Name of Practice: Asthma Health Education by Louisiana Pharmacists (HELP) Initiative Abstract Asthma affects approximately 7 percent of the Louisiana Medicaid/Louisiana Children's Health Insurance Program (LaCHIP) population, with total asthma-specific annual expenditures reaching over 97 million dollars according to the most recent Louisiana Medicaid/LaCHIP claims data from 2007. Asthma HELP, a telephone-based disease management program for Louisiana Medicaid/LaCHIP recipients diagnosed with asthma, was implemented by the State of Louisiana to provide asthma education through telephone counseling and age-appropriate written materials in an effort to provide recipients with the knowledge necessary to manage their asthma symptoms. Preliminary outcome data indicate that Asthma HELP enrollees had a 47 percent decrease in the number of emergency department visits during the 12 months following enrollment as compared to the 12 months prior to enrollment. Problem: Asthma, an inflammatory disease of the lungs and one of the leading chronic conditions in the United States, results in approximately 5,000 deaths annually, according to the "Trends in Asthma Morbidity and Mortality Report" published by the American Lung Association in May 2005. The Centers for Disease Control and Prevention reports that one-quarter of all emergency visits in the U.S. each year are due to asthma. Louisiana Medicaid/LaCHIP administrative claims data indicate that more than 83,000 Louisiana Medicaid/LaCHIP recipients had at least one paid claim with a diagnosis of asthma during 2007. The prevalence of asthma in the general population has increased dramatically in recent years, with a 75 percent increase from 1980 to 1994. The prevalence of asthma among children under the age of five increased by more than twice that rate, or 160 percent, during the same time period. Asthma was chosen for a disease management intervention because of the prevalence of asthma among Louisiana Medicaid/LaCHIP recipients, high utilization of asthma-related services, and research indicating that asthma education improves health outcomes for patients diagnosed with asthma. Approach: Asthma HELP is a telephone-based disease management program designed to promote positive health outcomes for Louisiana Medicaid/LaCHIP recipients diagnosed with asthma. With authorization and support from the Louisiana Department of Health and Hospitals Medicaid Pharmacy Benefits Management Program, the Asthma HELP program was developed and implemented through a collaborative effort of pharmacists, health data analysts, and administrative personnel from the University of Louisiana at Monroe Office of Outcomes Research and Evaluation (OORE). The initiative was considered a value-added service of the existing contractual relationship between the two organizations. All components of the program, including brochures, action plans, and supportive software, were initially based on the National Heart, Lung, and Blood Institute Expert Panel Report 2 (EPR-2): Guidelines for the Diagnosis and Management of Asthma and were subsequently updated to reflect the most current version. Asthma HELP was implemented by the State Department of Health and Hospitals as a pilot study in April 2005 in the southeastern parishes of Louisiana, targeting recipients 13 years of age and older. Enrollment was temporarily placed on hold in August 2005 due to Hurricanes Katrina and Rita. Because of the increase in respiratory hazards, such as elevated mold concentrations and dust exposure, and widespread relocation of the original enrollees in the aftermath of the two hurricanes, the program was expanded statewide in January 2006 to include recipients of all ages. Although all ages are eligible, approximately 70 percent of Asthma HELP enrollees are children; of these children, 13 percent are enrolled in the Louisiana Children's Health Insurance Program (LaCHIP). Recipients who have had two or more asthma-related emergency department visits within a six-month period are targeted for enrollment. However, any Louisiana Medicaid/LaCHIP recipient diagnosed with asthma is eligible for participation. Recipients may also be referred by their physicians. Each recipient who chooses to enroll is assigned to a specific pharmacist certified in asthma education by the National Asthma Educator Certification Board (NAECB). One pharmacist is assigned to the recipient throughout enrollment to promote a trusting relationship, a vital component of the program's success. Enrollees are offered the following services and items: Telephone counseling sessions monthly, or more frequently if needed, on various asthma-related topics, such as triggers, types of asthma medications, management of asthma exacerbations, and action plans Educational materials, such as brochures, games, puzzles, and children's books, developed by OORE staff or obtained through supplemental donations from pharmaceutical companies and various asthma-related organizations Instructions for use of various asthma-related devices, such as nebulizers, peak flow meters, and metered-dose inhalers Communication with the physician on behalf of the patient, on matters such as refill requests for controller medications and requests for development of action plans Toll-free help line where asthma educators are available 6 days a week, 10 hours per day Upon receiving feedback from Asthma HELP enrollees, it became evident that there was a need to consider the patient's level of asthma knowledge at the time of enrollment. A uniform educational process has been discarded in favor of a more individualized approach that takes into account the severity of the patient's asthma, knowledge of the disease, and ability to manage his or her symptoms. After an initial assessment, the pharmacist determines the order in which topics are discussed, and spends as much time as is necessary to ensure the enrollee fully understands the topic. No formal instrumentation is utilized to assess initial patient knowledge; a determination is made based upon patient response and feedback regarding the educational material. Following expansion of the program to include children of all ages, another issue was encountered. Considering the fact that the ultimate responsibility of the child's healthcare falls upon the parent/guardian, the initial intent was to speak with the parent/guardian exclusively when offering asthma education. However, based upon caregivers' comments, it soon became clear that children are often very eager to learn about their condition and ways to better manage their symptoms. As a result, an opportunity for the child to be included in the educational process has now been incorporated. With adequate consideration of the child's age and level of understanding and after permission from the parent/guardian has been obtained, the child can be addressed directly during educational sessions.
Asthma HELP and Louisiana Medicaid/CommunityCARE, a comprehensive health delivery system linking Medicaid/LaCHIP recipients to primary care physicians, entered into a collaborative effort to educate providers about the Asthma HELP program and asthma treatment protocols. CommunityCARE nurses conduct chart reviews and offer providers Asthma HELP materials - brochures, action plan templates, informational flyers, and forms - in an effort to encourage patient referrals to the program. Continuing education credits (CEU) for asthma care management are offered to nurses working in provider offices who participate in the CommunityCARE educational sessions. Results: Program outcomes were measured using a study group that met each of the following inclusion criteria: Continuous eligibility for Louisiana Medicaid/LaCHIP for 12 months pre- and post-enrollment. Enrollment in only the Louisiana Medicaid/LaCHIP program for 12 months pre- and post-program enrollment. Medicare enrollees were not included. A six month lag period for both pre- and post-enrollment to allow adequate time for claim processing and claim availability to ensure a complete claims history. Hurricanes Katrina/Rita parishes excluded. An initial outcomes study evaluating Asthma HELP indicated that total asthma-related costs per person dropped by 21 percent when comparing 12 months pre-enrollment to 12 months post-enrollment. Also, enrollees experienced a 47 percent decrease in asthma-related emergency room visits and a 46 percent decrease in asthma-related hospitalizations. If we look specifically at the impact on the children enrolled in the program, results indicate the same downward trend in asthma-related costs, emergency room visits, and hospitalizations. For example, when comparing 12 months pre-enrollment to 12 months post-enrollment, there was a 23 percent decrease in total asthma-related costs per child. Also, the children experienced a 56 percent decrease in asthma-related emergency room visits and a 30 percent decrease in asthma-related hospitalizations. In addition to cost savings, the most beneficial aspect of the program is the positive impact on the lives of the enrollees. For example, Sherry, a 15-year-old high school student, loved sports but was unable to participate due to the debilitating asthma symptoms she experienced on a regular basis. After enrollment, her asthma educator taught her the importance of her controller medication and instructed her on proper technique. As a result, her asthma is now under control and she plays basketball every day after school. Another enrollee, Betty, aged 55, had been to the emergency room 17 times during the year prior to enrollment and was unable to work due to her symptoms. Eight months after enrolling, she experienced an improvement in her symptoms and was able to have a six month period free of emergency room visits. She is now able to do volunteer work. These patients have been empowered to take the necessary steps to manage their asthma symptoms and return to the activities they enjoy. Future plans: Continued growth of enrollment through physician referrals, in addition to targeted recipients Production and distribution of an instructional video, demonstrating proper technique for various asthma devices, to all enrollees Educational outreach to increase asthma awareness in settings such as school-based educational programs and health fairs Application of predictive modeling techniques to identify recipients for potential enrollment Further information: Contact:
Melissa Dear, RPh, AE-C
Director, Asthma HELP
Office of Outcomes Research and Evaluation
University of Louisiana at Monroe
318-410-4360
dear@ulm.edu Sandra Blake, PhD
Director, Office of Outcomes Research and Evaluation
University of Louisiana at Monroe
318-410-4359
blake@ulm.edu M.J. Terrebonne, PD
Director, Louisiana Medicaid/LaCHIP Pharmacy Benefits Management Program
Louisiana Department of Health and Hospitals
225-342-9768
mterrebo@dhh.la.gov Mary Scorsone, RN, BSN
Community CARE Region III
985-449-4722
mscorson@dhh.la.gov
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