By Jason Bramwell  

With a social ROI of 1.73, the hospital's Community Asthma Initiative is devoting time and money to successfully keeping children with asthma out of the ED and in school-largely through key partnerships with families, primary care providers, schools, and community organizations.

When you think about the important responsibilities of a nurse case manager, integrated pest management probably isn't the first thing that comes to mind. But for nurse case managers in the Community Asthma Initiative (CAI) at Children's Hospital Boston, visiting the homes of inner-city children with asthma and educating parents on ways to prevent mice and other pests from triggering asthma attacks is a crucial part of the job.

"When we saw the level of pest problems in some of the homes we went into, we quickly realized we needed to become pest management experts," says Susan Sommer, RNC, NP, nurse case manager for CAI.

During comprehensive 1 1/2-hour home visits, nurse case managers and community health workers root out and demonstrate how to block pest entryways and give families HEPA vacuum cleaners, bedding encasements, plastic storage bins, copper gauze, and other products to help rid homes of pests, mold, dust, and other asthma triggers.

"We spend a lot of money on supplies," says Sommer. "But when you compare the cost of a $100 to $150 vacuum to a month's worth of inhaled steroids, which can cost $200 to $300, then a vacuum is a great investment."

The lengthy home visits also allow time for in-depth, personalized evaluations and education about asthma prevention and treatment.

The home visits are just one aspect of a year-long partnership that CAI forms with children and their families-as well as primary care providers, schools, and various community organizations-to ensure patients get the right interventions, from inhaled steroids to exercise. The nurse case managers even work with city home inspectors to ensure landlords fix leaking pipes and other environmental hazards.

The time and money invested in CAI-which has served approximately 700 children since it began in October 2005-have paid off. The program's social ROI is as high as 1.73 when all the successful outcomes-including missed school and parental work days-are taken into account, says Sommer. After 12 months in the program, 259 children and their families showed:

  • A 64 percent reduction in emergency department (ED) visits
  • A 79 percent reduction in repeat hospitalizations
  • A 41 percent reduction in missed school days
  • A 46 percent reduction in missed work days
  • A 56 percent increase in the number of children with asthma action plans

Partnering with Primary Care

CAI specifically targets children from three Boston neighborhoods-Roxbury, Jamaica Plain, and Dorchester-because these districts are close to Children's Hospital and have very high childhood asthma rates. When children from these neighborhoods are admitted to Children's Hospital or arrive in the hospital's ED, a CAI nurse case manager and a community health worker encourage the child and family to enroll in the CAI program. CAI has approximately 175 new enrollments each year.

One key strategy in improving asthma outcomes for these children: strong ties with local community health centers and primary care providers (PCPs). Half of the patients in CAI receive primary care from one of Children's Hospital's three clinics, while the other half are distributed among 10 community health centers.

When CAI first started, staff-which includes a physician director, two nurse case managers, an asthma educator, and an administrative support person-quickly learned the importance of good communication with PCPs.

"When we started doing the initial outreach to patients, some of the clinics were a little confused: 'Who are these people visiting our patients in their homes?'" says Sommer, who adds that the two nurse case managers went to the clinics and introduced the program. "Now the PCPs are more than happy to have us as part of the team, and we communicate back and forth about patients," she adds.

After a child enrolls in CAI, a nurse case manager or community health worker conducts an initial home visit in which tailored asthma education and a home environmental assessment are provided. The nurse case manager then contacts the child's PCP, and they work together to assess what the child and family need to manage the child's asthma.

The child is then referred to or provided with the necessary services, which include the following:

  • Follow-up visits with the PCP to continue to monitor asthma control and provide an individualized asthma action plan to be shared with the family, school nurse, or other caregivers, such as childcare providers
  • Referrals-as needed-to Children's Hospital allergists for allergy testing and/or other specialists for expert evaluations and care
  • Referrals to other community resources, such as the Boston Inspectional Services Department and smoking cessation programs
  • Advocacy assistance with landlords or housing authorities
  • Assistance with enrollment in health insurance, if needed
  • A resource guide to educational, support, and physical activity programs in the family's neighborhood

CAI nurse case managers and community health workers also arrange for one to two follow-up home visits-or more as needed-with patients and their families in the program to review asthma management techniques, identify progress and barriers, and provide referrals to any additional needed services.

Patient information is exchanged between CAI and the PCPs via an electronic health record, secure email system, or by phone. "Children's also launched an asthma registry-thus far available to all Children's Hospital providers-that really condenses a lot of information about the asthma patient's history, allergies, pulmonary function, tests, and whether they had a home visit," says Sommer.

Collaborating with Community Agencies

The CAI program is not alone in trying to improve asthma outcomes across Boston. In fact, a number of other Boston agencies, organizations, and providers-including the Boston Asthma Initiative and the Boston Public Health Commission-have been active for more than a decade in providing asthma education and home visit programs.

Wisely, CAI formed partnerships with these other programs to help patients get needed services.

Pest management and patient advocacy. CAI counts on the Boston Inspectional Services Department for enforcement of the state sanitary code, when landlords won't voluntarily exterminate pests or fix deteriorating apartment buildings.

"Sometimes we'll advocate directly with landlords and be successful," says Sommer. "But a lot of times inspectional services has the teeth to really get landlords to do the right thing. Families are sometimes afraid to report the conditions, but they are actually more protected if they go through inspectional services because then it's illegal for landlords to harass them or retaliate in any way."

"The Boston Public Health Commission really helped guide us the first year around the kinds of integrated pest management supplies we should provide," continues Sommer. "They also directed us to a pest control expert who trained us on integrated pest management techniques."

Standardized asthma home visits. In 2008, the Boston Public Health Commission created a working group that brought together the different city agencies/organizations involved in asthma-related home visits, including CAI, Boston Medical Center, Tufts Medical Center, and various city agencies/referring providers. According to the commission, the partnership aims to:

  • Identify and standardize best practices for asthma home visits in Boston, including a standard protocol and common educational and data collection tools
  • Link clinical providers to home service providers through a centralized referral process, allowing access to linguistically and culturally competent home visitors throughout the city
  • Facilitate data sharing and evaluation
  • Negotiate as single body with payers for insurance reimbursement

Payment sources. "A big communitywide initiative is around finding a payment model that covers the cost of comprehensive asthma care, including home visits," says Sommer.

Approximately 70 percent of families in the CAI program are on Medicaid, which does not currently pay for home visits. Many need help covering the cost of pest management materials and supplies to manage allergens in the home, such as HEPA vacuum cleaners and allergen-proof bedding encasings.

Right now, these extra expenses are funded in part by the hospital and government grants, as well as private donations.

But the hospital-and other asthma providers across Massachusetts-are counting on an alternative payment arrangement with MassHealth, the state's Medicaid program. MassHealth plans to roll out a pilot bundled payment program for high-risk pediatric asthma patients in the near future.

In a recent State Health Watch article, MassHealth's chief medical officer, David Polakoff, MD, says the bundled payment will be large enough to cover the cost of traditionally covered asthma services (such as office visits and spirometry testing), as well as home visits, which are not typically paid for by MassHealth. "We are giving them a sum of money to care for all aspects of one disease in one patient," he said ("MassHealth's Bundled Payment Approach: A 'Baby Step' Toward Broader Reform," State Health Watch, April 2011).

Being Flexible

"CAI is really a qualitative leap forward for the hospital in terms of asthma care in the community and exemplifies its commitment to community health," says Sommer.

Accomplishing this community mission requires collaboration and partnership with families, other providers, and many other stakeholders, she says. "There's a lot at stake to figure out how we can all partner together, and you have to have humility to do so."

"Being flexible has been a really key piece for us," continues Sommer. "Otherwise, we wouldn't have been effective in addressing environmental issues, sharing best practices, and having an approach that is culturally and linguistically competent to serve our population well," she says.


Jason Bramwell is associate editor of newsletters & forums, HFMA (jbramwell@hfma.org).

Interviewed for this article: Susan Sommer, RNC, NP, nurse case manager, Community Asthma Initiative, Children's Hospital Boston (susan.sommer@childrens.harvard.edu).
 

Publication Date: Wednesday, June 22, 2011