The work around asthma control is an excellent case example of the collective impact on health that can be achieved through the collaborative strengths of health care and public health, said session moderator Terry Allan, health commissioner of the Cuyahoga County Board of Health in Ohio and a past president of the National Association of County and City Health Officials (NACCHO). Allan noted that work on asthma control has its roots in the successful experience with lead hazard control, where medicine and public health have a long-standing relationship around case identification and referral processes leading to interventions that reduce exposures.
More than 10 million U.S. children have been diagnosed with asthma.1 Those who bear the greatest burden from asthma are often low-income and minority children. Because children with asthma are more likely to miss school, asthma can compound the disadvantages of poverty. Missed work days by parents needing to stay home to care for their children with asthma also widens the opportunity/financial gap.
As clinicians work to optimize care and manage exacerbations, public health and partner agencies can be the eyes and ears of the clinicians in the home environment. Partners can provide data, educational reinforcement, environmental assessments for trigger identification, and remediation of these triggers in the home environment. Known triggers in
the home include, for example, mold, dust mites, cockroaches, rodents, tobacco smoke, and household chemicals. Wet basements, leaky roofs, and old carpets are common in substandard housing and pose risks to those living with asthma. Asthma trigger reduction in the home works, Allan said. Demonstration projects across the country are providing the evidence and designing the process to take this work to scale. A recent pilot involving doctors and public health workers in Cleveland, for example, led to a 58 percent reduction in hospitalizations among low-income children with asthma. These efforts are opening the door to sustainable fee-for-service opportunities with public and private payers, Allan said. These successful collaborations also build respect and trust, which open the door for broader initiatives and powerful population health alliances.
In this session, Shari Nethersole, executive director for community health at Boston Children’s Hospital and assistant professor of pediatrics at Harvard Medical School, and Margaret Reid, director of the Division of Healthy Homes and Community Supports at the Boston Public Health Commission, discussed a collaborative approach to asthma care in Boston as a case example of a successful health care–public health collaboration. Box 5-1 provides an overview of session highlights.
Key Themes of the Session on Asthma Care
- Asthma control is rooted in previous public health–health care collaboration to mitigate lead hazards to children’s health (Allan)
- The greatest burden from asthma is borne by low-income and minority children—asthma is the leading cause of hospital admissions at Boston Children’s and school absenteeism in Boston Public Schools Hospital (Nethersole)
- Regional partners are helping to spread and scale the Community Asthma Initiative model, including with support from a Centers for Medicare & Medicaid Services Innovation Center grant (Nethersole)
- The initiative currently receives grant and hospital community benefit support, but leaders are working to secure insurance coverage of initiative services (Nethersole)
- The Boston Asthma Home Visit Collaborative emerged as the solution to a fragmented patchwork of services and receives support from the Massachusetts Department of Health (Reid)
- Communication is key, and sustaining a partnership requires crediting all partners in publications and in attracting media coverage and giving all partners opportunities to represent the collaborative and to present on its progress (Reid)
From 2003 to 2005, when the planning process for the Community Asthma Initiative was taking place, asthma was found to be the leading cause of hospital admissions at Boston Children’s Hospital, Nethersole said. Asthma is also the leading cause of absenteeism from Boston Public Schools. Seventy percent of the children who were hospitalized came from five low-income, predominantly African American and Latino neighborhoods in Boston. The asthma hospitalization rates for African American and Latino children were four to five times higher than the rate for white children; however the prevalence is about two times higher, suggesting the issue is around asthma control. This disparity was the stimulus for the program, she said.
Individual and Family Intervention
The Community Asthma Initiative is an individual and family intervention program focused on providing better asthma education and case management. Care coordination is provided by bilingual and bicultural community health workers and nurses during home visits. These caregivers work with the family to establish goals for asthma control and identify barriers to good asthma control. Barriers could include, for example, a lack of understanding of asthma and medications, a lack of medication adherence, environmental triggers at home or at school, and a lack of or inadequate insurance coverage or high co-pays for patients with private insurance. Community health workers and nurses also assess the environment and provide supplies for remediation, such as high-efficiency particulate arrestance vacuums, bedding encasings for protection from dust mites and other allergens, and integrated pest management solutions. Nethersole pointed out that a vacuum is a one-time cost of $80 to $90, which is less expensive than a 1-month supply of Flovent® for the control of asthma.3 The initiative works closely with the Boston Public Health Commission’s Breathe Easy at Home program (discussed by Reid in this chapter), and referrals for other specific community services are provided as needed, including child care, job resources, and legal resources.
Data collected at baseline and at 6 and 12 months after enrollment in the program showed statistically significant improvements in health
2 Prior to the presentation, a brief video about the Community Asthma Initiative at Boston Children’s Hospital was shown. The video can be viewed at http://iom.nationalacademies.org/Activities/PublicHealth/PopulationHealthImprovementRT/2015-FEB-05/Videos/Case%20Study%204/20-Nethersole-Video.aspx (accessed August 25, 2015).
3 Flovent® is the registered trade name for fluticasone propionate aerosol inhaler.
outcomes. At 12 months, there was a 57 percent decrease in emergency room visits and an 80 percent decrease in any hospital admissions due to asthma (Woods et al., 2012). Nethersole noted that more than 1,200 patients have been enrolled over 8 years, and the results are consistent. Similarly, missed school days due to asthma decreased by 43 percent, and missed work days for parents caring for a child with asthma decreased 51 percent. With regard to return on investment, Nethersole said that the total cost per child for asthma care services in 2006 was about $3,000 prior to enrollment in the Community Asthma Initiative. Twelve months after enrollment, the cost per child was reduced to about $1,300, and after 2 years, the cost per child was $750. (For comparison, a similar population that did not get the Community Asthma Initiative had an asthma care cost per child of about $2,000 the same year, which was about $1,300 at 12 and 24 months later.4)
In addition to the patient-directed work of the Community Asthma Initiative, there is also a large community education component, including workshops in the community and in schools. The Community Asthma Initiative has a Family Advisory Board and a Community Advisory Board that meet three times each year. Parents advise the initiative on what is working and what is not.
Replication and Dissemination
Nethersole summarized some of the ongoing efforts to replicate and disseminate the Community Asthma Initiative model. The initiative is working with Health Resources in Action and the Asthma Regional Council of New England on a more regionalized approach to asthma. Health Resources in Action has a Center for Medicare & Medicaid Innovation grant to study the outcomes and cost-effectiveness of home visits and case management across several states and in several locations within Massachusetts. The Community Asthma Initiative has also developed a program replication manual to guide others in starting an asthma home visiting and case management program, including advice on partnerships and monitoring and evaluation.5
The initiative is looking at how to move the model upstream, from identifying children through emergency room visits and hospitalizations as the index point to identifying them in the primary care setting. The
4 “There was a significant reduction in hospital costs compared with the comparison community (P <.0001), and a return on investment of 1.46” (Woods et al., 2012, p. 465).
goal is to provide better asthma education, management, and control in the medical home to prevent hospitalization or emergency room visits. Boston is fairly unique in that there are 23 community health centers within the city limits, Nethersole said, and 50 to 60 percent of the children in Boston receive their care in these centers. Boston Children’s Hospital also has a very large primary care practice onsite and an adolescent clinic, which together provide primary care for about 15 percent of the children in Boston. There is an opportunity to engage with community health workers in these practices to change the management of asthma.
At the start of the Community Asthma Initiative there was also discussion about payment models. The initiative is currently supported through Community Benefit dollars from the hospital and several grants. The initiative is now working with insurers to secure coverage of these services. She noted that legislative efforts to mandate insurance coverage for these asthma services were not successful; however, the state legislature did include a mandate in the 2011 state budget for Medicaid to conduct a pilot of bundled payment for pediatric asthma care. The pediatric high-risk asthma bundled payment pilot is now under way at three sites in the state. There is a per-member, per-month payment to the primary care practice to cover the cost of high-risk asthma patients who have been jointly identified, Nethersole explained. The payment will not cover the cost of the service the Community Asthma Initiative is providing, she noted, but it is the beginning of developing a new payment model.
The Boston Public Health Commission has conducted asthma home visits for a long time, Reid said. In 2008, with evidence of persistent disparities in asthma outcomes, the Public Health Commission decided to revamp its asthma home visit program to better incorporate individualized disease management. As part of the process a needs assessment was conducted, including interviews with clinicians who made referrals for asthma home visits, organizations conducting home visits, and home visit clients. The assessment found that programs came and went based on grant funding, making it difficult for clinicians to make a referral because they often did not know what programs existed. In addition, clinicians were confused by the different services and providers. There were variations in content and quality of programs. Some programs served only specific geographic, institutional, or racial/ethnic/non-English-speaking populations, leaving some communities underserved. As a result, the Boston Public Health Commission contacted various stakeholders to discuss developing a collaborative home visiting system for asthma in Boston.
The vision of the Boston Asthma Home Visit Collaborative is that any
person in Boston who could benefit from home visits for asthma receives them; that the visits are consistent and of high quality; that they result in improved asthma control; and that they are funded primarily by those sources that pay for traditional medical care and are perceived as cost-effective. The collaborative sought to build capacity to offer home visits in as many languages as needed and to establish a centralized referral system that identifies the most culturally and linguistically appropriate agency to provide the visit to a given family.
Reid noted that the collaborative has had fairly stable participation since 2009. The Public Health Commission convenes the group. Boston Children’s Hospital has provided some funding and significant human resources in terms of expertise, she said. The Boston Medical Center has a home-visiting program and has been very involved. The U.S. Environmental Protection Agency (EPA) has provided funding, and its regional asthma manager participates. Other collaborative members include the Neighborhood Health Plan, a New England–based plan with a large Medicaid population; Partners Asthma Center, a large health system in Boston; and Tufts Medical Center.
The collaborative meets monthly. Funding from EPA helps to cover the cost of a facilitator who is an asthma policy expert. Having a facilitator allows the collaborative to be intentional about being sure that every voice is heard, Reid said. This is critical because the collaborative involves many stakeholders, including clinicians, public health administrators, program directors, community health workers, payers, and others. The home visit structure is modeled after existing evidence-based home visiting programs, such as one in Seattle/King County, Washington. Among its activities, the collaborative has developed, tested, and modified data collection forms and educational materials and provided training and support for community health workers performing home visits. A pilot evaluation of clinician and client satisfaction and asthma control test improvements was completed after year 1, with a second evaluation completed in 2013.
Community health workers tend to have very stressful jobs and often work in isolation, Reid said, and support and integration have been shown to impact retention. There are monthly meetings of community health workers who perform asthma home visits. A nurse, nurse practitioner, or physician attend every meeting to provide clinical oversight, along with a facilitator from the Public Health Commission. The community health workers engage in problem solving, peer-to-peer learning and support, resource and information sharing, and reinforcement of training and education. The goals are standardizing across service providers, retaining community health workers, and increasing skills and knowledge. Boston is the third most expensive rental housing environment in the country,
Reid said, and its public housing is among the oldest in the country. Housing stability, energy/heat stability, and food security are immediate concerns for many people. Community health workers need to know all of the resources available and be able to make referrals. Many find that until they can help families with their immediate, urgent needs, asthma is not going to be their priority.
Reimbursement for Community Health Worker Asthma Home Visits
The Massachusetts Department of Public Health has also prioritized universal access to quality community health worker–led asthma home visits across Massachusetts, Reid said. Priority areas for action are achieving insurance reimbursement for community health worker asthma home visits and driving demand for home visits among payers and providers. The state’s Department of Public Health selected the Boston Public Health Commission to develop and implement asthma home visitor training and support for the state. Training includes both asthma content and community health worker skills. Because many organizations are not familiar with integrating community health workers into their system, there is also supervisor training available.
A consultant was hired to conduct a needs assessment and make recommendations to the Massachusetts Department of Public Health Asthma Prevention and Control Program. The assessment found some openness among insurers to pay for asthma intervention visits by community health workers, Reid said. Some insurers were already convinced that this approach works, while others wanted to see more cost–benefit analysis and evidence of efficacy. To expand reimbursement, insurers wanted standardized training of community health workers, standardized skills assessment and evaluation, and an easy referral system. As noted above, the Boston Public Health Commission has been selected to oversee the training of community health workers for the state, including a mentorship or practicum phase, and is looking to partner with other asthma home visiting programs to provide mentorship. City and state public health agencies are also working together to develop a performance-oriented assessment that will include home visit observation, and the state is piloting an electronic referral from clinical sites to community health sites, with feedback of information.
Boston Breathe Easy at Home
Reid also described the Boston Breathe Easy at Home program, which helps providers to address housing and environmental triggers for their patients with asthma. Clinicians can make online referrals for housing
code enforcement inspections from the Boston Inspectional Services Department (Reid et al., 2014). They then receive notifications by e-mail when the inspections have been scheduled, any violations that were found, and when violations are resolved. Most violations are resolved by the landlords, without the need for intervention from the court system. Reid noted that the Boston Housing Authority has signed a memorandum of commitment with the code enforcement agency that they will respond within 24 hours to these complaints.
Much of the open discussion in this session focused on challenges faced by the collaborative initiative in addressing asthma in the community. Participants also discussed costs and care coordination, making use of geographic information to identify areas of need, addressing asthma upstream, patient privacy, and training.
The panel discussed further the challenges of dealing with housing code violations to improve the living environment for patients with asthma. Allan raised the issues of retaliation from landlords when referrals for inspections are made and homeowners are responsible for the costs of remediation to address water, electrical, or other problems. Reid said fear of retaliation is very prevalent (including when the landlord is a family member of the tenant). When the code inspector arrives for a Breathe Easy at Home inspection, he or she stresses to the landlord that the tenant did not register a complaint. The inspector explains that the tenant has asthma and that the doctor is concerned about the tenant’s health and has asked for the inspection. Another challenge is scheduling the inspection. Failure mode and effects analysis showed that one of the immediate failure modes is the inability to reach people to follow-up after a referral is made despite many attempts by the Inspectional Services Department to reach them (Murphy et al., 2015). The analysis also showed areas for improvement and ways to adapt better to the individual in the home (e.g., the hours that calls or inspections are done, the use of phone calls to reach people when many people now text message). Cost is also a challenge, Reid agreed. Boston, like many communities, has small homeowner grants and loans that can help small property owners to maintain decent housing and offers technical assistance on such issues as integrated pest management. The City of Boston is now conducting proactive inspections for code violations (i.e., without referrals), and this work illustrates
the diverse mix of partners in public health collaboration, Reid said. In this case, the Office of Fair Housing is a key resource for asthma control.
Nethersole listed several other challenges, including turnover of staff at partner organizations, differences in outcome expectations (e.g., long-term policy change versus addressing immediate needs), and disputes over ownership (i.e., who takes credit for what). Reid added that the capacity to be the lead agency may be dependent on one dynamic program director. If that person leaves, everyone suffers during the gap period until another leader is established.
Reid noted that although improving public awareness and communication are part of the core mission and function of public health, they are less so for other agencies that might be partners. When doing intergovernmental work, such as working with the city’s housing agencies, it is important for public health to not always be out in front, she said. Be sure, for example, that manuscripts include all members of the steering committee from the different agencies, that media coverage acknowledges other partners, and that other agencies have a chance to give presentations.
Mary Pittman from the Public Health Institute asked whether there have been challenges from other provider groups over potential conflicts in scope of practice. Reid said that in the Boston Public Health Commission, the community health workers are in union positions, and the state of Massachusetts is working on a credentialing system.
Robert Kaplan of the Agency for Healthcare Research and Quality noted that another challenge is the ability to recognize value as services become broader. There is a need for both health outcome indicators and process indicators, he said. Another concern is that the process becomes so complicated for providers that it collapses under its own weight. For example, recent discussions with a provider group suggest that they are spending an estimated $50,000 per physician per year to provide all of the indicators of performance to the health plans. Nethersole agreed that there is the potential for overmeasuring and having too many indicators to follow. For the asthma initiative, it is difficult to tease out what part of the intervention makes the difference. Is it the home visit, the supplies provided, the education? Can these pieces of the program be separated? The bundled payment pilot program is looking at a limited number of indicators, such as asthma control test, asthma action plans, number of visits, and pharmacy visits. She noted that a staff position has been added for the pilot because the tracking of indicators adds another level of administrative burden for which there is no system currently in place.
George Isham of HealthPartners reflected on the concept of reaching out and doing things that are not usually paid for by health care but that can have significant impact on health care costs. He recalled comments by Sarah Linde of the Health Resources and Services Administration in the first case study discussion about the Secretary of the U.S. Department of Health and Human Services’ intent to reform payment models. He asked about the challenges of transitioning to a system of shared financial performance around achieving improved health outcomes regardless of whether improvement is the result of medical care, good housing, or other interventions. One of the challenges, Nethersole said, is that even though pediatric asthma is a major driver in terms of hospital admissions overall, it is not the biggest driver of pediatric costs. The major drivers of cost in pediatrics are special health care needs and complex medical problems. Efforts to address costs focus on chronic illness. However, even though asthma is a chronic illness, it is not comparable in costs to caring for children who are machine dependent or ventilator dependent. Many organizations are still trying to determine the best way to structure new payment systems, but we are moving in the right direction, she said.
Costs and Coordination of Care
Lloyd Michener from Duke University said that North Carolina pays for community health workers through Medicaid. The state continually makes adjustments to ensure that the trade-off between avoidable hospital admissions and the cost of the community health worker is balanced and that the use of community health workers remains cost-effective. Michener added that at Duke there are 17 different care manager lines, and a challenge is coordinating who does what, and when, to ensure appropriate care and cost-effectiveness. Nethersole said that they are working to understand what the care coordinators, patient navigators, and case managers are doing in primary care and how that connects with the asthma home visitors and asthma community health workers.
Nethersole said that cost trade-offs (or gains) are theoretical at this stage of the asthma program; the hospital is not yet gaining from its investment, but insurers are beginning to realize savings. The hospital and its pediatric physicians’ organization have begun to develop a Medicaid accountable care organization, and there will be data systems that can track this information. Simulations of expenses, quality measures, and value equations will be done, which will become real as the hospital negotiates with managed care resources. The resources are being committed with the goal that, over time, the costs will be mitigated. Aside from the Community Asthma Initiative, the community benefits program supports other partnership programs. A needs assessment identified asthma, obe-
sity, behavioral health, and child development as focus areas, and Boston Children’s Hospital has a strong relationship with 11 of the community health centers in the city on these issues. The hospital has moved away from small, disconnected programming at the health centers to focused initiatives with data collection and quality improvement at the health centers.
A participant agreed that it helps to approach these issues as networks, not as individual practices. It also helps to focus on multiple diseases, as concerns such as diabetes and hypertension are often prevalent in the same community. This multipractice, multidisease approach also helps to secure sustainable funding. Another participant concurred and added that it is a mistake to have one patient-centered medical home try to develop all of these capabilities. It is important to build a web of capability around them.
In response to a question about the inclusion of school nurses in the coordination of care, Reid said that the e-referral pilot project includes communication between community health centers and school nurses so that the nurse has the asthma action plan for the child. In Boston, four nurse leaders each work with a cluster of schools to receive and route the communication to each of the city’s 135 schools.
Allan asked why Boston Children’s Hospital has sustained this collaboration over the years. Nethersole said that the primary reason is the results—the improvement in asthma management and, ultimately, in outcomes for children in Boston regardless of primary care provider. The case manager makes sure the patient has an appointment scheduled with the primary care provider within 2 weeks of an emergency room visit or hospitalization, follows up after the appointment, and serves as a facilitator of bidirectional communication with the primary care provider—actions that support effective management of childhood asthma.
Mining Geographic Information
A participant asked about mining geocoding data to identify needs. He cited a case in Cincinnati where pediatricians recognized a large volume of illness coming from a certain housing complex. They contacted legal aid, housing, and public health and found out that the landlord had gone bankrupt. Through legal aid, they were able to facilitate new roofs and remediation of rodents and mold. It was suggested that having the community proactively identify these concerns would be more effective than waiting for an astute clinician to notice or for a patient to complain about the housing. Nethersole responded that getting this type of data from Medicaid has been challenging. They have done geographic information system mapping of their own patients, but not to the building
level. The Boston Public Health Commission has identified specific housing developments where a number of patients reside, but conversations with the management of those housing developments have had varied outcomes. Some of the issues are general upkeep concerns that do not trigger legally mandated change. Reid said the focus is on upstream interventions. For example, the goal at a large housing development proximal to one health center is not to fix specific apartments of people with asthma but to promote a plan to eliminate cockroaches, rodents, and mold from the whole development so everyone gets healthier.
Pamela Russo of the Robert Wood Johnson Foundation mentioned a project in Louisville, Kentucky, that uses inhalers from Propeller Health that include a geographic information system. The device tracks the time and place each time the inhaler is used. Health care providers, the health department, and the city government in Louisville came together on this project because the high prevalence of asthma and respiratory disease was preventing the city from attracting new employers.
Pittman said that the asthma program in California is starting to look upstream. One program, Ditching Dirty Diesel, is focused on reducing truck idling in low-income communities with higher asthma rates. Reid said that an environmental justice organization in Boston called Alternatives for Community and Environment has mapped the public transportation bus routes and parking lots and found that the bus lots are all located in the lowest-income neighborhoods. This means that empty buses drive through those neighborhoods to get to the lots and often idle in the lots.
Allan asked about data sharing with the housing inspectors and others within the context of the Health Insurance Portability and Accountability Act (HIPAA). Reid said that when a patient accepts the clinician’s recommendation for a home inspection referral they sign a HIPAA release form. On the referral form there are boxes to check for what the patient reports is in the home so the inspector knows what to look for (e.g., mice, mold, lack of heat). When the inspector goes to the home, he or she gets written permission again from the individual. Nethersole said that there was a lot of discussion about what information should be shared on a referral form for the Asthma Home Visit Collaborative. There needs to be enough information to inform the process for the visiting health worker.
José Montero of the New Hampshire Department of Health and Human Services asked about incorporating the lessons learned into the training of the next generation of pediatricians, nurses, and other providers. Nethersole responded that the American Board of Pediatrics requires that advocacy be included as part of pediatric residency so that they understand the community agencies and resources that are available. Reid said that some of the residency programs send their medical residents to conduct home visits and inspections with public health staff.
A webcast participant asked whether community health workers are trained to look for lead hazards or are required to report lead hazards that they find in the course of an asthma home assessment. Reid responded they are trained to look for a number of environmental problems and make referrals for code inspections.