Project 3dii: Expansion of the Home Environmental Asthma Management Program

Transcription

1 1 Project 3dii: Expansion of the Home Environmental Asthma Management Program Asthma Primary Care Project Participation Opportunity

2 Purpose 2 This Project Participation Opportunity is specifically targeted towards OneCity Health Partners who provide primary care to pediatric and/or adolescent populations and want to make the asthma home based self-management program available to their patient populations by collaborating/providing community health workers (CHWs) services and home remediation services. Please note that this is not a procurement process, but a way for OneCity Health partners to self-identify interest in participating in project implementation. Under DSRIP, OneCity Health is required to meet several objectives under the Home Environmental Asthma Management Program DSRIP project. Achieving these objectives will require collaboration between several types of OneCity Health partners, including clinical services, CHW services, and home remediation services.

3 3.d.ii Asthma Home-Based Self-Management Program: Project Requirements 3 1. Expand asthma home-based self-management program to include home environmental trigger reduction, self-monitoring, medication use, and medical follow up. 2. Establish procedures to provide, coordinate, or link the client to resources for evidence based trigger reduction interventions. Specifically, change the patient s indoor environment to reduce exposure to asthma triggers. 3. Develop and implement evidence-based asthma management guidelines. 4. Implement training and asthma self-management education services, including basic facts about asthma, proper medication use, identification and avoidance of environmental exposures that worsen asthma, self-monitoring of asthma symptoms and asthma control, and using written asthma action plans. 5. Ensure coordinated care for asthma patients includes social services and support. 6. Implement periodic follow-up services, particularly after ED or hospital visit occurs, to provide patients with root cause analysis of what happened and how to avoid future events. 7. Ensure communication, coordination, and continuity of care with Medicaid Managed Care plans, Health Home care managers, primary care providers, and specialty providers. Use EHRs or other technical platforms to track all patients engaged in this project.

4 Target Population 4 The interventions target people with asthma who meet at least one of the below criteria, which were approved by the Clinical Leadership Team during application planning. o Were admitted to the inpatient unit for asthma exacerbation with in the last 12 months o Were in the emergency department with asthma exacerbation two or more times within the last 6 months o Received a prescription for systemic corticosteroids two or more times within the last 6 months o Have prescription patterns indicating overuse of short acting beta agonists (e.g. albuterol) Phased Approach o Year 1 and 2 recruitment will focus on ages 0-18 o We will also accept referrals from older patients, but will not actively recruit them until year 3.

5 State-defined Metrics for Asthma Project 5 Type of metric Patient engagement commitment Asthma-specific clinical improvement metrics Measurement The number of participating patients based on home assessment log, patient registry, or other IT platform. 584 by 3/31/16 (DSRIP year 1) Annual commitments: 4,674 (DSRIP year 2) 9,348 (DSRIP year 3) 11,695 (DSRIP years 4 and 5) Admissions with principal diagnosis of asthma (ages 2-17; ages 18-39) People ages 5-64 with persistent asthma who received at least one controller medication who filled controller prescription (during at least 50%, at least 75% of treatment period) Asthma medication ratio in people ages 5-64 with persistent asthma (controller: total asthma meds 0.50) Other clinical improvement metrics affected by asthma project Potentially avoidable admissions (PQI 90 for ages 18+, PDI 90 for ages 6-17) Potentially avoidable readmissions (3M) Potentially avoidable ER visits (3M) ED use by uninsured Medicaid spending on ER and inpatient services

6 Partner Roles in Implementation of Asthma Model 6 Both partners and CSO will have obligations in success of implementation These roles and responsibilities will be specific to partner types Contract structure and processes will be developed to support the work required for implementation for each partner type Clinical services Active partnership with primary care (including schoolbased clinics), inpatient, and ER; also will accept referrals from other clinical settings Community health workers (CHWs) Trained personnel with understanding of local communities who will provide home visits Home remediation services Removes sources of allergens from the home such as mold and vermin

7 Clinical Partners: Roles and PPS Support for Primary Care Team 7 Partner responsibilities Examples of activities CSO support Provide clinical care consistent with national standards Implement processes to: Consistently and accurately document asthma classification in medical record Assess control during follow-up visits Follow guidelines for medication prescription Use Asthma Action Plan Provide asthma education Provide follow-up visits available within 7 days after asthma-related ER or hospital visit Support for certification in asthma education for PCMH staff member Education/ training on: Clinical guidelines for asthma classification and management Spirometry use Billing for reimbursable services related to asthma (spirometry, asthma education) Spirometer Identify patients with poor asthma control Implement processes to identify patients during clinic visit who meet inclusion criteria Leverage population data to identify poorly controlled asthmatics for intervention Tools and sample workflows As feasible, IT support for EHR development, registry development, and leveraging of population-level data (e.g. EHR data, billing data)

8 Clinical Partners: Roles and PPS Support for Primary Care Team (cont.) Partner responsibilities Examples of activities CSO support Screen patients for home assessment needs, and track number screened (engagement metric) Screening questionnaire incorporated into visit workflow Report number of screened patients Training in use of screening tool As feasible, support incorporation of tool into EHR 8 Refer patients to CHW to assist in selfmanagement, if indicated For patients who decline CHW, administer detailed home assessment tool in clinic setting Create and track a registry of patients with persistent asthma Root cause analysis for patients who went to ER or hospital for asthma exacerbation Create process for referrals Standardized tool for assessment of home environment through patient interview conducted in clinic Refer directly to home remediation services, if indicated (for patients who decline CHW) Use IT platform to track patients with persistent asthma, including those meeting inclusion criteria and those referred to CHW program Identify potentially modifiable factors leading to acute event Linkage to CHW program Training in motivational interviewing and techniques to encourage program acceptance Standard assessment tool provided; training as needed Linkage to home remediation services Provide template of log or registry for clinical use; promote incorporation into EHR Training/or tool for root cause analysis

9 Community Health Workers: Roles and PPS Support 9 Partner responsibilities Examples of activities CSO support Reinforce education in asthma self-management with patient and family Reinforce and support self-monitoring skills Reinforce and support appropriate medication use Training or retraining of CHW staff to PPS standards Ongoing educational opportunities to increase and update knowledge Assess home environment Coordinate care Provide materials to assist in trigger reduction in the home environment Teach home cleaning strategies Refer to home remediation services, if indicated Communicate with primary care team, specialty providers, and care managers (including Health Home and managed care plans) as needed Refer to care management or social work for complex needs Coordinate clinical follow-up for root cause analysis after any ER or hospital visits Provision of materials to assist in trigger reduction (e.g. pillowcases, cleaning products) Care management platform Tracking and reporting Track and report process and outcomes measures to CSO Care management platform

10 Home Remediation Services: Roles and CSO Support 10 Partner responsibilities Remediation of home environment to address factors that exacerbate asthma symptoms Examples of activities Remove triggers such as mold and vermin, through advocacy or direct intervention

11 Two Types of Organizational Configurations 11 Configuration 1: Hospital/Clinical-Based Program Configuration 2: Community-based Community-Based Workers Internally hired Community- Based Workers Clinical Sites External Community Health Worker Programs via CBOs Home Remediation Services

12 Patient vignettes Pediatric Asthma Patient: Out-Patient Clinic 12 Juan, age 5 Juan lives with his parents and 2 older siblings in a rented, single family house in the South Bronx. Juan was diagnosed with asthma at age 2, and was hospitalized when he was 4 months old due to a (+)RSV URI. Juan has been to the ER multiple times since then, sometimes twice within 7 days. In the past year, Juan missed at least 35 days of daycare due to his asthma. He has prescriptions for budesonide and albuterol but his mother did not fill them because their insurance was expired, and she did not understand the notification for renewal. His father smokes cigarettes but never inside the house and Juan s aunt and uncle came from Mexico to live with them, and now Juan sleeps in a living room which has an old carpeted floor which the landlord refuses to change. Scenario 3 Juan has another asthma exacerbation Juan is brought to the walk-in clinic by his mother with a cough and trouble breathing. Juan is registered to the Out- Patient Walk-in Clinic where he is assessed and treated following the NIH Recommendation for Asthma Management Juan meets criteria for referral to home-based management program Juan is referred to the community health worker (CHW) for education and home services CHW sees Juan in the clinic and his mother agrees to participate in the Home Environmental Assessment for his Asthma Management At the end of the visit, Juan is scheduled for a follow-up with his PCP in two weeks, and a home visit appointment by his CHW within 72hrs after his acute visit to the clinic Juan is diagnosed with a mild asthma exacerbation and will be registered to see the nurse practitioner who is covering the walkin clinic CHW provides additional selfmanagement education and patient supplies and links Juan to other services to properly manage his asthma, such as smoking cessation, Healthy Homes, manage care office and social workers Juan follows up with his PCP at the clinic where he gets evaluated using NIH recommendations: he gets an updated AAP, a medication form for his school and an appointment to come back in 6 weeks to assess level of control CHW works with Juan and his mother to develop strategies for minimizing triggers CHW conducts a second follow-up home visit to resolve identified barriers and ensure that linkages that were made are being taken care During the home visit, the CHW ensures that Juan is adhering to the treatment plan and conducts initial environmental trigger identification CHW calls Juan s home within 48 hours of the clinic visit, to check on him and to confirm the home visit CHW documents updates on electronic health records/ patient registry and ensures that Juan follows up regularly with PCP. CHW ensures communication and reporting back to Juan s PCP Juan is sent home with prescriptions for 30 days and his asthma action plan (AAP), basic asthma education was provided to his mother at the clinic CHW conducts a third follow-up home visit to resolve identified barriers and ensure that linkages to care are being addressed

13 Logic Model for Pediatric Clinic Workflow and Interventions 13 INPUTS Pediatric Clinic Pediatric Chairman Attending Physician Nurse Health Educator Social Worker Finance Counselor Resources: Pediatric Specialists: Pulmonologist and allergist Asthma Program Quit Smoking Program Pulmonary Function Test / Spirometry Blood Lab for IGE and allergy testing Electronic Health Record - AAP Community Partners (NYC Asthma Partnership) Language appropriate services (interpreter services) Visiting Nurse Services CHW Services Activities IT training to all team members on patient Registry EPR-3 Asthma Guidelines Review (Physicians) Spirometry Training for clinical staff: performing and interpreting Asthma Certification Training for Nurses and Allied Health Personnel Asthma Management Education to patients and Parents Home Environmental Assessments Integrated Pest Management (IPM) Referrals Interviews/surveys with consumers about quality of care OUTPUTS Reach Pediatricians / Primary Care Providers Nursing and Allied Health Staff in the clinic Asthma Program / Health Educators Home environmental visiting nurses / CHW NYC DOH IPM Services GSI Technical Support Patients with asthma and their families Increase in documented Asthma Severity Classification Increase in documented Asthma Control Status Classification Increase in documented prescription of Inhaled Corticosteroird as a long term control medication Increase in documented Asthma Action Plan Increase in documented Spirometry lung values Increased Asthma education documentation by the asthma educator or nurse educator Increase in documented Home Environmental Assessment Improved Asthma Self-management OUTCOMES Short Medium Long-term Decrease asthmarelated Hospitalizations Decrease asthmarelated Emergency Room visits Increase Asthma Control Status Improved community health Reduction in Asthmarelated mortality Improved quality of life Assumptions: Reinforcement will result in PCPs applying new guidelines to practice. Changes will result in an improvement asthma selfmanagement education system. Integrated asthma care team will result in comprehensive delivery of care. External Factors: Cultural barriers to care Visit time constraints imposed by practice administration

14 Important Dates!!! 14 Interested partners should the completed Partner Interest Form to by January 27th with the subject line Asthma Primary Care. OneCity Health will contact all partners to discuss site selection for early implementation of this project in consideration of the availability of community health workers by February 5, By responding to this Project Participation Opportunity, partners who do not participate in early contracting will nonetheless provide valuable information for intermediate and longterm planning for OneCity Health, as we determine available partner resources, possible training needs, and local network readiness for subsequent stages of implementation.

15 Q & A 15 Questions!!