AEPA
                                        United States
                                        Environmental Protection
                                        Agency
                                                                    Children's  Mercy
                                                             Hospitals and  Clinics
    2005 Winner of EPA's National Environmental Leadership Award in Asthma Management
What's Inside
>  The Asthma Management Program
>  Tracking and Targeting Patients for Interventions
>  Results Achieved by the Program
>  Scientific Evaluation of Home Assessments
>  Community Involvement
>  Lessons Learned
 Dr. Jay Portnoy and
 staff from Children's
   Mercy accept the
     2005 National
     Environmental
  Leadership Award
from Jeff Holmstead,
Assistant Administra-
 tor for the Office of
  Air and Radiation.
Children's Mercy Hospitals and Clinics successfully promote control of environmental triggers through case management,
asthma counseling, home walkthroughs, and provider education, resulting in reduced use of high-cost medical services and
improved quality of life for its asthma members.
 Children's Mercy Hospitals
 and  Clinics
 Kansas City, Missouri

 Snapshot
 >  Non-profit hospitals and clinics covering 9 counties
 *  Children's Mercy owns a Medicaid managed care
    plan, Children's Mercy Family Health Partners
    (CMFHP), with 45,000 members
 *  CMFHP's network has 2,400 providers and 31
    hospitals
 >  16.8 percent of children in CMFHP plan have
    asthma
 >  65  percent of CMFHP members participating in the
    asthma program are black, 27 percent are white,
    4.7 percent are Hispanic, and 2.3 percent list
    themselves as other races
 >  Children's Mercy is contracted by CMFHP to run 3
    interdependent  asthma management programs
 >  3-part comprehensive asthma management
    program has been in place since  2001
    Children's Mercy Hospitals has three complementary asthma
    programs. First, it trains primary care providers at affiliated
    clinics in asthma diagnosis and management to ensure
    providers are following up-to-date guidelines on asthma
    management. In particular, the education component
    encourages providers to develop an asthma action plan for
    each asthma patient. Second, Children's Mercy enrolls
    members with severe asthma in a case management program;
    these members also meet with an asthma counselor who
    addresses management of indoor environmental triggers.
    Third, if indoor triggers seem to be a serious problem,
    enrollees may be eligible for home visits that include technical
    inspections of plumbing and ventilation systems, along with
    collection of environmental samples. Through its
    environmental assessments, Children's Mercy is attempting to
    correlate improvements in the presence of triggers and
    asthma severity with home modifications and repairs. These
    programs are further described below

    Children's Mercy is contracted by Children's Mercy Family
    Health Partners (CMFHP) to run three interdependent asthma
    management programs for CMFHP members. Dr. Jay
    Portnoy, chief of the allergy, asthma, and immunology section
    at the hospital, noticed in the mid 1990s that some members
    who were following their medication requirements were not

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Children's Mercy Hospitals and Clinics
2005 Winner of EPA's National Environmental Leadership Award in Asthma Management
experiencing an improvement in the severity of their asthma
symptoms. In addition, 5 percent of CMFHP members
were responsible for 60 percent of asthma-related claims.
Dr. Portnoy realized a more comprehensive approach that
included education and addressed environmental triggers
was necessary. "The overall goal of the asthma disease
management program is to empower families to understand
and demand good health care, enable providers to give that
care, and to increase access to community resources," Dr.
Portnoy says.

The Asthma  Management Program
Children's Mercy's asthma management comprises
three programs  to educate  primary care
physicians; provide education and case
management to members with asthma;
and address environmental factors
affecting members' asthma. The first
program, Kansas City Children's
Asthma Management Program
(KG CAMP), is  an education
program for primary care providers
at Children's Mercy-affiliated clinics.
KG CAMP was begun with a grant
from the Robert Wood Johnson
Foundation. Staff at clinics  that have
the largest percentages of CMFHP
members  receive 8 weeks of on-site
training from a team  of certified
asthma educators (respiratory
therapists) in asthma diagnosis and
assessment, environmental
management of triggers, and guidelines for treatment. This
training helps primary care  providers better educate their
patients in the basics of asthma management. It has also
helped to make  the delivery of asthma care more consistent
from practice to practice, an outcome that CMH believes to
be a "tremendous benefit." Providers are reimbursed for the
time they spend developing medication action plans for and
reviewing the plans with CMFHP members. Providers
generally develop action plans for non-CMFHP members as
well, although they may not be reimbursed by other insurers.
Asthma educators have also developed a CD-ROM to be
used for review and for training new providers. The asthma
educators' evaluations have shown that providers continued
to retain the material taught during training one year after
participating in KG CAMP.

The second program, Take Action Against Asthma
Program (TAAAP), works with CMFHP members who
have visited the  emergency department or called a nurse
triage hotline for an asthma attack. TAAAP was originally
funded by a Centers for Disease Control and Prevention
grant. This program's approach is based on the approach
     used in the National Cooperative Inner City Asthma Study
     conducted in the 1990s.1 In TAAAP, asthma case managers,
     who are social workers, work with patients during and after
     hospitalization and after emergency department visits to
     answer questions, determine the need for education or other
     resources, and manage care during hospitalization. The case
     managers also administer a "healthy homes" questionnaire to
     determine whether environmental triggers need to be
     addressed. Based on the results, they may refer members to
     environmental specialists, as described below, or to resources
     such as environmentally-safe cleaning supplies, air
     conditioners, vacuums, or replacement bedding.

                      In addition, asthma counselors, who are
                      also social workers, provide individual
                      education on self-management of
                      asthma, as well as separate group classes
                      for parents and children. Meetings may
                      take place at the hospital, libraries,
                      community centers, members' homes, or
                      other locations. The asthma counselors
                      also address psychosocial factors that can
                      affect patients' ability to manage their
                      asthma. For instance, they may refer
                      members to programs addressing
                      housing concerns or to nonprofit
                organizations for other problems.

               The third program, the Environmental Health
              Program, works with enrollees to address
            environmental factors affecting their asthma. Based
       on the results of the healthy homes questionnaire, the
     community liaison, a respiratory therapist, may call the
     member or his or her caregiver to get more information.
     The liaison may work with the family over the phone or at
     the hospital to discuss ways  to lessen exposure to
     environmental triggers, or if necessary, may request an
     environmental assessment of the enrollee's home to be
     conducted by a specialist.

     The assessment includes a visual inspection of mechanical
     systems such as heating, cooling, ventilation, plumbing, and
     moisture control (including gutters) systems. The specialist
     also conducts a walkthrough to note visible problems with
     air quality, allergens and dust, moisture control, chemical
     exposure, and safety. Finally, the specialist takes
     environmental samples.
            R 3rd, Gergen PJ, Mitchell H, Kattan M, Kercsmar
      C, Grain E, Anderson}, Eggleston P, Malveaux FJ, Wedner
      HJ. A randomized clinical trial to reduce asthma morbidity
      among inner-city children: results of the National
      Cooperative Inner-City Asthma Study. Journal of Pediatrics
      1999 September; 135(3):332-8

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2005 Winner of EPA's National Environmental Leadership Award in Asthma Management
                          Children's Mercy Hospitals and Clinics
The liaison then mails the member's family a report with the
sampling results, the specialist's observations, and an
environmental action plan. The action plan discusses steps
for reducing exposure to triggers, such as removing
carpeting or improving ventilation. The liaison follows up
with phone calls to assist families in implementing the plan.
School districts have contracted with the Environmental
Health Program to assess schools and daycare centers. The
environmental specialist also is present on designated days at
Children's Mercy asthma/allergy/immunology clinics to
meet with members. This program is available free to
CMFHP members. Non-members must be referred by their
primary care providers; if insurance does not cover the
assessment, Children's Mercy will pay the full cost.
Historically, commercial HMOs and PPOs have been
reluctant to cover assessments.

Tracking and Targeting Patients for
Interventions
In order to effectively use limited resources, Children's
Mercy Family Health Partners targets its intensive
interventions to those who need it most. Members are
assigned to one of five categories. The number of members
in each stratum changes constantly because status changes are
recorded in real time.

>  Stratum 1 includes those who may have or may develop
   asthma based on medical history but who have not yet
   been diagnosed. These members are identified based on
   a screening for asthma medication prescriptions or
   related diagnoses (e.g., bronchitis), and are tracked to
   ensure earlier diagnosis and treatment should asthma
   develop.
>  Stratum 2 includes those with a diagnosis of asthma.
   They receive training in how to follow an action plan for
   their medication, where the dose and medicine required
   change based on severity of symptoms. Their providers
   are reimbursed for developing asthma action plans once
   they have completed the in-office intervention.
>  Stratum 3 members, who have persistent asthma, as
   defined by National Institutes of Health Guidelines,
   receive one-on-one sessions with aTAAAP asthma
   counselor.
>  Stratum 4 members use hospital services frequently
   (based on a utilization score of 3.0 or more, where
   emergency department visits are worth 1 point and
   hospitalizations 2 points), so they work with an asthma
   case manager in addition to aTAAAP counselor. In
   some cases they may get environmental assessments.
   Stratum 4 members consist of the top 1.5 percent of
   utilizers.
>  Stratum 5 members are in the top 0.4 percent of
   frequent users; they qualify for automatic home
   inspections and meetings with environmental specialists.

Utilization scores are constantly recalculated, so if a member
goes 6 months without an emergency department visit or
hospitalization, his or her score drops to zero, and the
member may move to a different stratum.

In addition to stratification and utilization scores, Children's
Mercy's asthma database contains data from each enrollee's
asthma action plan. Providers submit a copy of each plan to
get reimbursed for the time spent reviewing it with their
patients. The action plan has the patient's prescription plan;
asthma counselors are able to check the prescription against
the fill rate.

Results Achieved by the Asthma Management
Program
The number of members diagnosed with asthma has
increased as primary care providers learn to distinguish
asthma from other illnesses. In addition, 2,500 enrollees now
have asthma action plans (when KG CAMP started, action
plans were nonexistent).

The asthma management program has resulted in significant
improvements in health among CMFHP members with
asthma. The number of members requiring high-cost
services declined from 300 to 200 in the first three years of
the program. Emergency department visits declined 40
percent from 10 per 1,000 members to six per 1,000
members during the same period and have since declined
further to 2 per 1,000 members. Hospitalizations decreased
more than 50 percent, from 2 per 1,000 members to less
than 1 per 1,000 members, and this rate has for the most
part held steady.

Qualitative improvements include improved quality of life in
members responding to quarterly quality of life surveys in
the year after enrolling in asthma management programs.
Primary care providers participating in focus groups also felt
that, as a result of their participation in KG CAMP training,
they were able to provide better care and education to their
patients, often reducing the need for referrals to specialists.
Providers noted that patients then seemed more receptive to
asthma self-management practices.

CMFHP has noted a 35-percent  decrease in the cost per
claim for asthma. The cost per member with asthma has
declined as well. Figure 1 shows the overall decrease in cost
per member since 2002; Figure 2 shows a breakdown of
how costs for different types of claims have changed over
the same period. (The "Other" category in figure 2 includes

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Children's Mercy Hospitals and Clinics
2005 Winner of EPA's National Environmental Leadership Award in Asthma Management
laboratory charges, home care visits, ambulance services,
psychiatric visits, and other such services.)

Figure I. Cost per Asthmatic per Month (One Year
Moving Average)
    15000

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                                       2005
Figure 2. Cost per Asthmatic per Month by Place of
Service (One Year Moving Average)
                      
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In addition, although the asthma management programs
were originally funded by grants, they are now self-
sustaining. Increased program costs are offset by saving
achieved through lower usage of high-cost medical services
and lower costs per claim.
Scientific Evaluation of Home Assessments
Children's Mercy and its partner, the Healthy Homes
Network of Greater Kansas City, are the recipients of a
three-year grant from the U.S. Department of Housing and
Urban Development. Children's Mercy and Healthy Homes
Network are conducting a scientific study to determine
whether environmental interventions are effectively reducing
asthma symptoms and trigger levels. Children with asthma
get free health assessments and environmental assessments
of their homes; the Healthy Homes Network may spend up
to $2,000 per home on interventions. Investigators measure
levels of allergen and particle concentrations, humidity, and
gases pre- and post-home intervention to determine
     whether the environment is different after the intervention.
     If so, CMH then wants to show that the environmental
     change results in a health improvement. The study also
     includes collection of health, spirometry, and quality of life
     data, both before and after the interventions. As members
     are enrolled in the assessment program, CMH will collect
     baseline information; perform the intervention; allow time
     for the effects to manifest; and then do follow-up
     assessments and data gathering.

     Community Involvement
     In addition to the work it does with the CMFHP
     membership, Children's Mercy's Environmental Health
     Program is involved with community outreach on asthma
     and indoor air quality. Staff from the Environmental Health
     Program are members of local asthma coalitions and air
     quality boards. They have also developed an outreach
     strategy for targeting different audiences. Asthma educators
     participate in local health fairs and conferences and provide
     training on environmental trigger reduction and spirometry.
        "The overall goal of the asthma
        disease  management program is to
        empower families to understand and
        demand good health care, enable
        providers to give that care, and  to
        increase access to  community
                                                          resources.
                                      Dr. Jay Portnoy
     For instance, Children's Mercy collaborated with providers
     to conduct provider-sponsored health fairs, ensuring that all
     CMFHP members with asthma were invited. Asthma
     educators conducted asthma screenings at provider offices
     and providers wrote asthma action plans. "The results
     showed that 20-30 asthma action plans could be written in a
     single morning or afternoon," says Dr. Portnoy. In 2004,
     Children's Mercy staff cosponsored an indoor environment
     conference for health care providers, school officials, and
     public health workers. Currently, they are planning a similar
     conference that will include events designed for the general
     public.

     Lessons  Learned
     The Environmental Health Program has grown over time as
     the environmental specialists have become more skilled at
     performing environmental assessments. They now have a
     better idea of what data to collect and have learned to
                                                     4

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2005 Winner of EPA's National Environmental Leadership Award in Asthma Management
                          Children's Mercy Hospitals and Clinics
 Getting Started
 >  Determine what kind of home visit program you
    want. A specialist such as an industrial hygienist may
    be best able to identify and address structural or
    technical problems that cause mold, for example.
    However, such programs may be more expensive,
    especially if they include environmental sampling.
 >  Determine how to follow up after a home visit.
    For example, decide whether there will be
    additional visits or phone calls.
 >  Apply for a grant if you are  not-for-profit. A grant
    can help you get your program off the ground.
    Once you show the program is cost-effective, plan
    management may be more willing to continue the
    program when the grant ends.
 >  Build incentives into your plan. Reimburse
    providers for time they spend developing asthma
    action plans and educating  patients.
develop hypotheses, assess those hypotheses, and interpret
the results of their assessments. They have developed tools,
such as the healthy homes questionnaire and the
environmental assessment worksheet, to track symptoms
and potential triggers. Currently, it is difficult to isolate the
extent to which improvements in asthma symptoms are due
to asthma education, case management, or interventions in
the home. With the Healthy Homes study described above,
Children's Mercy hopes to determine the effect of home
interventions on asthma.

Children's Mercy believes that its asthma management
approach is relevant to treatment of other health problems.
The hospital is therefore creating a new department, the
Department of Health Management, which will use the
same principles of provider training, counseling for patients,
and home and lifestyle assessments to treat problems such as
obesity and attention deficit hyperactivity disorder. "At the
heart of the new department is the innovative approach of
providing resources and education directly to medical
service providers at the health plan level," says Dr. Portnoy

Children's Mercy has shown that it can be cost-effective to
provide intensive services for chronic diseases on a targeted
basis. Such services result in better health and reduce the
need for high-cost emergency services.

For more information on the Children's Mercy asthma
program, contact Candace Ramos, Community Health
Educator, at clramos@cmh.edu or (816) 983-6806.

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