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CMS Innovation Grant CT Asthma Programs PCMH Committee 12/11/13

Little Air Home. Community Asthma Integrated Resources. CMS Innovation Grant CT Asthma Programs PCMH Committee 12/11/13. Michael Corjulo APRN, CPNP, AE-C Veronica Mansfield APRN, AE-C, CCM. CMS Health Care Innovation Challenge .

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CMS Innovation Grant CT Asthma Programs PCMH Committee 12/11/13

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  1. Little Air Home Community AsthmaIntegrated Resources CMS Innovation Grant CT Asthma ProgramsPCMH Committee 12/11/13 Michael Corjulo APRN, CPNP, AE-C Veronica Mansfield APRN, AE-C, CCM

  2. CMS Health Care Innovation Challenge $1 billion to implement the most compelling new ideas for delivering the three-part aim: • Improved care • Better health • Lower costs

  3. Asthma Regional Council of New England: AHealth Resources in Action Program HRiA Mission: To help people live healthier lives and create healthy communities through prevention, health promotion, policy and research. ARC’s Mission: To reduce the impact of asthma across New England, through collaborations of health, housing, education, and environmental organizations with particular focus on the contribution of schools, homes, and communities to the disease and with attention to its disproportionate impact on populations at greatest risk.

  4. Why a New Model of Asthma Care?

  5. Chronic Disease Management Care Coordination Community & Culture Pt Education

  6. Medical Home Support

  7. The Chronic Disease Management Safety Net • Shared Community Resources • Accessible to Medical Homes • Regionally-based • Shift costs from acute care • Not limited by individual payer sources • Address complex chronic disease issues • Pt/Family education and self-management training • Care coordination • Home / environmental assessments and interventions • Teams of specialty trained health care providers • Asthma and Diabetes Educators • Community Health Workers

  8. New England Asthma Innovation Collaborative Project Components: • Service delivery expansion • Workforce development • AE-C • CHW (Bilingual) • Committed Medicaid payers • Payer and Provider Learners Community

  9. NEAIC Partners: Health Care Providers MA: • Children’s Hospital Boston • Boston Medical Center • Baystate Children’s Hospital RI: • RI/Hasbro Hospital • St. Joseph’s Health Services CT: • Middlesex Hospital (greater Middlesex region) • Children’s Medical Group (greater New Haven region) VT: • Rutland Regional Medical Center

  10. NEAIC Partners: Health Care Payers MA: • Neighborhood Health Plan • BMC HealthNet • Health New England RI: • Neighborhood Health Plan, RI CT: • CT Department of Social Services\ASO Other potential partners: MassHealth, Dept of Vermont Health Access, Aetna, Network Health, United Health Care

  11. CT Sites • CAiR (Community Asthma Integrated Resources) • Start-up program • Childrens Medical Group (Hamden) • Covers Greater New Haven Region • www.pedicair.org • Little Air Home • Expansion of Little Air Program • Middlesex Hospital Center for Chronic Care Management • Covers Middlesex County • http://middlesexhospital.org/our-services/hospital-services/chronic-care-management/asthma-management

  12. Who Qualifies?

  13. Teams • Team Leaders • PNPs who are AE-C • RNs • Supervise CHWs • Provide Asthma Education • CHWs • Bilingual English and Spanish • MA CHW training program • Asthma specific training • Motivational Interviewing training

  14. What Makes This Different? • Fundamental focus on supporting the Medical Home • Think of us like an extension of your practice • NCQA/PCMH, Easy Breathing, NHCMG • Merge clinical expertise with cultural competence • We have the time and resources to address barriers to good asthma control • We do what you want and not what you don’t • Environmental Training and Supplies • Integrated Pest Management • Real-time or prompt communication • Unique reports

  15. How This Works • Review Referral • Make appt for one-time clinic visit (1 ½ - 2 hrs) • Detailed history and assessment • Initiate comprehensive education • Report concerns/recommendations to PCP • HV 1 • Environmental assessment • HV 2 • Deliver supplies and demonstrate use • HV 3 • Optimize self-management capacity

  16. Current Numbers

  17. Lessons Learned (so far) • Marketing a new program is a lot of work • Diplomatic persistence pays off • Providers • Families • Most families welcome the home visits (& supplies) • Although some are very challenging • Parents have been extremely appreciative • Providers are finding us easy to work with ……outcomes

  18. Home Little Airs Home

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