled families and patients.
“The community health educators have experience in doing home visits and connecting with people,” Steppe says. “They’re also on the community team, which includes a medical director and nurse practitioner.”
CHEs work with them in their homes, and they educate families in ways they understand.
“Educators speak the language of asthma, talking a lot about asthma and adherence,” Steppe says. “It amazes me how many times we have to remind people which medicine to take. We even put red stickers on their albuterol, and they still take the wrong medicine each day.”
CHEs continually reinforce the right way to take medications and prevent asthma attacks.
• Clinic visit. The high-risk asthma patients visit an allergy health clinic for their initial case management. The initial clinic visit goals include developing an asthma action plan and giving patients access to a 24/7 call line, Steppe says.
“At that clinic visit, we give the patient a loading dose of prednisone,” she says.
Patients also are told to use the call line whenever there’s a medical emergency or breathing problem.
“Of the people who call the call line, 70% have been able to manage the exacerbation with help by phone, and they haven’t had to go to the ER,” Steppe says.
• Other community team members. Other team members include an RN and a respiratory therapist who work with families in both health clinics and community settings.
The nurse handles sick call triage, helping the families deal with their child’s asthma flare-up at home unless an ED visit is necessary. Respiratory therapists help the children handle issues that might arise while they’re at school. This could include meeting with school nurses or other staff and educating them about asthma emergencies.
• Asthma and schools. Since Shelby County schools only have a nurse one day a week, the respiratory therapist also meets with school secretaries and anyone else who might be called upon to help with a child’s asthma attack.
“We also want schools to know that they have high-risk patients in their schools, and if one of their students comes to the ER, we tell them about it,” Steppe explains.
Also, respiratory therapists give families a school packet with medication and information.
“Then I follow up with the school and try to make a personalized visit for each patient with the school,” she says.
Occasionally, one of the team members will visit a school to help with a child’s asthma attack, she adds.
“If you don’t have a nurse in every school, every day, it’s a great challenge for us,” Steppe says. “In our area, asthma is the No. 1 health-related reason why children miss school, and it has a domino effect of children missing school and parents not working that day.”
• Home visits. After the first clinic visit, CHEs visit the patient’s home and perform an environmental assessment, looking for common allergens as defined by the Environmental Protection Agency.
CHEs also identify patients’ social determinants of health and make referrals to help them with issues related to housing, utilities, transportation, and so forth.
Health educators also reinforce what patients heard in the clinic about their illness. “Hearing it once in a busy clinic is never enough,” Steppe explains. “They explain what asthma is, how it’s a constriction, swelling, and mucous, and that’s why people need a daily medication.”
They’ll educate the children, if they’re old enough to understand. They’ll also reinforce the need for families to visit with a primary care physician for annual check-ups and vaccines.
• Primary care provider visits. In CHAMP’s pilot program, the only negative outcome was that enrolled families visited their primary care providers less frequently than families not in the program, Martini notes.
“We found that when people had a strong positive relationship with the allergy clinic, the parents thought of the clinic physicians as their doctor,” Martini explains. “We’d call and say, ‘We need you to have your doctor’s visit,’ and they’d say they just went to the doctor, but it wasn’t the family doctor.”
This was an area the program needed to strengthen, Steppe says.
The solution was to have CHEs ask families if they’ve made an appointment with their family doctor and to follow up to see that the appointment was kept.
“Professionals working with families might actually go with them to the family doctor appointment and share the patient’s asthma action plan with the primary care physician,” Martini says.
• Asthma registry. “We developed this program with an asthma registry, a data system where we record everything we do,” Steppe says. “All of our children are Medicaid patients, so every month the Tennessee Medicaid Administration downloads all medical information from all patients into our registry.”
CHEs use the data to see which patients have not filled their prescriptions on time. Then they’ll call the family and ask if they need someone to pick up the medication.
“The ability to look at that data and have access to it makes the difference for any asthma program,” Steppe says. “We’ve crafted the data and made it usable.”