Children's Asthma Management: Partnering to Improve Clinical Training

Asthma is the most prevalent chronic illness among children and the leading cause of school absenteeism.¹ It is also a costly condition, with total annual spending for children’s asthma-related hospital visits coming in at over $300 million.² Even among children with health care coverage and access to primary care, managing the disease to prevent asthma emergencies has proven difficult.³

The Enhancing Care for Children with Asthma Project, a partnership between Health Care Service Corporation (HCSC) and the American Lung Association of the Upper Midwest (ALAUM), aims to improve health outcomes for children with asthma by supporting the implementation of nationally recognized asthma-care guidelines at primary care health centers with high-risk patients, including physician offices, federally qualified community health centers, school-based clinics and other primary care clinics.

Establishing Collective Focus

The asthma project was developed as a part of HCSC’s signature health and wellness initiative, Healthy Kids, Healthy Families® (HKHF). This initiative began in 2011 in an effort to leverage the strong ideas and relationships of HCSC’s Blue Cross and Blue Shield health plans in Illinois, New Mexico, Oklahoma and Texas. Each state health plan has a history of awarding community-based grants to local population health programs with similar objectives. Healthy Kids, Healthy Families introduced a new structure for grant-making that enables the health plans to band together, share best practices and expand successful partnerships across all four states to maximize impact.

Through Healthy Kids, Healthy Families, the health plans in each of the four states award grants on a local level in four pillar focus areas:

• nutrition
• physical activity
• managing and preventing disease
• supporting safe environments

HCSC also selects a key nonprofit partner(s) in each focus area to function as a pillar partner, working across the four states to implement a consistent program. These partners and programs are selected for their ability to implement sustainable, measurable programs with a strong emphasis on outcomes.

While HKHF initially launched with the goal of improving the health and wellness of over one million children within three years, the initiative has reached well over seven million children in that period and is no longer a time-bound initiative. Rather, HKHF is now part of HCSC’s ongoing commitment to improving community health and is being expanded to include HCSC’s newest health plan, Blue Cross and Blue Shield of Montana.

Follow the Data Trail

In evaluating resource distribution from the first year of Healthy Kids, Healthy Families, HCSC staff saw that programs in the disease prevention and management pillar had focused primarily on prevention through the activities of the plans’ mobile health vans. They decided to spur project diversity in that focus area by looking for a new pillar partner to work specifically on disease management. By looking at claims data to identify patterns of high spending around chronic diseases, they identified several key issues that would benefit from better management and reached out to nonprofits that had existing programs to address those needs.

Ultimately HCSC selected the American Lung Association of the Upper Midwest as its pillar partner in disease management. In their claims review, HCSC staff noted an outsized number of pediatric asthma-related emergency department visits, representing a problem that is not only costly but also traumatic for children and their families. ALAUM brought to the table an evidence-based model for helping providers integrate recommendations for pediatric asthma care into primary care practice. The model is based on the National Asthma Education Prevention Program developed by the National Heart, Lung, and Blood Institute. ALAUM also demonstrated experience working closely with primary care providers and a willingness to collaborate with American Lung Association (ALA) chapters in Illinois, New Mexico, Oklahoma and Texas to bring the model to all four states.

Reaching Providers

To introduce the model to providers with high-risk patients, ALAUM engaged four clinical and public health professionals to serve as state project managers. Project managers used claims data from HCSC to target areas of greatest need and recruit health centers to participate in a year of training to help improve asthma care practices. Nearly 70 health centers were recruited into these cohorts over the three-year term of the project.

Each month staff from all participating health centers assembled with the state project manager to learn about implementing one new guideline. The guidelines address all stages of care from intake to outpatient, and all levels of clinic staff were involved in the training. In addition, ALAUM and its ALA partners in each state held monthly technical assistance calls with the health centers and offered individual problem-solving help as needed.

The response from health centers has been overwhelmingly positive. Many providers saw the need for better asthma management among their patients but did not have the time or resources to evaluate institutional problems and develop processes for introducing guidelines-based care. ALAUM and its partners provided the operational guidance that health centers needed to implement best practices in pediatric asthma management.

The provider response was encouraging for HCSC. Although initially concerned about targeting contracted providers, HCSC found that ALAUM’s role as point of contact with the health centers alleviated any potential unease. Moreover, feedback from the health centers showed that they saw the project as a value-added service from the health plan—one that improves the health of their patients and the strength of their practices. HCSC and ALAUM representatives believe this positive response stems from the project’s focus not on past clinical outcomes but on moving forward with effective tools and strategies.

Gauging the Possibilities

Across three years and 69 clinics, the Enhancing Care for Children with Asthma Project has improved asthma management for an estimated 480,000 children with asthma and their parents. Ongoing evaluation of the project has employed process measures, chart reviews and claims analysis to track progress on short, intermediate and long-term outcomes. Case studies from 23 year-one cohorts indicate improvement across all quality indicators from baseline to twelve months after intervention. Additionally, improvement continued for almost all quality measures at 18 months after invention as well, indicating long-term, sustainable change within the clinical setting (Figure 1).

The project also has the potential to move beyond the four original states. ALAUM’s training model is seamlessly reproducible and easily modified based on local needs and resources. The ALA of New Mexico, for example, is working with the University of New Mexico on a monthly webinar series based on the model, scaling it down to improve accessibility. The ALA’s nationwide presence means similar partnerships for improving pediatric asthma management in other states are also well within reach.