SEfft
United States
Environmental Protection
Agency
IMPLEMENTING AN ASTHMA
HOME VISIT PROGRAM:
r
10 Steps To Help
Health Plans
Get Started
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This document shares the experiences of seven health care organizations
that offer asthma home visit programs. It is intended to provide health
insurance plans with general guidelines—based on the experience of other
health care organizations—on what to consider when incorporating a home
visit program into an existing asthma management program. The content in
this document does not represent official EPA policy or guidance.
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The U.S. Environmental Protection Agency (EPA) has
launched a nationwide asthma public education and
prevention program. The goal of this program is to
make the public and the medical community more
aware of environmental asthma triggers and simple
ways to reduce exposure to these triggers, especially
at home.
Along with proper medical treatment, effective
management of environmental triggers in the home
can reduce the number and severity of an individual's
asthma episodes. This reduction may result in fewer
emergency room visits and hospitalizations, increasing
a person's quality of life and reducing health plans'
cost of care.
Home visits are one way to give enrollees the tools
they need to address their asthma effectively as part
of a comprehensive disease management program
incorporating medical and environmental management
techniques. EPA developed this guide with input from
seven health care organizations that offer asthma
home visits as part of their comprehensive asthma
management programs. It incorporates their
experiences establishing and operating home visit
programs, and reflects their belief in the value, both
to the enrollees and to the health insurer, of such
programs.
HOW TO USE THIS GUIDE
This guide should be used
primarily by health plans that have
established asthma management
programs. It offers step-by-step
instructions on how to implement
an asthma home visit program
with a particular emphasis on
environmental risk factor
management. The guide is
organized around 10 essential
steps in the implementation
process, from program inception
to program evaluation:
1. Learn about the benefits of
a home visit program as
part of a traditional asthma
disease management
program.
2. Get your health plan's
leadership to buy into the
program.
3. Form an implementation
team.
4. Develop the structure of
the home visit program.
5. Determine which enrollees
will be visited at home.
6. Develop outreach strategies.
7. Determine what outcomes
and outputs will be
measured and how they
will be measured.
8. Develop tools and forms
and train staff.
9. Form relationships or
partnerships with community
asthma organizations.
10. Implement the program and
track its results.
The guide also provides
references to additional
resources you may want to
consult. These resources provide
information on asthma, asthma
disease management, and asthma
home visit programs.
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Contents
Program Overview
Prevalence and Costs of Asthma
Environmental Risk Factor Management
Asthma Home Visits .
1
1
1
3
10 Steps to Help Health Plans Get Started 4
Learn about the benefits of a home visit program as part of
a traditional asthma disease management program 4
Get your health plan's leadership to buy into
the program
Form an implementation team
Develop the structure of the home
visit program
Determine which enrollees will be visited at home
5
5
6
9
Develop outreach strategies 10
Determine what outcomes and outputs will be
measured and how they will be measured 11
Develop tools and forms and train staff 12
Form relationships or partnerships with
community asthma organizations 13
Implement the program and track its results 14
A Final Note . 14
Asthma Resources . 15
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Program Overview
Prevalence and Costs
of Asthma
The Centers for Disease Control and
Prevention (CDC) estimate that more
than 20 million people in the United
States have asthma, including 6.1 million
children.1 Asthma is responsible for
nearly 500,000 hospitalizations, 1.9
million emergency department visits, and
more than 4,000 deaths annually. In the
United States, members of certain racial
and ethnic groups are at greater risk of
suffering and dying from asthma. Health
care costs ($11.5 billion) and indirect
costs (such as lost productivity from
missed school and work days) bring the
total cost of asthma to $16.1 billion
annually.2
Although the reason for the increasing
prevalence of asthma cases is not well
understood, the factors that cause
asthma episodes—and the means of
preventing and controlling episodes—are
well defined. To serve their enrollees
better, many health plans have developed
chronic disease management programs
for the treatment of asthma. In fact,
according to a 2002 survey by America's
Health Insurance Plans (AHIP), 83
percent of health maintenance
organizations (HMOs) and point of
service (POS) plans report having a
disease management program for
asthma.3
Health plans continue to adopt asthma
disease management programs in an
effort to provide comprehensive health
services to their enrollees.
Environmental Risk
Factor Management
While asthma cannot be cured, it is
most effectively controlled with
comprehensive care that includes medical
and environmental management
techniques. The National Institutes of
Health (NIH) acknowledges that the
indoor environment is an important
factor in the growing asthma problem.
For successful long-term asthma
management, NIH recommends a
comprehensive program of assessment
and monitoring, medication, patient
education, and control of factors that
contribute to the severity of asthma.4
These factors can include inhaled
allergens and irritants (indoors and
outdoors), exercise, certain foods and
medicines, and viral respiratory infections.
NIH's National Heart, Lung and Blood
Institute (NHLBI) says in its Guidelines
for the Diagnosis and Management of
Asthma that exposure of sensitive
patients to inhalant allergens has been
shown to increase airway inflammation,
airway hyper-responsiveness, asthma
symptoms, need for medication, and
death due to asthma. Irritants, such as
secondhand smoke, are associated with
decreased levels of pulmonary function,
increased requirements for medication,
and more frequent absences from work.
Exposure to a mother's secondhand
smoke is a risk factor for developing
asthma in infancy.5
At the request of EPA, the National
Academy of Sciences (NAS) assessed the
relationship between indoor air
exposures and asthma. NAS's goals in
examining chemical and biological
agents that might affect asthma were to:
• Provide the scientific and technical
basis for communications to the
public on the health impacts of
indoor pollutants related to asthma
and on mitigation and prevention
strategies to reduce these
pollutants.
• Help to determine what research is
needed in these areas.
NAS's report, Clearing the Air,
concluded that:
• Exposure to secondhand smoke,
nitrogen dioxide and indoor
allergens—dust mites, cockroaches,
pet dander, and mold—can make
asthma symptoms worse.
• Exposure to dust mites can cause
children of any age to develop asthma.
• Exposure to secondhand smoke can
cause preschool-aged children to
develop asthma.6
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Given these relationships, an essential
part of a comprehensive asthma
management program is identifying and
reducing exposures to allergens
(especially inhaled allergens) and irritants
that can increase or exacerbate asthma
symptoms (i.e., environmental "triggers").
This strategy of reducing exposures to
environmental triggers is consistent with
and supports the national guidelines.
These environmental triggers are listed
below.7
DUST MITES
Triggers: Body parts and droppings.
Where Found: Highest levels found in
mattresses and bedding. Also found in
carpeting, curtains and draperies,
upholstered furniture, and stuffed toys.
Dust mites are too small to be seen with
the naked eye and are found in almost
every home.
PESTS (SUCH AS COCKROACHES
AND RODENTS)
Triggers: Cockroaches - Body parts,
secretions, and droppings.
Rodents - Hair, skin flakes, urine, and saliva.
Where Found: Often found in areas
with food and water such as kitchens,
bathrooms, and basements.
WARM-BLOODED PETS (SUCH AS
CATS AND DOGS)
Triggers: Skin flakes, urine, and saliva.
Where Found: Throughout entire house,
if allowed inside.
MOLD
Triggers: Mold and mold spores, which
may begin growing indoors when they
land on damp or wet surfaces.
Where Found: Often found in areas
with excess moisture such as kitchens,
bathrooms, and basements. There are
many types of mold and they can be
found in any climate.
SECONDHAND SMOKE
Trigger: Secondhand smoke - Mixture of
smoke from the burning end of a
cigarette, pipe, or cigar and the smoke
exhaled by a smoker.
Where Found: Home or car where
smoking is allowed.
NITROGEN DIOXIDE (COMBUSTION
BY-PRODUCT)
Trigger: Nitrogen dioxide - An odorless
gas that can irritate eyes, nose, and throat
and may cause shortness of breath.
Where Found: Associated with gas
cooking appliances, fireplaces,
woodstoves, and unvented kerosene and
gas space heaters.
While developing its asthma education
program, EPA recognized that public and
private health plans are in a good position
to address environmental risk factor
management because health plans serve
people with asthma, their families, and
their primary care providers. In addition,
health plans pay a substantial portion of
the $11.5 billion spent annually to treat
asthma. Consequently, EPA is reaching
out to health plans to encourage them to
incorporate environmental risk factor
management in their asthma disease
management programs. One technique
for introducing people with asthma to
environmental risk factor management is
the home visit. Recent studies continue
to support home-based interventions
tailored to meet an individual's sensitivity
and exposure to environmental triggers.8
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Asthma Home Visits
Home visits provide an opportunity to educate people with asthma and to help
them effectively manage their disease by participating in asthma management
programs developed with their primary care physicians (PCPs). A home visit
provides an ideal setting to educate, review medication plans, and help families to
identify environmental factors in their homes that may contribute to the severity
of asthma.
The primary purpose of a home visit is to identify and mitigate the effects of
exposure to environmental triggers in the home. Going to the family's home can
be very effective because more information can be learned from, and given to, a
person face to face at home than over the telephone or in a doctor's office. At the
same time, the asthma management team can use the visit to assess the indoor
environment where a person spends much of the day and evaluate firsthand
sources of triggers and potential pathways that may lead to asthma flare-ups.
Home environmental assessment for asthma triggers has the potential to improve
an individual's and the family's understanding and skill development to manage
asthma effectively. In addition, PCPs can use the results of the environmental
assessment to understand the context of exposure better and tailor treatment
accordingly.
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10 Steps To Help Health Plans Get Started with
Asthma Home Visits
1
Learn about the benefits of a
home visit program as part of a
traditional asthma disease
management program.
The use of home visits to incorporate environmental risk
factor management into traditional asthma management
programs offers many benefits. Understanding how
environmental risk factor management benefits enrollees and
the health plan is critical to justifying a home visit program
and obtaining the support of health plan executives.
A health plan that already has an asthma management
program is probably realizing a return on its investment. By
building on the existing infrastructure and investment, and
by adding environmental risk factor management through
home visits (thus enhancing asthma management), the plan
may expect to increase its return further. Environmental risk
factor management can provide medical, financial, and economic
benefits, as well as public relations or competitive advantages.
• Medical benefits. Enrollees may experience overall
improvements in their quality of life as well as
decreased symptoms, fewer severe episodes requiring an
emergency department (ED) visit or hospitalization,
and improved preventive care and self-management of
their asthma.
• Financial benefits. The health plan and payers may
save on costs when rates of hospitalizations and ED
care decrease. Enrollees benefit financially by missing
fewer work days and may also benefit by spending less
on costly emergency care.
• Economic benefits. Payers and society benefit from
increased productivity from fewer missed work and
school days.
• Public relations or competitive advantages. Many
health plans stress strong disease management to
differentiate themselves from the competition. A
comprehensive asthma management program that
includes environmental risk factor management further
demonstrates the health plan's commitment to quality
care. Given the prevalence of asthma in the United
States, many prospective enrollees look for asthma
management programs, and a comprehensive program
that includes home visits can give a health plan a
competitive advantage.
A detailed marketing strategy built around environmental
risk factor management might include these points:
• Helping enrollees reduce their exposure to indoor
triggers may improve overall indoor air quality and
benefit others in the household.
• This approach promotes community involvement (from
the plan, providers, enrollees, and other organizations)
in managing asthma.
• Health care providers will be given the tools necessary
to manage asthma comprehensively.
CASE STUDY 1— COST SAVINGS
One Mid-Atlantic health plan saw dramatic cost savings and improved health outcomes within 6 months of enrolling people with
asthma in its home visit program. The plan saved $74.83 per member per month (PMPM) after instituting a home visit program.
Participating enrollees had significantly fewer hospitalizations, fewer emergency department visits, and fewer urgent physician
visits. Preventive medication use increased, while the use of "rescue" medications decreased, an indication that the enrollees
were managing their disease better.
The chart below shows the per-member-per-month costs and savings across the entire asthma enrollee population (about 8,000
members out of a total membership of about 300,000) that resulted from the home visit program.
PMPM Costs and Savings, Pre- and Post-Home Visit Program
Category of Service
PCP/specialist costs*
ED visit costs*
Inpatient admission costs*
Home care costs
(includes asthma
program home visits and
non-asthma program
home health care)
Total
Pre-Home Visit Program
$1 2.30
$13.85
$112.07
$1.00
$139.22
Post-Home Visit Program
$9.10
$1 1 .99
$38.77
$4.53
$64.39
Savings PMPM
$3.20
$1.86
$73.30
($3.53)
$74.83
* With primary diagnosis of asthma
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2
Get your health
plan's leadership to buy
into the program.
Raising key executives' awareness of the
program is crucial. Determine which
executives need to approve and support a
home visit program, such as the Chief
Executive Officer, Chief Financial Officer,
Chief Medical Officer, or Medical
Director. Explain the program and the
medical, financial, economic, and public
relations benefits of incorporating
environmental risk factor management
and home visits into traditional clinical
asthma management programs.
Be prepared to present the home visit
program's operational details as they are
developed (from Steps 4 to 9), its
estimated costs, and its potential savings.
Determine necessary resources (in
addition to current expenditures if an
asthma management program is already in
place), prepare a budget, and obtain the
necessary commitments from upper
management. Budgets should include:
• Staff time to develop the program.
• Development of educational
materials and a case management
protocol.
• Staffing for the program or
outsourcing costs.
• Ongoing operational costs including
resources for data gathering and
analysis.
It may also be helpful to estimate
program costs in accordance with the
health plan's underwriting practices. For
example, many health plans evaluate the
cost of their programs on a per-member-
per-month basis.
A pilot program may be a good way to
demonstrate positive health outcomes
and financial savings before executives
make a long-term commitment. The
same health plan highlighted in Case
Study 1 on page 4 decided to offer a
home visit program to all of its enrollees
with asthma after conducting a pilot with
50 severe pediatric asthmatics. Nurses
were sent to the homes of these 50
enrollees to educate the families about
the disease and proper self-care. Within 6
months of the home visit, the plan saw a
dramatic improvement in utilization.
Participating enrollees had significantly
fewer hospitalizations, fewer emergency
department visits, and fewer urgent
physician visits. Preventive medication use
increased, while the use of "rescue"
medications decreased, an indication that
the enrollees were managing their disease
better. Although a pilot need not involve
a large number of enrollees, it should be
able to measure changes in clinical
outcomes, such as claims utilization and
quality of life assessments, to show
program benefits.
1^ m Form an
implementation team.
A health plan that has an asthma
management program that does not yet
include home visits may already have in
place a team that could implement a
home visit program. This team may
consist of the individuals who developed
or run the current asthma management
program.
If a health plan must form a new team, it
likely will include the Medical Director,
Health Services Director, Director of
Utilization Management, Director of
Quality, asthma case manager (if an asthma
program already exists), one or two
network physicians with a significant
asthma patient load, a data programmer
or analyst, and a person with asthma or
their caregiver. The person with asthma
or the caregiver may be able, based on
their own experience, to suggest ways to
overcome implementation barriers, such
as resistance to or unavailability for home
visits.
The implementation team should initially
meet at least monthly to start developing
the program's details, including its goals,
components, and implementation plan
(e.g., whether to outsource, number of
home visits provided) and its participant
eligibility criteria. Steps 4 to 9 provide
additional information on specific
development activities. The team should also
develop a realistic implementation schedule.
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1 • Develop the structure
of the home visit program.
A. Determine program goals
The first step in structuring a home visit program is to
determine the program's goals. Goals may relate to the
number and characteristics of enrollees the program will
serve, or the health outcomes and cost savings desired.
Goals can also express less tangible outcomes such as
strengthening ties with community organizations or
increasing PCPs' knowledge of environmental risk factor
management. The implementation team may want to begin
collecting baseline data that will provide a point of
comparison for the outcomes and outputs selected for
tracking (see step 7).
B. Define major components of the home visit program
Once the program's goals are defined, several factors should
be considered when designing the program components.
These factors include the number of enrollees estimated to
be eligible for the program (see Step 5), individual patient
needs, and available resources (monetary and staff). Above
all, the program should be tailored to the needs of the
organization and its members. If the proposed program
would involve a change in the benefit structure, sample
benefit language should be drafted. It should be presented
to key executives along with the proposed program
structure. The major components of a home visit program
that should be considered include:
ENCOURAGING THE
USE OF ASTHMA ACTION PLANS
Some plans provide monetary incentives to
providers for quality performance, including completion
of asthma action plans. One Midwest plan experienced
a 162 percent increase in the number of action plans
between 2000, when the program was
implemented, and 2002.
Individual Asthma Action Plan. Most plans that
have asthma management programs stress the need for
individual action plans if self-management of asthma is
to succeed. During the home visit, the home visit
provider can introduce the concept of self-management
and provide instruction in how to develop, with the
help of a physician, a personal plan that includes
controlling environmental triggers.
General Asthma Education. Some plans use the
home visits to educate enrollees on asthma issues
broader than environmental risk factor management.
Topics may include general disease comprehension;
appropriate medication use; use of equipment such as
peak flow meters, spacers, and nebulizers as necessary
for self-management; and guidelines for appropriate
care utilization. Some health plans use tests (before
and after the home visit) to assess the effectiveness of
their educational efforts, measuring such factors as
acquisition of appropriate skills.
Environmental Assessment. An assessment survey
form or checklist may be helpful in searching for and
identifying potential indoor triggers. Home visit
providers should look for indicators of the presence of
common triggers (e.g., dust mites, pests, pets, mold,
secondhand smoke, and nitrogen dioxide) throughout
the home. The home visit provider should give special
attention to the sleeping area. The checklist may also
address other issues, such as housing defects that
contribute to the presence of triggers or the impact of
outdoor air pollution on asthma. See Step 8.A for a
description of EPA's Asthma Home Environment
Checklist.
Environmental Trigger Education and Mitigation.
If sensitivities to particular indoor triggers are known,
the home visit assessment should begin by focusing on
exposures relevant to these sensitivities. If a trigger is
found, the home visit provider should explain how the
trigger affects the person's condition and provide
advice on how to reduce exposure to the trigger.
Recommendations should be viable for the enrollee's
means and conditions (e.g., keeping pets out of the
bedroom, smoking outside the home and car,
frequently washing bed linens and stuffed toys in hot
water). Depending on the plan's benefits, providers
could refer enrollees to smoking cessation programs,
offer trigger-reducing items such as dust-proof
(allergen impermeable) bed and pillow covers, or
provide hands-on assistance in educating enrollees
about mitigation techniques. Health plans need to
communicate clearly the extent of the services they will
provide to the enrollee.
Health plans that serve a low-income population
should carefully consider the effort that will be
required to make their home visit programs successful.
They should realistically evaluate whether their benefit
structure and operating budget will allow for the
services that a low-income population would need.
Making social service referrals, providing products at
no cost, and providing hands-on assistance and
instruction with product usage and other mitigation
techniques are essential for a low-income population.
Resource Referral. Information about community
resources—including those that focus on asthma and
those that address related social needs—may be given
to the enrollee when appropriate and available. For
example, a renter who cannot easily address his or her
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building's mold problems may
benefit from a referral to a tenant
advocacy organization or the local
housing authority. Local asthma-
focused organizations may be able
to help enrollees obtain allergen-
reducing items. See Step 9 and Case
Study 5 for more information on
using community resources.
Recordkeeping and Reporting.
An important component of a home
visit program is recordkeeping and
reporting. Health plans will want to
record and track information to:
• See how individual enrollees
are affected.
• Assess improvements in the
home visit program
participants' symptoms.
• Calculate cost savings or other
benefits to the health plan.
When designing a home visit
program, a health plan will
need to determine how data
will be collected, aggregated,
monitored, tracked, and
reported. Steps 7 and 8 discuss
more fully the information
health plans may consider
tracking.
COMPLIANCE WITH THE
HEALTH INSURANCE
PORTABILITY AND
ACCOUNTABILITY ACT (HIPAA)
HIPAA requires certain notifications
and disclosures to people using
health care services to protect the
privacy of their medical records.
Information collected under a home
visit program must be handled
according to HIPAA regulations,
consistent with a plan's compliance
policies and practices.
Follow-up. The home visit program
may include some form of follow-up
with the enrollee, either by
telephone or an additional home
visit, to assess compliance with
recommendations, track overall
progress, and support continued
self-management.
• When to follow up. When
the follow-up is conducted will
depend on the health plan and
its outreach capabilities; many
plans report following up one
week to one month after the
initial visit.
• How to follow up. The
frequency and intensity of
follow-up could depend on
the enrollee's self-care ability.
This could be determined by
demonstration of new skills
or changes in behavior, as well
as an ongoing review of the
enrollee's asthma symptoms,
episodes, and use of urgent
care. Many plans do not make
follow-up home visits if the
telephone follow-up and
utilization data clearly show
that an enrollee is managing
his or her disease effectively.
C. Determine number of home visits
to be provided
The decision on the number of home
visits to provide should consider several
factors, including:
• Who will receive home visits.
• The information to be collected.
• The extent of the home visit
provider's responsibility for
education and mitigation.
• The specific goals and health outcomes
the visits are meant to accomplish.
• Budgetary constraints.
• Enrollee follow-up required to
achieve desired outcomes.
• Cultural and language issues,
including the need to establish trust
before conducting an assessment.
While many plans have succeeded with
only one or two visits per enrollee, some
provide as many as six visits. One option
is to develop a flexible program that
provides enough home visits for an
enrollee to achieve the desired health
outcomes. That number may be
determined by several techniques,
including:
,
7
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• Pre- and post-visit asthma management program
knowledge tests to determine how many home visits
the enrollee needs.
• A telephone follow-up after the initial visit. The case
manager may identify issues that indicate additional
home visits are necessary. These issues include a lack of
progress, worsening symptoms, or continued
demonstration of limited knowledge of the disease.
D. Determine who will conduct the home visits
This step has two components: deciding what sort of
professional should conduct the home visits, and deciding
whether the visits should be performed by health plan staff
or by a third party vendor.
A variety of professionals can conduct home visits:
respiratory therapists, nurses, social workers, asthma
management program case managers, home health care
workers, and community outreach workers. The skills
appropriate for a home visit program will depend on its
goals, the type of education or mitigation to be provided,
the budget, and the availability of personnel. Each group of
professionals has potential advantages. For example,
respiratory therapists will be very familiar with asthma and
its treatment. Nurses and social workers may be able to take
a broader view and pay more attention to possible psycho-
social issues. Asthma management program case managers
(who may be medical or non-medical personnel) may also
take a broad view of the enrollee and his or her family.
Home health care and community outreach workers may be
more attuned to local cultural or language issues. If the
home visit program will address both medical and
environmental issues, the home visit provider must be
capable of addressing both competently.
Besides deciding what sort of professional should conduct
home visits, a decision must be made on whether to use a
third party vendor or health plan staff. Each option has
strengths and weaknesses, as shown below in Exhibit 1. The
goals of the program and the characteristics of a plan's
enrollees (e.g., population demographics, size, asthma
severity) can offer guidance.
Case Study 2 on page 9 shows how both in-house staffing
and outsourcing can be effective.
The staffing decision may also be influenced by funding or
payment options. As described in Case Study 2, several
health plans have obtained grants to pay for additional in-
house staff for home visit programs. In addition, one
Midwest plan received a grant from the Department of
Housing and Urban Development's Healthy Homes
program that allowed it to pay for thorough home
environmental assessments by an environmental specialist.
Health plans may also be able to develop alternatives that
address potential staffing issues. For example, while
outsourcing may seem to be the best way of addressing a
culturally diverse population, a health plan may have
multilingual staff who are appropriate and available for this
activity.
Exhibit 1. Characteristics of Program Staffing Options
Consideration or Goal
Health Plan Staff
Third Party Vendor
Coverage of all members with asthma
May be more efficient as it may
not require additional in-house
staff to serve large population
Monitoring and tracking outcomes
Communication and tracking are generally
easier because staff members are often linked
to the same telephone and computer system
Culturally diverse enrollee population
May specialize in
communicating with culturally
diverse populations
Quality control and accountability
May be more accountable because they share
the same organizational goals
Expertise in asthma care
May have specialists, such as
respiratory therapists, who are
knowledgeable about asthma
and familiar with equipment and
techniques used for self-
management
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CASE STUDY 2 - THIRD PARTY VENDOR VERSUS HEALTH PLAN STAFF
Many plans base their staffing decision on factors such as service area, community needs, and funding. For example, plans
serving large geographic regions or large populations tend to outsource visits to third party vendors, while smaller plans serving
local areas can use health plan staff effectively to conduct home visits. The cases below describe the decisions and rationale of
four plans.
THIRD PARTY: LARGE SERVICE AREA AND COMMUNITY NEEDS
• A Northeast metropolitan health plan, Plan A, relies on respiratory therapist (RT) vendors to conduct home visits for
its large, urban population. The plan believes these providers are more familiar with asthma and the equipment used
in its treatment than the home health care nurses they formerly employed. Plan A pays the vendors $75 per visit, plus
the cost of certain necessary medical equipment provided by the vendor.
• Plan B, another Northeast health plan, contracts with RTs and home health care nurses to conduct the visits. It
prefers to outsource rather than to maintain the large staff that would be needed to cover the service area (the entire
state). Plan B also knows that the vendors are very familiar with their local communities. Plan B pays $80-$125 per
visit, depending on the particular contract.
HEALTH PLAN STAFF: ACCOUNTABILITY AND QUALITY CONTROL
• A large Mid-Atlantic health plan, Plan C, contracts with home health agencies that are part of the same health system
as the health plan. This plan thinks that there is better accountability and quality control when working with an in-plan
provider. Plan C pays its home health vendor a case rate of $425 to provide as many visits as needed.
• A West Coast county-based plan, Plan D, started its program as a Health Plan Employer Data Information Set (HEDIS)
demonstration project. The health plan employs one nurse who is solely responsible for asthma disease
management. She designs and leads community education programs and makes about 40 home visits per month.
Because she works only with the health plan's membership, she has been able to recognize enrollees' needs and
adapt the program to serve that population better. She believes that there is "more control" when the visits are kept
in-house. Recently, Plan D received a Health Resources and Services Administration (HRSA) grant to add an
additional nurse and outreach worker in order to expand the program and provide more home visits. Operational
costs include the salaries and equipment used by the nurses and outreach worker.
E. If using an outside vendor, develop and negotiate
contracts and payment terms
If home visits are outsourced, they could be paid for on a per
visit or per case basis. This decision depends on how many
home visits are expected and on their specific goals. A case
rate may be more effective when several visits per enrollee are
anticipated. Case Study 2 provides additional information on
how some plans pay for vendor services.
Third party contractors should be clear about program goals
and the plan's expectations for the visits. Adequate reporting
is essential, both to assure quality and to determine
subsequent outcomes.
Some health plans have successfully partnered with non-
profit organizations, rather than contracting with
STRATIFYING ASTHMA SEVERITY
Standard classifications identified by NHLBI's Practical
Guide for the Diagnosis and Management of Asthma:
• Mild intermittent
• Mild persistent
• Moderate persistent
• Severe persistent
commercial vendors, who conduct home visits at no or low
cost to the health plan. This option should always be
explored. (See discussion in Step 9 for further information.)
} • Determine which enrollees will be
visited at home.
Depending on their available resources and the size of their
asthma enrollee population, some plans offer home visits to
all enrollees with asthma while others visit only those
enrollees with the most severe asthma. Many plans believe
that telephonic care management and regular patient-
physician interaction are sufficient for the enrollees with
mild cases of asthma—and often for enrollees with moderate
cases as well. These enrollees often improve from simple
instructions on how to use their medications appropriately.
Telephonic care management should also cover
environmental triggers to help enrollees assess their homes.
Those with the most severe asthma, however, have the
greatest potential to benefit from home visits. They may not
be knowledgeable about environmental triggers, may be
unaware that they have regular contact with triggers in their
homes, and, in some cases, may have other complicating
issues. Whether a home visit program will be offered to
some or all of a plan's enrollees with asthma, there must be
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CASE STUDY 3 - ENROLLEE GROUPING
Most plans use some combination of disease assessment and utilization data analysis to group their members according to the
severity of their disease. One Mid-Atlantic plan uses a detailed questionnaire about symptoms to rank new members who are
identified as having asthma. The plan applies specific utilization criteria to established members' claims information to
determine the severity of their disease. Members are considered low, moderate, or high risk based on the following definitions:
Low: Minimal office visits, no ED visits or hospitalizations for asthma, low pharmacy use.
Moderate: One ED visit for asthma in 6 months, and/or inhaled beta-agonist to anti-inflammatory ratio of
3:1 or greater.
High: Two or more ED visits for asthma in 6 months, and/or one or more hospitalizations for asthma,
and/or inhaled beta-agonist to anti-inflammatory ratio of 5:1 or greater.
a mechanism to identify them. Health plans that have
asthma management programs identify enrollees with
asthma through various means that include:
• Welcome calls.
• New member health assessment surveys.
• Asthma utilization reports (e.g., office visit claims data,
ED and hospitalization claims, inpatient claims,
pharmacy claims).
• Physician referrals.
• Case manager identification (e.g., at time of ED or
hospital admission or discharge).
• Computerized disease registries.
After enrollees with asthma have been identified, data from
one or more of the sources listed above can be used to
gauge the severity of their asthma. Stratification of enrollees
by zip code may allow plans to focus resources on areas with
disproportionately higher rates of asthma. (Most plans use at
least the asthma utilization reports.) Case Study 3 describes
how one plan ranks its enrollees with asthma by disease
severity.
Plans with multiple payers with different benefits will need
to ensure that enrollee referrals are consistent with the
benefits provided by their payer. In some cases the asthma
case manager or other individual who is familiar with the
benefit structures may need to make referrals for home
visits, rather than the primary care physician.
6
Develop outreach strategies.
An active, creative outreach program enables a plan to
contact enrollees with asthma—particularly those in the
Medicaid population—in order to schedule and complete
home visits. Outreach to primary care physicians and other
health care providers is also important. An effective outreach
strategy must consider the following questions.
A. Who contacts the enrollees, and how is contact made?
In some plans, the person who will conduct the home
visit does the scheduling. Other plans have outreach
coordinators, and still others hire or form partnerships with
outside organizations to find the enrollees. (See Case Study 4,
below.) Eligible enrollees generally are called before the
home visit, but some enrollees may not have telephones. In
those cases, a nurse or other outreach professional may try to
find individual enrollees in person.
Most plans will make more than one attempt to reach an
eligible enrollee with asthma. Plans report that, once contact
is made, most enrollees are very receptive to the concept of a
visit "to help with your (or your child's) asthma."
B. What are the features of a successful outreach
strategy?
Flexibility and attention to the specific characteristics of the
enrollee population are hallmarks of successful outreach
strategies. For example:
CASE STUDY 4 - OUTREACH STRATEGIES
Many health plans, particularly those serving the Medicaid population, find that there are barriers, such as out-of-date contact
information, to overcome when contacting enrollees to schedule home visits.
• One Northeast plan contacts PCPs to get the most current telephone numbers and contact information.
• The same plan often gets enrollees' most current contact information from pharmacies, when that information is not
available from PCPs. Plan representatives determine where the enrollee last filled a prescription, and then contact the
pharmacy to check for an updated telephone number.
• Another Mid-Atlantic plan works with a local group called Allies Against Asthma, which has a "community ambassador" program.
Community members help to locate hard-to-track enrollees so they can be asked to participate in the asthma home visit program.
10
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• Multi-lingual staff or translation
services are often necessary for
scheduling and completing visits.
• Flexible scheduling (e.g., lunch
hours, nights, weekends) greatly
increases a plan's chances of visiting
all eligible enrollees.
• Providing an incentive for enrollees
to schedule and complete a specified
number of visits can help an
outreach strategy succeed. Examples
of incentives are:
• Dust-proof (allergen
impermeable) mattress, pillow
case covers, or other
environmental mitigation
equipment or supplies.
• School supplies.
• Telephone cards.
• Gift certificates (especially to
stores selling trigger-reducing
items).
C. How will health care providers find
out about the home visit program?
Whether PCPs and other health care
providers refer patients or recommend
that they participate in a home visit
program can also affect the participation
rate. The health plan should consider an
outreach effort to notify its providers
about the home visit program, explain
enrollee eligibility, describe the referral
and enrollment process, and discuss the
benefits of the program.
i m Determine what
outcomes and outputs will
be measured and how
they will be measured.
Plans measure the effectiveness of their
asthma management programs in
different ways. The measures used to
determine success should relate to the
goals set in Step 4. In the early months of
a program, outputs (e.g., number of
enrollees with asthma participating in the
home visit program and number of visits
completed) are the easiest measures to
collect. A health plan should be able to
retrieve this information from the system
it uses to track the scheduling and
completion of home visits (discussed
further in Step 8.C). Output information is
useful in determining the reach of the
program. It also provides information on
the level of effort (e.g, number of visits,
number of staff hours necessary to achieve
program goals).
Over the longer term, information should
be collected that shows the program's
impact on outcomes, such as reduced
asthma ED visits and hospitalizations.
After reviewing several months' worth of
outcomes data, targets (e.g., a 30-percent
reduction in ED visits) can be set. The
most common health outcomes measured
for enrollees in asthma management
programs are:
• Asthma ED visits (either ED
visits/1,000 or as a percentage of
enrollees in the asthma management
program).
• Asthma hospitalizations (either
hospital visits/1,000 or as a
percentage of enrollees in the
asthma management program).
• Percentage of enrollees with asthma
with high bronchodilator use.
• Anti-inflammatory/inhaled beta-
agonist ratio (3:1 or greater is cause
for concern).
• Missed days of school or work.
• Written asthma action plans
(percentage of enrollees with
asthma).
• Appropriate changes in behavior
through acquisition of self-
management skills. For example, if
the home visit program includes
education about dust mites, laundry
procedures may be assessed
(enrollees in the program are
washing bedding at the
recommended frequency and water
temperature 2 months after the initial
home visit).
• Increased knowledge; for example,
understanding medication usage,
knowing what can trigger asthma,
and understanding how to mitigate
or control those factors.
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Health plans that offer PCPs information
and resources on environmental risk
factor management also may want to
track the percentage of physicians using
this information and determine whether
they demonstrate more knowledge
about these topics after exposure to
the information.
Most plans pick at least two of the
outcome measures listed above,
depending on their reporting capabilities.
(Much of this information comes from
claims data.) ED visits and hospitalizations
are generally the easiest to measure and
can clearly demonstrate the medical and
financial impact of an asthma
management program, especially if a
home visit component has been added to
an existing program. Whether or not a
plan already has an asthma management
program, baseline data on health
outcomes should be recorded before the
home visit program, or as early as
possible after it begins, so its impact can
be determined. Keep in mind that
improvements might not be
instantaneous; plans report that it takes at
least 6 months to a year for the actions to
produce significant results in the data,
although improvement in the day-to-day
lives of each enrollee visited can usually
be seen much sooner.
i Develop tools and
forms and train staff.
Health plans that have home visit
programs use most, if not all, of the tools
and forms described below. One or more
members of the implementation team
(discussed in Step 3) should take
responsibility for gathering and
developing the necessary tools and forms
and for training and educating the rest of
the asthma management program team
about home visits. Everyone needs to be
aware of the ways in which the existing
asthma management program will be
different as a result of the new home visit
component. At some plans, many of the
tools and forms described below are
already in place (e.g., asthma action plans
and enrollee tracking and reporting
systems) and only minor adjustments are
necessary. Others will need to devote
more resources to developing the
necessary infrastructure. References have
been given where applicable to help
locate examples.
When developing a training program,
keep in mind that it is also important to
train physicians and other health care
providers. At a minimum, they will need
to know about the program, who is
eligible, when and how to make referrals,
and asthma management program
components to be tracked.
A. Asthma Home Visit Checklist
The checklist provides a comprehensive
list of questions related to environmental
asthma triggers commonly found in and
around the home.
EPA developed a checklist of questions
and action steps designed to help identify
and mitigate environmental asthma
triggers commonly found in and around
the home. The checklist has 13
categories9 to help the home visit
provider focus on the activities or items
in the house that might produce or
harbor environmental triggers. The EPA
Asthma Home Environment Checklist is
provided in an appendix to this Guide. It
can also be downloaded in pdf format
from EPA's Web site at
www.epa.gov/asthma/pdfs/
home_environment_checklist.pdf.
EXAMPLES OF ASTHMA
ACTION PLANS
Pediatric/Adult Asthma Coalition of New
Jersey (http://www.pacnj.org/)
Regional Asthma Management &
Prevention Initiative
(http://rampasthma.org/AAP%20page.htm)
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B. Individual Asthma Action Plan
A written asthma action plan is developed by the enrollee
and his or her physician or case manager to help in the
management of asthma episodes. This customized plan
encourages the enrollee to self-manage his or her asthma.
Asthma action plans are sometimes called asthma self-
management instructions or written guidelines for asthma.
Asthma action plans can be organized in any number of
ways, but the important thing is that the individual action
plans give enrollees and their families information that can
help them manage their asthma. Plans may include a list of
the person's triggers and how to avoid them, instructions
for taking asthma medicine, information on what to do if a
child has an asthma episode, instructions on when to call a
doctor, and emergency telephone numbers.
Action plans should be created and reviewed with the
enrollee's physician or case manager and updated at least
once a year.
C. Intake form, form letters, and reports for
communicating with physicians and enrollees with
asthma
Intake forms can be used to record basic information on an
enrollee newly referred to or identified for the home visit
program (e.g., symptoms, asthma history, physician,
medications). Information on this form can be entered into
a computer system, as discussed in 8.D below. Plans that
have home visit programs use form letters such as these:
• A letter to the physician when a enrollee has been
identified for the home visit program (either from
utilization data or from a hospitalization).
• An outreach letter to members to schedule visits (when
telephone attempts fail).
• A reminder letter to members about recommended
action steps or follow-up visits.
• A letter or report to the physician describing home
visits, findings, and recommendations.
D. Educational materials
Many health plans develop educational and informational
materials as part of their home visit programs. Materials for
enrollees can educate them about the home visit program
and how it will help them to address environmental asthma
triggers commonly found in the home. Health plans may
also want to provide similar materials to physicians as part of
their health care provider outreach effort (see Step 6.C).
Plans may also want to distribute to their providers copies of
the National Heart, Lung, and Blood Institute's Practical
Guide for the Diagnosis and Management of Asthma.10 This
document includes a variety of implementation aids, including
reproducible patient handouts.
E. Enrollee tracking system and reporting
It is imperative to track, and to be able to generate reports
of, the following items as enrollees are deemed eligible for
the home visit program:
• Outreach attempts and status.
• Other correspondence (e.g., letters) with members and
physicians.
• Dates and times of home visits.
• Summaries of visits: topics covered, findings,
recommendations.
• Personal knowledge of disease self-management (from
pre- and post-home visit tests) and acquisition of self-
management skills.
• Follow-up needed.
If these items are tracked properly, the forms, letters, and
reports described in Step 8.C can easily be generated to
facilitate communication with members and physicians. It is
especially important to be able to report to the enrollee's
PCP so that he or she can follow up with the individual.
The PCP will also be able to reinforce during office visits
the concepts that were taught during home visits.
Form relationships or
partnerships with community
asthma organizations.
Whether home visits are outsourced or made by health plan
staff, it is important for the health plan to be familiar with
community groups and organizations that focus on asthma.
Formal and informal relationships with such groups promote
the sharing of valuable information and the dissemination of
best practices. There may be opportunities for formal
referral relationships or collaboration that will enhance the
home visit program while reducing or offsetting some of the
program costs. Health plans should begin to explore
forming relationships with other organizations during goal-
setting (Step 4).
For example, community groups such as the Regional
Asthma Management & Prevention Initiative (RAMP) in
California provide educational materials in various languages
and other types of support. As highlighted in Case Study 5,
Allies Against Asthma coalitions sponsor "community
ambassador" programs in which designated community
members can assist in locating and communicating with
individuals who have asthma. Other community groups may
provide thorough environmental assessments or trigger-
reducing items free of charge to health plan members in
need of such interventions. Public housing authorities and
tenant advocacy groups can help enrollees in situations
where poor housing conditions aggravate symptoms.
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In addition to community asthma groups,
health plans may find that schools and
employers can also be helpful partners
who can work with them to build or
strengthen community resources.
Implement the
program and track its
results.
Use the tools and forms described in Step
8 and remember to follow up with the
enrollees' PCPs. Coordination with
patients' physicians (e.g., PCPs and
specialists) is key to the success of the
home visit program. After determining
what outcomes to measure (Step 7) and
how to measure them, use the trended
results after 6 months to determine:
• The overall efficacy of the in-home
visit program.
• Areas that could be refined (e.g.,
education on mitigations, guidelines
for determining number of visits).
• Whether the program should be
expanded (especially if it was a pilot
program).
Tracking program outcomes and using
the results to improve the home visit
program will improve the plan's overall
performance, demonstrate the value of
the program, and build provider and
consumer support.
Consider publishing, or at least
disseminating, the results of the program
analysis. Promoting program results will
demonstrate the value of home visit
programs to health care purchasers.
It will also improve the medical
community's overall understanding of the
benefits afforded by asthma home visit
programs.
A Final Note
The steps outlined above are meant to serve
as a general guide for health plans
considering whether to begin an asthma
home visit program. The recommendations
are based on current disease management
principles and the experiences of health
plans that are providing home visits to
enrollees with asthma. To achieve the best
outcomes, however, it is important to tailor
a program to the needs of your
organization and its members. Regardless of
program complexity or structure, the keys
to success are:
• Careful planning.
• Strong outreach.
• Community partnerships.
• Ongoing data collection and
comparison to baseline data.
• Program review.
CASE STUDY 5 - LEVERAGING ASTHMA RESOURCES IN THE COMMUNITY
The State of Washington's Medicaid program sponsors an asthma management program
for fee-for-service Medicaid clients. The asthma management program is operated by a
third party vendor. The home visit program is for enrollees with severe asthma or who
have given an indication that they could benefit from face-to-face, rather than telephonic,
care management. Such indicators may include language barriers, significant complex co-
morbidities, home safety issues, mental health barriers, difficult socio-economic issues,
and environmental issues. The program includes home visits by field nurses who conduct
comprehensive clinical assessments. If a nurse identifies potential environmental triggers
in the home, he or she may refer the enrollee to the local American Lung Association of
Washington, which conducts free home environmental assessments and provides free
mattress and pillow case covers as needed. Any health plan can also take advantage of
this important referral source, so it is important to become knowledgeable about asthma
resources in the community early in the program development process.
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Asthma Resources
Many available resources provide education on asthma,
asthma disease management, home visits, and related topics.
A few of them are discussed below.
• Allergy & Asthma Network Mothers of Asthmatics
(www.aanma.org): AANMA is a donation-based nonprofit
organization dedicated to helping people affected by allergies
and asthma through education, advocacy, community
outreach, and research. AANMA provides services to patients
and physicians including education materials for all ages,
monthly award-winning publications, a toll-free help line,
Hispanic outreach, and a Web site (www.breatherville.org/
breatherville.htm) featuring Breatherville, USA™, an online
town where learning about allergies and asthma is a positive
experience.
• Allies Against Asthma: AAA is a national demonstration
project funded by The Robert Wood Johnson Foundation.
The Allies Against Asthma Web site (www.asthma.umich.edu)
is a free resource center for individuals and organizations
interested in community-based programs to address pediatric
asthma, particularly in poor, urban, and minority
communities. The Web site includes a "Resource Bank,"
which contains materials, survey instruments, and other tools
for use in controlling and managing asthma.
• American Academy of Allergy, Asthma, and Immunology
(www.aaaai.org): AAAAI is the largest professional medical
specialty organization representing allergists, clinical
immunologists, allied health professionals, and other
physicians with a special interest in allergies. AAAAI's Web
site includes informational resources, public education
materials, and a "Just for Kids" section that contains games,
puzzles, and other activities to help children learn about and
manage their asthma.
• American Lung Association (www.lungusa.org): ALA is the
oldest voluntary health organization in the United States. Its
focus is fighting lung disease in all its forms, and it particularly
emphasizes asthma, tobacco control, and environmental
health. ALA's Web site contains a great deal of general asthma
information as well as links to local ALA offices throughout
the country.
• America's Health Insurance Plans (http://www.ahip.org):
AHIP is the national association representing nearly 1,300
member companies providing health insurance coverage to
more than 200 million Americans. Taking on Asthma is a joint
initiative of AHIP and the American Academy of Allergy,
Asthma, and Immunology (see above). Taking on Asthma
offers a resource guide (http://www.takingonasthma.org/
resources.htm) that outlines the evidence-based guidelines for
asthma care and features case studies of effective health plan
programs, including the control of environmental risk factors.
• Asthma and Allergy Foundation of America (www.aafa.org):
AAFA is a patient organization dedicated to "improving the
quality of life for people with asthma and allergies and their
caregivers, through education, advocacy and research." AAFA
has developed numerous educational materials that are
described and can be ordered on-line from its Resource
Catalog.
The Center for Health Care Strategies: CHCS has a guidance
document called Achieving Better Care for Asthma Toolkit
(www.chcs.org/usr_doc/AchievingBetterCareForAsthmaTool
kit.pdf). This guidance offers a structured approach for
addressing quality improvement and a collection of "lessons
learned" by a diverse group of health plans serving Medicaid
members. It is comprehensive and covers many topics in
addition to home visits. It offers practical, realistic approaches
that can help Medicaid plans develop new asthma
management programs or improve existing programs.
The Centers for Disease Control and Prevention:
CDC's National Asthma Control Program
(http://www.cdc.gov/asthma/NACP.htm) conducts
epidemiological studies and provides statistics on the
prevalence and costs of asthma. It also provides information
on effective interventions for asthma control, including
methodology for identification of the interventions, results,
lessons learned, information on the interventions themselves,
a bibliography of reviewed literature, and case studies of
several interventions. Other resources, such as a speaker's kit
for health care professionals and links to other asthma-related
CDC sites and organizations, are available.
The National Asthma Education and Prevention Program:
NAEPP was initiated in March 1989 to address the growing
problem of asthma in the U.S. (http://www.nhlbi.nih.gov/
about/naepp/index.htm). NAEPP is administered and
coordinated by the National Heart, Lung, and Blood
Institute of the National Institutes of Health. NAEPP has
state-of-the-art clinical practice guidelines for diagnosing and
managing asthma (http://www.nhlbi.nih.gov/guidelines/
asthma/asthgdln.htm). It provides information on treating
asthma at all severity levels and stresses both clinical and self-
management strategies.
Other materials can also be used to enhance the effectiveness
of a home program. For example, some pharmaceutical
companies make asthma education kits that can be sent to
children and their families; many are very child-friendly and
include tools such as puppets, CD-ROMs, and other
educational materials that help children and their families
better understand the disease while reinforcing good disease
management behaviors.
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For more information on EPA's national asthma program,
visit http://www.epa.gov/asthma.
EPA encourages the use of its materials when promoting environmental
risk factor management.
To access EPA's materials, visit
http://www.epa.gov/asthma/publications.html.
To order these materials at no cost, call EPA's Indoor Air Quality
Information Line at 1-800-438-4318.
1 Centers for Disease Control and Prevention.
(http://wwwxdc.gov/nchs/products/pubs/pubil/hestats/asthma/asthma.htm)
2 National Heart, Lung and Blood Institute. Morbidity & Mortality: 2004 Chartbook on
Cardiovascular, Lung and Blood Diseases, (www.nhlbi.nih.gov/resources/docs/04_chtbk.pdf)
3 America's Health Insurance Plans. 2002 Annual Industry Survey of Health Insurance Plans and
Chartbook Findings, (http://www.ahip.org/content/default.aspx?docid=2244)
4 National Heart, Lung and Blood Institute, National Asthma Education and Prevention Program.
Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. NIH
publication number 97-4051. (www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf)
3 See footnote 4.
5 National Academy of Sciences, Clearing the Air: Asthma and Indoor Air Exposures.
(vww.nap.edu/books/0309064961/html)
7 To learn more about actions to manage environmental triggers, consult EPA's Asthma Home
Environment Checklist at http://www.epa.gov/asthma/pdfs/home_environment_checklist.pdf.
8 Morgan W.J., Grain E.F., et al. Results of a Home-Eased Environmental Intervention among
Urban Children with Asthma. New England Journal of Medicine 2004; 351:1068-1080,
Sept. 9, 2004.
9 Building information, secondhand smoke, pets, consumer products, heating and cooling systems,
bedding and sleeping arrangements, flooring, upholstered furniture and stuffed toys, window
treatments, cooking appliances, moisture control, pest control, and outdoor air pollution.
10 National Heart, Lung and Blood Institute, National Asthma Education and Prevention
Program. Practical Guide for the Diagnosis and Management of Asthma. NIH publication
number 97-4053. (www. nhlbi. nih.gov/health/prof/lung/asthma/practgde/practgde.pdf)
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Acknowledgments
The U.S. Environmental Protection Agency would like to
acknowledge the following organizations that shared their
experiences in developing and implementing asthma home
visit programs:
Affinity Health Plan
Children's Mercy Hospitals and Clinics, Health Management
Department/Asthma
Contra Costa Health Plan
Horizon NJ Health
Neighborhood Health Plan
McKesson Health Solutions
Optima Health Plan
The U.S. Environmental Protection Agency would also like
to acknowledge the contributions of the following people
who reviewed drafts of the guidance and provided valuable
comments and insights:
Patricia J. Barta, Centers for Health Care Strategies;
Jeri E. Bryant, Harvard Pilgrim Health Care; Rita Carreon,
America's Health Insurance Plans; Caroline Erceg, America's
Health Insurance Plans; Suzanne M. Gaynor, U.S. Department
of Housing and Urban Development; Geralyn Glenn,
America's Health Insurance Plans; Kevin Kennedy, Children's
Mercy Hospitals and Clinics; Anne Kelsey Lamb, Regional
Asthma Management and Prevention Initiative;
Kara Miller, Ohio Department of Job and Family Services; and
Prentiss Taylor, M.D., Amerigroup Health Plans.
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