Implementing Interventions in Diverse Communities:The Asthma Partnership Of New York

Pediatric Pulmonary Center Meeting

March 1-3, 2007

Arlington, VirginiaNew York StateDepartment of Health

“Despite some improvements in awareness, care and management, asthma still remains an epidemic in New York state with significant public health and financial.

Disparities among high and low income groups and variation in care processes, quality and cost of care persist.

More system level activity is necessary to accelerate and spread improvements for all New Yorkers.”

New York State Asthma Plan 2006-2011

New York’s Call to Action

Objectives

Describe the Burden of Asthma In New York

Define the role of the Asthma Partnership of New York

Highlight New York’s strategies to improve asthma outcomes

BRFSS Prevalence of Asthma Among Adults by Survey Year, New York State & Nationwide

5.4

7.0

6.3

8.9

7.77.9

7.6

7.37.5

7.87.5

8.37.6

0

1

2

3

4

5

6

7

8

9

10

1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

Percent

New York Nationw ide

National Asthma Survey – NY 2003

National Asthma Survey – NY 2003

National Asthma Survey – NY 2003

National Asthma Survey – NY 2003

National Asthma Survey – NY 2003

Healthy People 2010 Objectives for Asthma Hospital Discharges per 10,000 population

New York State (1994-2004)

22.4

18.0

34.9

71.7

NY 02-04

26.4

22.9

28.0

86.8

NY 94-96

11.024.825.825.365+ Yrs

7.716.318.721.05-64 Yrs

17.331.235.743.30-17 Yrs

25.066.172.175.50-4 Yrs

Age Group

HP 2010NY 00-02NY 98-00NY 96-98

Total Cost of Asthma Hospitalizations New York State, 1993-2002

$0

$100,000,000

$200,000,000

$300,000,000

$400,000,000

$500,000,000

$600,000,000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

The total cost of asthma hospitalizations has increased 44%, from $322 million in 1993 to $465 million in 2004.

The top 20% of asthma hospitalizations consumed ~ 55% of the total cost for asthma hospitalizations.

The average cost per asthma hospitalization increased 106% from $5,656 in 1993 to $11,634 in 2004.

This occurred despite the average length of stay for asthma decreasing 24% from 4.9 days to 3.7 days during the same time period.

Use of Appropriate Medications for Children with Asthma, 1999-2003 Trends by Payer

404550556065707580

1999 2000 2001 2002 2003

Measurement Year

Sta

tew

ide

Ave

rage

Commercial Medicaid CHPlus

5-17 Years: Commercial, Medicaid5-18 Years: Child Health Plus Source: QARR data

Use of Appropriate Medications for Adults with Asthma, 1999 -2003 Trends by Payer

404550556065707580

1999 2000 2001 2002 2003

Measurement Year

Sta

tew

ide

Ave

rage

Commercial Medicaid

Source: QARR data

New York State Asthma Report Card – Modified HEDIS Asthma Measures*

MODIFIED HEDIS MEASURE STATEWIDE AVERAGECHILDREN (5-17)

STATEWIDE AVERAGEADULTS (18-56)

1 or More Controller Scripts in 2004** 69.8% 70.1%

3 or More Controller Scripts in 2004 47.4% 55.0%

5 or More Controller Scripts in 2004 32.9% 43.9%

*Cohort comprised of enrollees in HMOS and PHSPs who qualified for the denominator of the 2005 HEDIS Measure, ‘Use of Appropriate Medications for People with Asthma.’

**Standard 2005 HEDIS Measure.

Asthma Disease Severity Categories Documented: By NHLBI Category(The exact terms (“Intermittent”, “Persistent”, “Persistent-mild”, etc.) must be recorded)

65%

12%

2%

9% 10%

2%1%

34%

0% 0% 0% 0% 0% 0%

87%

26%

11%

27%23%

11%

5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Not recorded Intermittent orMild Intermittent

Persistent Persistent - mild Persistent -moderate

Persistent -severe

Exercise-induced asthma

Response Categories

% o

f A

ll R

evie

wed

Ch

arts

All Records

Lowest

Highest

N=845 Reviewed Medical Charts

NY Asthma BCAP Overall 2004 and 2005 Audit Results

Asthma Assessment Documentation Responses For Persons with Asthma Assessed in the Review Period

54%

31%

22%

90%

44%

7%5%

0%

82%

3%

94%

75%

56%

98%

93%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Daytime symptoms ofwheezing OR cough OR

shortness of breath (SOB)recorded

Nocturnal symptoms ofwheezing OR cough OR

SOB

Activity-related symptoms ofwheezing OR cough OR

SOB

Frequency of prescribedquick-reliever (ß-agonist orrescue) medications

Frequency of use of quick-reliever (ß-agonist or rescue)

medications

Response Categories

% o

f A

ll R

evie

wed

Ch

arts All Records

Lowest

Highest

N=845 Reviewed Medical Charts

NY Asthma BCAP Overall 2004 and 2005 Audit Results

Smoking Assessment Was Performed

39%

71%

4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

All Records Highest Lowest

% o

f A

ll R

evie

wed

Ch

arts

N=845 Reviewed Medical Charts

NY Asthma BCAP Overall 2004 and 2005 Audit Results

Member Has an Updated Asthma Action Plan Documented in the Medical Record During the Review Period

27%

95%

0%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

All Records Highest Lowest

% o

f A

ll R

evie

wed

Ch

arts

N=845 Reviewed Medical Charts

NY Asthma BCAP Overall 2004 and 2005 Audit Results

Patients with All Four NY Asthma Guideline Elements(Documentation of Asthma Severity, Prescribed Controller Medications,

Asthma Triggers, and Asthma Action Plan)

10%

29%

0%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

All Records Highest Lowest

% o

f A

ll R

evie

wed

Ch

arts

N=433 Reviewed Medical Charts, 2005 Review Only

NY Asthma BCAP Overall 2004 and 2005 Audit Results

What will it take to spread improvements and

reach New York’s diverse communities? Change will not happen on the scale needed unless

there is collaboration and alignment of priorities across stakeholder groups.

There must be some awareness that the stakeholders are more likely to achieve the goal by working together than individually.

“Americans are a peculiar people. If in a local community a citizen becomes aware of a human need that is not met…suddenly a committee comes into existence…and a new community function is established. It is like watching a miracle.”

de Tocqueville, 1840

Definition of Terms - NY Partner: an associate or organization who works with other

partners, including the NYSDOH, toward a common goal

Partnership: a cooperative relationship between Partners who agree to share responsibility for achieving the goal of reducing the burden of asthma

Coalition: An organized group of partners within a specific region who work together to achieve a shared goal through a population based sustainable systems approach and some awareness that they are more likely to meet their goal by working together than individually.

State Asthma Program: Implementation of coordinated asthma activities based on the New York State Asthma Plan and led by NYSDOH with statewide partners

Who are NY’s Partners?

Statewide Partnership (advisory, and implementation role)

Regional Coalitions (advocacy, implementation role)

Local/Project Specific Partners (advisory, implementation, sponsor role)

Statewide Partnership

NYSDOH Partners

Center for Community Health Center for Environmental Health Child Health Plus Department of Environmental

Conservation Information Systems and Health

Statistics Group Office of Health Systems Management Office of Managed Care Office of Medicaid Management Office of Science and Public Health Office of Rural Health Public Affairs Group Wadsworth Center for Labs and

Research

External Partners American Lung Association Healthcare Association of New York State Community Health Centers Association of NY Pediatric, IM, Family Practice Professional

Societies Medical Society of the State of New York Health Plan Association of New York State State Education Department New York State Nurses Association NYS Association of School Nurses Pharmacy Society of the State of New York NYS Regional Asthma Coalitions

Role: Shape, align, implement and monitor New York’s action to reduce the burden of asthma

NYS Regional Asthma CoalitionsCoalition Partners

• Approximately 100 partners per coalition such as:•Health Care professionals/organizations•Insurers•Local Health Departments•Schools/daycares•Community groups/organizations (ALA)•Pharmacists•Faith based organizations•Housing•Environmental organizations•Businesses•Media•Others

Role: Control asthma through a regional, population based, sustainable systems approach.

Local or Specific Project Partners

Best Clinical and Administrative Practices (BCAP): Improving Asthma Outcomes in NYS (2004-2006)

Project Partners:

•NYSDOH Asthma Program•NYSDOH Office of Managed Care•Center For Health Care Strategies (CHCS)•Island Peer Review Organization (IPRO)•13 Medicaid Managed Care Plans•Providers•Regional coalitions

Role: Translate the Asthma Guideline into practice, coordinate interventions and share information among partners

NYSDOH Guidance Team

Surveillance Health Care CommunityEnvironment and

Occupational Health

NYSDOH Leadership Team

Statewide Partnership

How are all these partners connected?

Moving New York Forward: “Re-Visioning Asthma”

Partners

National Initiative for Children’s Healthcare Quality (NICHQ): Boston/Seattle

MacColl Institute for Chronic Illness Improvement (Dr. Ed Wagner, Mike Hindmarsh)

Broad Representation across DOH and NYCDOH&MH , including Executive Level buy in and support)

Statewide Partners: professional societies, specialists, health plans, advocacy organizations, ALA, regional coalition reps, patients/parents etc.

Role

• Expert in system change and improving asthma care among children

•Expert in population based chronic care improvement and aligning system change aims at multiple levels in the health system and community systems.

•Expert in Public Health, Medicaid, Managed care, Epidemiology, Environmental and Occupational Health

•Expert in clinical, advocacy, regional issues, patient/community experience

• July 2005 new strategic planning began

• Reviewed burden of asthma in NYS

• Emerging new evidence

• Result…

“Framework for Improving Asthma Outcomes in NYS”

New York State Asthma Plan 2006-2011

Statewide Public/Private Collaboration

•Leadership•Shared Vision: Priorities Goals

•Partners: People with Asthma, Providers, Plans, Purchasers, Legislators, Public Health…

Ongoing Surveillance, Data Integration, Evaluation, Performance Measurement & Research

Improved Asthma Outcomes (Short Term/Long Term) and Optimized Value

Informed,Activated

Consumers/Communities

Motivated,Integrated Health

Care Delivery

•Consensus Guidelines •Medical Home•Care Management• IT connectivity & support•QI models & activities•Provider networks•Provider education

SupportiveInsurance &Payment

Transformed Healthcare System

•Community support and buy-in•Public disclosure of health system performance

•Consumer education

•Consumer-directedcare decisions

Engaging Consumers/Communities

Framework for Improving Asthma Outcomes in New Y ork State

•Expanded access to health insurance•Model benefit package for asthma services •Administrative simplification•Expanded funding for services/benefits not adopted by payers•Performance Incentives

Improving HealthcareDelivery/Quality

Aligning Finance/

Insurance

Mobilizing PublicHealth

•Asthma friendly communities, schools, work and home environments

•Public awareness andknowledge of asthma

Integrated Public Health System

1. Seamless, evidence- based, patient/family centered asthma care exists for all New Yorkers with asthma.

2. Disparities in asthma diagnosis, treatment and outcomes are eliminated.

3. "Asthma-Friendly" communities exist in New York.

4. Policy makers, health care providers and consumers have an increased understanding of asthma and treat and manage asthma effectively.

5. A Statewide Public/Private Collaboration exists to shape, implement and monitor New York’s action which will improve asthma outcomes in New York.

NYSAP 2006-2011 Goals

Prioritizing Strategies

150 38 strategies (based on framework) 3 face to face meetings and 2 surveys Each strategy rated based on a two by two matrix

high or low impact – the degree to which this strategy is supported by evidence and would improve health related outcomes and quality of life and reduce symptom burden, preventable hospitalizations and deaths;

high or low feasibility of implementation – the degree to which the necessary resources, partners and political will are available and can be conducted in the real world.

Goal 1: Seamless evidence-based patient/family centered asthma care

Update NYS Asthma Consensus Guideline pending NAEPP updates

Develop Asthma Guideline for patients

Develop and establish the “NYS Center For Innovation”

Develop and implement a model benefit package for that support good asthma care

Goal 2: Eliminate disparities in asthma diagnosis, treatment, and outcomes

Develop, implement and spread a multi-modal asthma home environmental intervention through a collaboration with NYS Healthy Neighborhoods Program, Health Plans and Providers in both urban and rural communities

Pilot and expand an asthma quality improvement collaborative within School Based Health Centers located in neighborhoods with high asthma morbidity

Goal 3: Create asthma-friendly communities in NYS Develop and implement a comprehensive NYS

School Asthma Management Policy

Implement tailored environmental trigger reduction interventions in identified high risk elementary schools

Create and promote the NYS Asthma Coalition Learning Network among state funded regional asthma coalitions in order to identify and spread best practices

Goal 4: Enhance awareness among policy makers, providers, and consumers

Maintain and expand asthma surveillance

Produce and disseminate NYS asthma surveillance information

Provide technical assistance for monitoring and evaluation of asthma interventions

http://www.health.state.ny.us/diseases/asthma/index.htm

Goal 5: Foster a statewide public / private collaboration to monitor asthma outcomes Refine and expand the:

Asthma Partnership of New York

Asthma Partnership of New York actively works together to set priorities, monitor plan implementation and results

Thank You!

Pat Waniewski, RN, MS

Asthma Coordinator, NYSDOH

Phone: (518)486-6065

Email: paw04@health.state.ny.us

http://www.health.state.ny.us/diseases/asthma/index.htm

New York State Department of Health Asthma Web page: