Use of a Childhood Asthma Registry To Vanquish Bad Outcomes

1. Use of a Childhood Asthma RegistryTo Vanquish Bad Outcomes David A. Link, MD Chief, Department of Pediatrics Associate Professor of Pediatrics Harvard Medical School

3. Childhood Asthma: Planned CareVanquishing Bad Outcomes Service area: Cambridge, Somerville, and metro north Boston Estimated # of children with asthma in service area = 6,000 - 7,000 1,800 children with asthma at Cambridge Health Alliance (CHA) CHA is an integrated health system 3 hospitals more than 20 primary care practices Network Health � a statewide Medicaid managed health program Personnel in asthma program = 5 The Planned Care Asthma Program is integrated into primary care and linked in the community. Annual budget of asthma program � $250K This excludes salaries of primary care providers and care teams Initiated with grant from RWJF � awarded April 2002- March 2006 seeds planted in 2000 with NICHQ project

5. WHAT IS A REGISTRY? A large DATABASE with a number of critically important functionalities which 1) connects all components of healthcare system 2) makes current patient information readily available 3) provides evidence-based guideline for diagnosis and management 4) generates regular reports - by site by provider for system for sub-populations 5) enables performance improvement by the healthcare system so that children lead measurably healthier lives 6) enables providers to do what they meant to do all along - "the right thing"

6. System Elements Connected to thePatient/Family by the Registry (PARENTS) PROVIDERS/SITES SCHOOLS (SCHOOL NURSES) �HEALTHY HOMES� RESPIRATORY DEPARTMENT INFORMATION TECHNOLOGY DEPARTMENT PEDIATRIC DEPARTMENT QUALITY MANAGEMENT/PERFORMANCE IMPROVEMENT DEPT PHARMACY HEALTH DEPARTMENT (MUNICIPAL) ADMINISTRATION EVIDENCE-BASED GUIDELINES FROM LITERATURE

9. Key Health Outcome and Process Goals Health Outcome Goals Dramatically reduce asthma-related Emergency Room visits Dramatically reduce asthma-related Hospitalizations Process Goals All children with asthma will be in the Childhood Asthma Registry 100% of children with persistent asthma will be on Controller Medications 100% of children will receive an Asthma Action Plan

10. Childhood Asthma:Patients in the Asthma Registry Option 2Option 2

11. Childhood Asthma: Severity Classification Distribution Option 1Option 1

13. Key Health Outcomes for Children with Asthma in the Asthma Registry Reduction in asthma ED visits Reduction in asthma admissions

14. Childhood Asthma:% Patients with Asthma Admissions Option 2Option 2

15. Childhood Asthma:% Patients with Asthma ED Visits Option 2Option 2

16. Financing Primary funding source: Cambridge Health Alliance Part of Chronic Care Management Model Personnel IT (Registry and EMR) Performance based rewards Secondary funding source: Robert Wood Johnson Foundation

17. Financing Cost of the Asthma program/year = $250,000 Net savings to payer with intervention/year = $843,000 Cost of keeping our children active and in school = Priceless

18. Financing Childhood Asthma Program costs - $250,000 (costs for 2000 children) Information Technology $60K (Registry, EPIC, reports) Healthy Homes Assessment $25K Home Supplies $25K School RN $30K Physician Champion $10K Leadership $20K Program Director (PI) $30K Performance Incentives $50K these are costs assigned to the asthma program, but are not necessarily additional costs to CHA

19. Perverse payment incentives Funding issues: Misalignment of outcomes and reimbursement Decreased ED and Admissions = decreased reimbursement to Cambridge Health Alliance Proposed solutions: Align reimbursement with outcomes ! [Payers please note!]

20. On the Horizon Vision for asthma program over the next 5 years: Reduction in asthma admissions and ED visits for children continues steadily towards the lowest levels achievable across the community Lessons learned in the asthma program will be applied to other childhood health conditions with similar outcomes (e.g., ADHD) Reimbursement will be aligned with outcomes

21. RESOURCING AND SUSTAINABILITY It takes money to keep an asthmatic child healthy - External grant $ or Internal budget $ Registry needs care and feeding - IT Intervention project needs a champion (? RN/MD) Administration MUST partner with clinical leadership and IT for success. "Eternal vigilance is the price of Liberty" *- likewise for healthy asthmatic children. *Edward Everett Hale

22. LESSONS LEARNED CHANGE IS HARD. The road to Hell (bad asthma outcomes) is paved with good intentions To succeed you need - real time data buy-in by providers consensus on goals RESOURCES project champion - leadership relentless commitment collaboration - with many! What does not work - exhortation to do good (concede this to clergy) lack of system complicated systems non-collaboration "We have met the enemy, and they is us" - Pogo

24. On the Horizon Milestones that will help achieve the vision Reduction of asthma admissions < 0.5% per year Reduction of asthma ED visits < 2% per year Successful Spread Childhood asthma program to broader community Lessons from asthma program applied to other prevalent childhood health conditions Reimbursement 50% of net savings realized accrues to the program (50% of $840K = $420K)

25. Summary Key take home messages Outcomes! Registry tracking capability feedback on performance Build strong linkages in the community Test and learn at pilot sites before spread to all Engage patients/families

26. Essential Elements for Success Key take home messages Leadership commitment and goal-setting hold people accountable in reaching the goal Resource the micro-system Evidence-based care Educate and Train Link performance outcomes to rewards & recognition

27. Summary: Short version We have what we need to control this disease Provider is key: change behavior Pro-active care via Registry Bring all partners to the table Align payments with best practice PROGRAM IS READILY REPLICATED