Kaiser Permanente: The Colorado Asthma Experience
Improving Gaps in
Care
Kaiser Permanente’s HealthTRAC Asthma Registry includes
42,000 members or about 8% of total Kaiser Permanente Colorado (KPCO)
membership. During 2010, the Kaiser Permanente
Colorado (KPCO) 12-month average for emergency department (ED) visits for
asthma was 35 per 10,000 members for pediatrics and 13.8 per 10,000 members for
adults. For asthma related inpatient
discharges, KPCO’s 12-month pediatric rate is 11 per 10,000 members and 2.3 per
10,000 members for the adult population. Both KPCO’s asthma related ED and
hospitalization rates were well below the published CDC and state rates. Hospitalizations
and ED visits are seasonal. Lower income and African-American populations have
higher hospitalization and ED rates than other socio-economic and ethnic
populations.
Research shows a linear association between increasing fills
of short-acting beta-agonist use and hospitalization and ED visits for asthma;
as fills for beta-agonist increase, so does the prevalence of hospitalization
and ED visits. For those patients with
persistent asthma, data shows correlation between regular use of an inhaled
corticosteroid (ICS) and decreasing hospitalization and ED rates. Regarding the HEDIS 2011 rate, KPCO ranked #1
in the nation in persistent asthma patients filling an ICS.
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Program Overview
Reach
Productivity
Value Proposition
Access and Support
Expansion Efforts
Asthma Care
Coordinators Key to Program Success
Several studies correlate asthma disease management programs
with lower costs resulting from decreased hospital and ED visits. KPCO Asthma Management Disease Program is led
by RNs known as Asthma/COPD Care Coordinators (ACCs) who work closely with
primary care physicians to:
- Outreach to patients overusing Albuterol or
under filling inhaled coticosteroids;
- Outreach to patients with an ED visit for an
asthma exacerbation;
- Provide patient education when requested by PCP,
Allergy or Pulmonologym Department;
- Perform spirometry to better assess asthma;
- Provide education for staff to correctly perform
and document spirometry;
- Support implementation of the “Albuterol Refill
Protocol”;
- Develop Asthma Action Plans in collaboration
with patients.
The ACC team also coordinates letter campaigns each year; two
that are pediatric-focused and two that are adult-focused. The letter campaigns strategically address
issues such as ICS under use, beta agonist overuse, back to school asthma education,
and promotion of the flu vaccine. To
date, the letter campaigns have shown a 23.8% response
rate for prompting patients to pick up an ICS.
The asthma program is also supported by the Allergy
Department, which sees patients who were hospitalized for asthma. In addition,
the Clinical Pharmacy Department supports KP’s regional asthma program from a
medication therapy and cost perspective.
A recent pharmacy initiative to outreach to patients on Advair and
convert them to Dulera has saved KPCO 2.5 million dollars. Asthma medication
cost is the biggest contributor to the overall cost of care for patients with
asthma and the pharmacy has played an integral part in helping keep medication
costs low.
The Asthma Governing Board oversees all asthma population
management efforts. The Asthma Governing
Board establishes the annual program goals and objectives and monitors key
asthma quality indicators to ensure that the organization is on track to meet
goals. When needed, the Asthma Governing
Board will discuss challenges and opportunities that may impact the
organization’s ability to provide evidence based care to KP members who have
asthma. In 2012, work is being done to solicit
members’ perspective by addition of 2 KP members to the Governing Board.
The Board includes representation from the Clinical
Informatics Decision Support team to ensure that the HealthTRAC asthma registry
is accurately identifying and stratifying the asthma population so that
resulting interventions, outreach, and in-reach can occur in a timely and
appropriate manner.
Reach
In 2011, the ACC team provided services for nearly 9,000 members with
asthma who were identified as at-risk.
ACC’s outreach to asthma patients
in high risk categories: those overfilling beta-agonist, those underfilling
inhaled corticosteroids and patients who have been in ED with asthma
exacerbation. The asthma/COPD care
coordinators utilize HealthTRAC reports to generate lists of names. In 2011 the
ACC’s outreached to 3,754 members.
Approximately 5,000 letters were sent to patients who were in the high
risk categories with a 23.8% rate of filling ICS. For 2012, the ACC’s are
completing a questionnaire for each outreach in their Health Connect
documentation.
Productivity
In addition to tracking patient
interventions, the team has identified tasks that may contribute to patient
care directly or indirectly, other tasks that support or educate staff or
providers and miscellaneous tasks. A
tracking tool has been developed for them to monitor these items for 4-8
weeks. This information will then be
analyzed with the help of project coordinators to identify areas of opportunity
for improvement in efficiency, productivity and/or quality. Process mapping and other tools will be used
by the team to streamline work flows and standardize processes.
Value Proposition (Optional in 2012)
Literature supports KPCOs’ continued
focus on increased use of inhaled corticosteroids in the persistent asthma
population and interventions for those who are overusing rescue medication.
These are key factors for improved asthma control and translates to lower ED
and hospital utilization at cost savings.
By partnering with Pharmacy
Operations, the Governing Board is seeking to decrease asthma medication costs.
One strategy is the Dulera conversion and limits to the number of albuterol
canister equivalents that are dispensed to patients in an effort to decrease
overuse and medication waste.
The Governing Board is researching
use of spirometry to support step down therapy which will decrease medication
cost for both the patient and KPCO. A
Canadian cost effectiveness analysis found 28% of randomly selected
physician-diagnosed asthma patients were misdiagnosed. Of the patients who were
misdiagnosed, 71% were on an asthma medication. In comparing the ongoing cost
of asthma medication and the cost of secondary screening to confirm the
diagnosis, the average cost saving per 100 individuals screened was $35,141
(Pakhale et al., 2011). A similar study in the U.S. used spirometry to confirm
physician-diagnosed asthma in pediatric patients and found nearly one third of
patients were misdiagnosed (Talwar & Leo, 2007).
Increasing Access and
Support for Evidence-based Guidelines
KP’s Colorado Community Benefit group has funded the Colorado asthma toolkit and
training program. The Colorado Asthma Toolkit Program (CATP) has
successfully trained 100 primary care practices in Colorado, mostly in rural areas and all
providing care to medically underserved patients. The 6 hour training aims to increase
knowledge of evidence-based guidelines.
A free spirometer and training in its use and interpretation is provided
as well as an understanding of asthma care management strategies in underserved
communities to help facilitate patient-provider interactions. Led by National Jewish Health, the program
has been in existence since 2007 and has resulted in increased use of
spirometry, asthma action plans and inhaled corticosteroid medication.
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Kaiser Permanente Efforts Outside of Colorado
Increasing
Community-Based Care
Kaiser Permanente has also funded The Breathmobile® (BMo) a
project by the Prescott-Joseph
Center for Community Enhancement, Inc.
located in Northern
California and Southern California. BMo
is a mobile asthma clinic equipped with an exam room, intake and waiting area,
with capabilities to test for vital signs and allergen skin testing and
spirometry. The team consists of
certified allergists – a pediatrician, registered nurse or nurse practitioner,
respiratory technician and a patient service worker/driver. The majority of the staff speak Spanish and
all services are available in multiple languages (English/Spanish).
In Southern California, the BMo operates in the Los Angeles,
Orange, San Bernardino and Riverside counties, and is governed by a partnership
with the Asthma and Allergy Foundation of America, University of Southern
California (USC), some medical centers, and County School Districts. These
mobile asthma clinics can visit 22–23 school sites per month, seeing children
with asthma.
In the Bay area, the mobile asthma clinic serves various
counties and school districts as well as areas where gaps are seen in care.
During the first year of operation, the Northern
California team saw a significant reduction in asthma-related
emergency room (ER) visits and school absenteeism from the previous year. ER
visits dropped from 71 to 2, and absenteeism dropped from 101 to 7 among school
children seen within a 4-6 week time period.
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