SAN FRANCISCO – A collaborative, community-based program to improve care for publicly insured children has reduced emergency department visits, hospitalizations, and costs, thanks in large part to a strong focus on asthma care.
Dr. Tom Peterson and his associates emulated a similar program at Denver Children’s Hospital to start the Children’s Healthcare Access Program (CHAP) for pediatric Medicaid recipients in Grand Rapids, Mich. Their 3-year-old program has been so successful that other Michigan counties are now copying it.
Dr. Tom Peterson
"It’s not just an asthma program, but asthma is the biggest and most collaborative project we’ve pulled together" in CHAP, he said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
In its first 3 years, CHAP connected almost 2,000 new Medicaid patients with clinicians and helped those clinicians access approximately $500,000 in provider incentives such as pay-for-performance incentives, he said. Of the approximately 15,300 children covered by CHAP, almost 6,000 were referred for CHAP services, including transportation for patients who might otherwise be no-shows for appointments.
In the CHAP population overall, emergency department visits decreased by 12% and hospitalizations decreased by 14%, reported Dr. Peterson, a pediatrician and executive director of safety, quality, and community health at Helen DeVos Children’s Hospital, Grand Rapids. Much greater decreases were seen in teaching clinics involved in CHAP.
Previous research by Dr. Peterson showed that children with public insurance or no insurance in Michigan were twice as likely to have asthma as were privately insured children (J. Pediatrics 2011;158:313-8.e2).
His hospital partnered with the Asthma Network of West Michigan and a managed care organization to pull together a group consisting of 40 pediatricians; 10-12 family physicians; and midlevel providers from four private practices, nine community- and school-based clinics, a pediatric resident teaching clinic, and a nurse practitioner clinic in CHAP.
The program features a team of six or seven people who help improve the children’s "medical homes" in primary care practices and help clinicians by coordinating the care. "Education is a significant piece of this, not just for the families but also for providers, sites, and patients," Dr. Peterson said.
CHAP can help practices improve efficiencies and scheduling. It helps coordinate care with mental health services, transportation, and other services. Education covers not just asthma but also flu shots, diet and nutrition, and inappropriate use of emergency departments. CHAP also acts as a neutral convener of meetings with community stakeholders (some of whom had never met together) to address systemic issues.
The asthma program within CHAP provides ongoing education and training of health care providers, families, and patients. High-risk children get monthly home-based visits for disease management for the first 6 months, then two visits in the next 6 months. CHAP pays attention to transitions of care between inpatient stays and medical homes, and now includes schools in postdischarge care. Services currently are provided by four certified, culturally skilled, multilingual asthma educators and two social workers, who may visit families to assist with psychosocial barriers to asthma care. CHAP also provides funding for home-based asthma case management through the Asthma Network of West Michigan.
Among seven high-risk children with asthma in CHAP’s case-management program, emergency department visits have decreased by 30% and hospitalizations have decreased by 63%, he said.
CHAP’s asthma team includes five pediatricians, asthma educators, an asthma and allergy specialist, school leaders or nurses, Medicaid health plan representatives and case managers, the Children’s Hospital quality improvement specialist, CHAP’s medical director and manager, and data analysts. "It’s a pretty diverse group of people to get together," Dr. Peterson said.
The CHAP team assesses participating medical practices for 12 characteristics "that we think constitute a really good asthma site," he said. These include asthma in-service training for staff and education for patients, having an in-office asthma educator, referring appropriate patients to CHAP or the Asthma Network of West Michigan, teaching peak flow monitoring, assessing exposure to environmental tobacco, in-office spirometry, use of management plans, the Asthma Control Test and an asthma registry, and routine 6-month asthma visits.
With 1 point allotted for each of the 12 factors, the average score of CHAP practices increased from 6 to 10 in the first 3 years of the program.
Priority Health, a managed care organization, provided kits for the program. CHAP is funded by the hospital and by a variety of private and corporate foundations, including the Douglas and Maria DeVos Foundation, W.K. Kellogg Foundation, Steelcase Foundation, Sebastian Foundation, Early Childhood Investment Corporation, Frey Foundation, Grand Rapids Community Foundation, Heart of West Michigan United Way, O’Donovan Family Foundation, and PNC Grow Up Great. Dr. Peterson said he has no conflicts of interest.