The Asthma Disease Management Program

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1 The Asthma Disease Management Program Element A: GHC-SCW is committed to helping members, and their practitioners, manage chronic illness by providing tools and resources to empower members to take action to improve their health and chronic conditions. GHC-SCW is committed to helping members self-manage their asthma and stay healthy through a variety of educational opportunities. Through this program, routine asthma evaluations are performed and education is given to help members gain control of their asthma and keep it controlled throughout their life. Element B - Program Content GHC-SCW has designed the Asthma Management Program to educate members about asthma, teach members how to self-manage their disease, emphasize the importance of regular care, and provide support tools and screenings for disease management. The content of the Asthma program includes condition monitoring, patient adherence to treatment plans, consideration of other health conditions, lifestyle issues and ongoing screening for behavioral health concerns. Element B Factor 1 - Condition monitoring GHC monitors the following indicators for all members in the program: Assessment of Lung Function (spirometry, peak flow monitoring) Symptom Assessment History of Eacerbations Medication Review Quality of Life/Functional Status (Asthma Control Test) Asthma Action Plan Annual Flu Vaccination Tobacco Use/Eposure Members can access their future appointments, outstanding orders for labs and diagnostics, medication lists, lab results through MyChart SM - an interactive online patient health portal. Members who have MyChart SM accounts have access to disease management information outside of GHC via Healthwise, an interactive shared learning tool. All encounters with health educators are documented in the EMR. Element B2 - Adherence to treatment plans Members work with the Asthma Educator, Registered Nurse Health Educators, Tobacco Cessation Counselor, nursing staff and their primary care practitioner who monitor patient adherence in the following areas:

2 Modification of risk factors Medication compliance and appropriateness Tobacco cessation Adherence to an individualized Asthma Action Plan Self-Administration of Inhalants Adherence to the clinical practice guidelines for asthma Adherence to peak flow action plans Adherence to scheduling regular practitioner appointments Physical Activity Level Tobacco Cessation Element B3 - Medical and behavioral health comorbidities and other health conditions The Asthma registry is updated weekly and includes current lab, prescription and risk factor data. GHC- SCW identifies members with asthma who also have ASTHMA, hypertension, cardiovascular disease, hyperlipidemia and/or depression. GHC-SCW is committed to a collaborative approach to disease management, especially for those members with multiple co-morbidities. Practitioners are encouraged to refer members to health educators, complementary therapists as well as to outside resources. GHC- SCW is the only local practice group and HMO to offer complementary medicine to its members. Referrals are quick and easy using our EMR or internal phone system. Members have several opportunities for a collaborative management approach to asthma care that are included in their insurance coverage. The Asthma Educator and Nurse Health Educators complete initial assessments for all members to assess for learning style preferences, cognitive abilities, socio-economic factors, and physical limitations prior to creating the patient driven treatment plan Clinic staff (includes pharmacy, lab, radiology, CMA s, LPN s, RN s, RT s, practitioners) have access to the electronic medical record and can see the problem list for each member. GHC-SCW utilizes a care team approach for members which ensure collaboration for those members with multiple co-morbidities requiring more intensive care. Practitioners have the opportunity to refer patients to a variety of other practitioners to support the needs of the patient. Eamples of referrals are to Nurse Educators and/or Behavioral Health Specialists. Registered Dietitians also have access to the EMR and document their encounters with members, contributing to the plan of care. A case manager can also be utilized to ensure appropriate care for those with more comple needs.

3 Element B4 - Health Behaviors Behavior modification is an essential component of an ASTHMA program. The Asthma Educator works with GHC-SCW members who have asthma to provide personalized education, support and to promote healthy lifestyle options. Members may have individual or family counseling sessions as needed. Others within the GHC-SCW system that can support our members include Nurse Educators, Tobacco Cessation Counselor, and Registered Dietitians if needed. Members with asthma who have documented tobacco use also receive outreach mailings providing them with cessation resources. These resources include tobacco cessation classes, individual counseling sessions with a tobacco cessation counselor, and information on community resources such as the Wisconsin Quit Line. In addition, GHC-SCW covers tobacco cessation medications on its formulary at 100% for the majority of its members. For those members who participate in the annual Great American Smoke out campaign, there is no copay for smoking cessation medications and they get free counseling for one year from the Tobacco Cessation Counselor. Members are requested to complete a pre-physical General Medical History Form every time they schedule a physical. They are mailed this before the appointment and are to bring it with them for review during the appointment. In the survey are questions about health behaviors such as alcohol consumption, tobacco use, hobby hazards, wearing seat belts, helmets and preventive self- eams. Based on responses to these questions, practitioners can counsel on at risk behaviors. Element B5 - Psychosocial issues GHC-SCW has incorporated the Aniety Screening tool GAD-7 into its electronic health record. This is a seven item aniety questionnaire that has been developed and validated in a primary care setting. It is a patient self-assessment tool that can be done in the practitioners office jointly with the practitioner or done independently and reviewed at a follow-up appointment. The assessment can be accessed from the members EMR under Screening Tools. All Behavioral Health staff also has access to this screening tool in their member assessments. Element B6 - Depression screening GHC-SCW has incorporated the Depression Screening tool, PHQ-9 into its electronic health record. The Patient Health Questionnaire - Nine is the standard among scales for monitoring symptoms of depression. It has been etensively studied as a screening measure for major depression in primary care settings. It is a patient self-assessment tool that can be done in the practitioners office jointly with the practitioner or done independently and reviewed at a follow-up appointment. The assessment can be accessed from the members EMR under Screening Tools. All Behavioral Health staff also has access to this screening tool in their member assessments.

4 Element B7 - Information about the patient s condition provided to caregivers who have the patients consent Family members and/or caregivers who want or need access to the patient s medical record are required to have a Release of Information consent form signed by the patient, indicating they may have access to their records. Patients may choose to share electronic access to their medical record by sharing password information to their MyChart account with family members and/or caregivers. Family members and/or caregivers who are GHC-SCW members have access to Healthwise, a shared decision making tool and healthcare resource available via MyChart. Each member can also see a Health Educator who can help them create an Action Plan that can be shared with the member s family, and is available to the member s health care team. Element B8 - Encouraging patients to communicate with their practitioners about their health conditions and treatment. Members have the ability to utilize MyChart SM which is a patient portal within Epic, the electronic medical record software. They can send messages directly to their practitioner, nursing staff, pharmacy, or member services as well as make appointments, complete the asthma control test, see lab and other diagnostic results. All members are encouraged to sign up for MyChart SM. MyChart SM is now available on both the iphone and Droid smart phones making it convenient for members who may have these devices. Outreach letters are sent to members in the Asthma Registry to encourage them to contact their practitioner and stress the importance of communication. In addition, if a member completes a Health Risk Assessment (HRA) and based on their results, they are encouraged to follow up with their practitioner and can click on a link that takes them directly to scheduling an appointment Element B9 - Additional resources eternal to the organization All GHC-SCW members are encouraged to complete a Health Risk Assessment (HRA) that is available free of charge through their employer or via MyChart SM. Members also have access to Healthwise, a shared decision making tool and health resource that is also available via MyChart SM. Practitioners can print information from Healthwise during the visit and give it to members to take home with them. Element C: Identifying Members for DM Programs GHC-SCW uses the following data sources to identify members for the ASTHMA management program: Claims or encounter data

5 Prescription data Problem list in the electronic medical record (AE updates PL with communication to PCP) Health risk assessment results Data collected through the utilization management or care management process Member referral Practitioner referral Clinical Care Management referral GHC-SCW does not use continuous enrollment criteria for identifying members. The Asthma registry updates weekly. Element D: Frequency of Member Identification The GHC-SCW Asthma disease registry updates weekly. (See Element C) In addition, the disease registry is run monthly to look for members who have outstanding asthma identifiers such as increased use of short acting beta agonist medication, decreased ACT score, or increased emergency department admissions, oral steroids. The asthma educator uses the registry to stratify outreach to our asthma members. Element E: Providing Members with Information How to use services - GHC-SCW sends a letter and a brochure titled Asthma Zone to eligible members annually. These highlight the importance of managing asthma and the resources available both internally and eternally along with contact information. How members become eligible to participate - Newly diagnosed members are sent a letter and a brochure Asthma Zone. The letter informs them that they are now part of the Asthma Management Program and the brochure highlights the importance of managing Asthma and the resources available both internally and eternally along with contact information. How to opt in or out - The letter sent to members eplains how they can opt out of the outreach associated with being on the Asthma registry. When members contact GHC-SCW QM staff to opt out, they are informed that they will be contacted in one year to follow up to see if they still wish to be ecluded from outreach efforts. Element F: Interventions based on Assessment GHC-SCW provides interventions for asthma members based on stratification. Different interventions are provided for members based on severity of illness, participation in completion of testing and eaminations as well as the results of those tests. Tier 1: All members with Asthma-targets those with well controlled asthma or intermittent asthma Interventions o Asthma Disease Management Program letter & brochure to be mailed to all asthmatic members annually

6 o o Annual flu shot reminder Access to Asthma Educator to help develop comprehensive plan of care including, but not limited to: Asthma assessment Spirometry Medication evaluation & education Trigger assessment Asthma education Environmental control plan Action plan development Tier 2: Includes members who have had recent Urgent Care visits, Emergency Room visits, and Hospitalizations for asthma. o Care includes all aspects of Tier 1 care, with the addition of aggressive outreach to ensure clinic follow up with a provider or Asthma Educator is obtained within 14 days of asthma event. Asthma Educator task done weekly. o Ongoing appointments, GHCMyChart, or letter follow up after interventions Type of Report Daily Weekly Monthly Quarterly Semi-Annual Annual Urgent Care Emergency Room Hospitalizations HEDIS Pharmacy Oral Steroids Member mail out Tier 3: Case Management o Includes members referred to Case Management by providers o Includes those who meet the following criteria: Two or more hospitalizations within a 6 month period Two or more specialists involved in the patient s care Three or more emergency room visits within a 6 month period Two or more co-morbidities Acute medical issues Comple coordination of care issues One asthma ER visit and one asthma hospitalization within a 6 month period Element G: Eligible Member Active Participation GHC-SCW annually reports the member participation rate to the Clinical and Service Quality Committee (CSQC).

7 Element H: Informing and Educating Practitioners Instructions on how to use the Asthma Management Program Practitioners are informed of the Asthma Management Program in the following ways: The Practitioner Handbook contains a copy of the Asthma Management Program description Practitioners receive a copy of the Asthma Management Program brochure Newly hired practitioners receive a brief overview from the HE Manager They are notified when outreach is done on members There are updates in organizational newsletters Health Maintenance Modifiers for labs and screening Best Practice Alerts (BPA s) How the organization works with practitioners patients in the program Practitioners have access to see an encounter in Chart Review for all contacts the member has with health educators, care management and case management. They can communicate using electronic messaging and/or in person. Element I: Integrating Member Information GHC-SCW utilizes a common electronic medical record (i.e. EpicCare) which allows for integration of member information for continuity of care. This information is etracted into a variety of reporting tools and reports utilized by GHC-SCW to focus on this member population to ensure focused and relevant interventions. This then allows for comprehensive resources for the following departments: health information line, case management program, utilization management program, quality management outreach program and health education. GHC-SCW utilizes two other EMR resources to integrate member information. Care Link allows staff to see the patients medical record if they have been seen at a partnering facility utilizing Epic. In addition, GHC-SCW participates in Care Everywhere, another tool developed by Epic to ensure access to patient information while they are traveling and out of the service area. Element J: Satisfaction with Disease Management All GHC-SCW members in the Asthma registry are surveyed for feedback on their thoughts and eperiences of the program. Additionally, those members who utilize care management are surveyed through the PAM and Comple Case Management survey tools. Randomly selected GHC-SCW members who had a visit with their practitioner, health education, complementary medicine, physical and/or

8 occupational therapy are sent a Press Ganey survey. Random samplings of members are also sent a CAHPS survey as part of GHC-SCW s accreditation process. All complaints are managed through Member Services per protocol. Element K: Measuring Effectiveness HEDIS results are analyzed monthly to look for trends or changes in compliance. GHC-SCW s Quality Management Team along with other stakeholders in the organization, actively look for QI projects throughout the year. These projects look at a variety of issues and target areas where a measure is below the 50 th percentile as well as ensuring measures stay above the 90 th and 95 th percentile. The projects will: 1) Address a relevant process or outcome; 2) Produce a quantitative result; 3) Be population based; 4) Have valid data and methodology; 5) Analysis with comparison to benchmarks and goals - use the HEDIS national 90 th percentile levels as goals for the Asthma measures. The Quality Management Department reviews and reports the results annually and compares them to these goals and to past performance.

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