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Disease Management Program: Asthma

Article Citation(s):
Jowers JR, Schwartz AL, Tinkelman DG, Reed KE, Corsello PR, Mazzei AA, Bender DR, Lochhead RA. Disease management program improves asthma outcomes. American Journal of Managed Care 2000;6:585-92.

Intervention Setting:
Participants’ homes

Target Population:
High-risk patients of all ages with asthma-related hospitalizations or emergency visits during the preceding 12 months who received care through one single Medicaid managed care plan in western Pennsylvania.

Program Description:
The Disease Management Program: Asthma (DMP: Asthma) integrates traditional treatment methods with a disease management program that focuses on creating a partnership between the patient and the health care team. The program goal is to empower patients with the tools and resources they need to comply with their treatment protocol.

DMP: Asthma:

1. identifies and address patient’s educational needs;
2. reinforces the asthma action plan provided by the primary care provider;
3. provides asthma educational materials and peak flow meters to guide the patient in long-term monitoring; and
4. teaches patients in the home environmental control measures to reduce exposure to known triggers, and conduct regular telecommunication with patients to ensure an open exchange between patients, physicians, and nurses.

Patient data for the 12 months before the start of the program were gathered for all patients from the managed care plan. Patients provided information on previous health care use, work- or school-related absenteeism, symptom severity, and self-management skills. After enrollment in DMP: Asthma, all patient-specific hospitalization and emergency visit claims data were reported to the research center within 30 days. The data pool was updated with every nurse/patient interaction.

Patients received published educational materials written at either the fourth grade (for children) or tenth grade (for adults) literacy levels. These publications covered understanding asthma; identifying triggers of asthma; recognizing asthma signs; peak flow monitoring; managing medication and supplies; and allergic reactions to animals, dust mites, mold, and pollen. Specialized respiratory care nurses provided care management for patients with moderate and severe persistent asthma. With the use of a comprehensive entry questionnaire the nurse gathered information about the patient’s asthma history, symptoms, medical history, prescriptions, use of a spacer and peak flow meter, understanding of asthma, and family support system. The assessment allowed care managers to determine when patients needed moderate or more aggressive intervention. Depending on disease severity, patients received four to six proactive telephone calls annually from care management nurses. The nurses used these calls to assess the patient’s health status, review the asthma action plan, verify the patient had the resources at home needed to prevent an attack, and provide asthma education on an individual basis. Patients were encouraged to contact nurses when they were symptomatic. This allowed nurses to assist patients in implementing their asthma action plan. Physicians received reports from the care managers summarizing their patients’ status and providing health care utilization and productivity data as reported by the patient. This occurred after every contact between patient and care manager.

Local home healthcare companies provided two home health visits by a nurse for each enrolled patient. These visits were used to evaluate patients’ health status, assess their ability to manage their asthma, and conduct in-home education. The first home health visit took place within 4 weeks of enrollment. At this time, the home health nurse reviewed asthma physiology, early warning signs, and the asthma action plan, and discussed the patient’s medication. With the caregiver, the nurse conducted a home environmental assessment for asthma triggers. The nurse taught patients environmental control measures and demonstrated correct use of the peak flow meter and a metered dose inhaler (MDI). The second home visit consisted primarily of a review of asthma symptoms, the asthma action plan, peak flow meter and MDI technique, and environmental triggers, and determined the need for further education and home visits.

Evaluation Design:
A pre-post design was utilized.

Sample Size:
The sample included 317 patients who completed at least 6 months of the program.

Outcome Measures/Results:
Outcome measures included health care use, productivity, and cost of care based on the 6 months before enrollment compared with 6 months after enrollment. Emergency visits decreased 67%, (from 546 to 180), hospital days declined 61% (from 157 to 62), and unscheduled doctor visits decreased by 62% (from 1083 to 413). Adult days missed from work declined by over 85% (879 to 131). Caretaker days of missed work decreased 71% (312 to 90) and child days missed from school showed a 30% decline (719 to 505). The financial benefits of these reductions in use and missed days, both direct and indirect, totaled more than $400,000. After an average adjusted care rate of about $303 per patient for 6 months (total $96,051), benefits remained well ahead of costs. Sixty-two patients from the larger group completed 12 months in the program. Both adult and caretaker days of missed work declined by over 90%, emergency visits fell 77% (140 to 33), and unscheduled doctor visits decreased 66% (171 to 58).

Materials available:
The Disease Management Program: Asthmais available for purchase from the National Jewish Medical and Research Center, 1400 Jackson St., M305, Denver, CO 80206.

The New York State Healthy Neighborhoods Program

Article Citation(s):
Lin S, Gomez M, Hwang S-N, Franko EM, Bobier JK. An evaluation of the asthma intervention of the New York State Healthy Neighborhoods Program. J Asthma 2004;41(5):583–95.

Intervention Setting:
Interventions took place in homes of study participants in New York City and seven New York State counties. Various New York Departments of Health, from large central metropolitan to nonmetropolitan counties, were funded to implement this program.

Target Population:
The study involved people in neighborhoods with high levels of environmental risk factors that can lead to asthma morbidity and mortality. This included households with minorities, children younger than 14 years, and residents with less than a high school education or with an annual income less than $16,452. This also included neighborhoods with inadequate physical environments (substandard, older housing, or households in remote rural areas).

Program Description:
This evaluation assessed the affect of the Healthy Neighborhood Program (HNP) asthma intervention over a 4-year period, 1997–2000. Each program provides environmental and educational assistance unique to its population and geography. The HNP asthma interventions use home visits to identify people with asthma, assess asthma morbidity and management, and identify environmental asthma triggers. The programs provide a variety of controls for asthma triggers and education to change behavior and improve asthma management.

The HNP intervention funds outreach workers trained to assist people with asthma and to address the cultural and linguistic needs of the target households. Outreach workers first visited a targeted neighborhood and left door hangers announcing the program. The intervention visits began at a subsequent visit to the neighborhood. Once a household agreed to participate in the program, an adult resident was interviewed to determine the individual needs of the residents, including children, and the asthma status of each resident. A room-by-room visual inspection of the dwelling was conducted, which included identifying asthma triggers. Education about asthma management, community services, and reducing asthma triggers, including the risks of cigarette smoke, was conducted during the home visit with the residents who have asthma. Environmental controls were also provided, as needed, including mattress and pillow covers, furnace filters, rodent baits, and cleaning equipment and vacuums; and their proper use was demonstrated.

Children from low-income families who did not have a regular physician were referred to a private children’s health insurance program subsidized by the state government. The programs were required to revisit a sample of households at least 90 days after the initial HNP visit to ascertain the effectiveness of the home visits, educational materials, and environmental controls. Information was collected on the use of products to reduce household allergens and the results of any referrals made to other agencies. An assessment was made as to whether sources of allergens were reduced or eliminated in each dwelling. Residents were interviewed to determine if they read any of the education materials provided and if they changed their behavior as a result. In addition, attempts were made 1 year after the initial visit to revisit all households that had an asthmatic member. The purpose of these 1-year revisits was to determine if there was improvement in asthma morbidity and to assess the reduction in asthma triggers present in the home. Information was collected on the number of hospital admissions, emergency room visits, and school or work days lost due to asthma. Information was also collected on the number of persons with asthma who had a written management plan from their physician, who knew the early warning signs of an asthma attack, and who monitored their peak expiratory flow daily.

Evaluation Design:
This was a pre-post design study. Following the HNP intervention, 25% of households in the program were revisited within 90 days. During the 1997–1999 cycle the goal was to revisit 25% of all households. During the 2000–2002 cycle the homes of all asthmatics were visited with the goal of revisiting a total of 25% of the households seen in 1 fiscal quarter selected by the individual programs during each funding year. Data were maintained from the initial visits, 90-day revisits, and 1-year asthma revisits.

Sample Size:
801 people with asthma, of all ages, in the targeted HNP areas.

Outcome Measures/Results:
One final health outcome measure (the rate of self-reported hospitalizations [admissions and emergency room visits]); three intermediate outcome measures (the percent of homes with cockroaches, the percent of asthmatics with a written management plan, and the percent of asthmatics using a peak flow meter); and the estimated net savings resulting from a reduction in hospital admissions due to asthma.

Details:
Because of changes in reporting requirements across the funding cycles (1997–1999 and 2000–2002), the findings are reported separately. Hospitalization rates (hospitalizations per 100 diagnosed asthmatics) at the initial HNP visits and 1-year HNP revisits for 1997–1999 showed for all six programs combined 86.0 hospitalizations per 100 persons with asthma per year. At the 1-year asthma revisit, the average hospitalization rate was 44.5 per 100 people, a decrease of 48.3%. The average percent change for the six programs was –61.2%, a significant decrease after the HNP intervention. After accounting for the decrease in baseline rates of about 25% over this period, the decrease attributable to the program was about 23%.

In the second reporting cycle, 2000–2002, asthmatics in five counties (n=835) showed a combined hospitalization rate of 95.6 visits per 100 asthmatics. At the 1-year followup, the combined hospitalization rate was 24.9 (N=493). The average percent change for the five programs was –68.1%. The incidence of cockroach infestation, percentage of asthmatics with a written asthma plan and those using a peak flow meter were also calculated. Cockroaches were found in 10.2% of homes on average (range 21.7% to 0.8%) in 7 counties before the intervention and in 5.8% of homes in the 1-year followup (range 14.4 to 0.0). Researchers found 15.6 % of asthmatics used peak flow meters at the initial HNP visit. One year following the intervention, 43% of asthmatics were using a peak flow meter. The average percentage of participants in the HNP with a written asthma management plan increased by 48%.