v>EPA
United States
Environmental Protection
Agency
Optima Health
What's Inside
> Optima Health's Asthma Management Program
> The Life Coach Program for Severe Asthmatics
> Results Achieved by the Life Coach Program
> Lessons Learned
Janis Sabol and George
Heuser, M.D., accept
the 2005 National
Environmental
Leadership Award from
Jeff Holmstead, EPA
Assistant Administrator
for the Office of Air
and Radiation.
Optima Health
Virginia Beach, Virginia
Snapshot
> Non-profit managed care system
(division of Sentara Health)
> Medicaid HMO, as well as
commercial HMO, PRO, and POS
plans
> Asthma management program,
including home visits, in place
since 1997
* Of 300,000 members, 8,000 to
9,000 have asthma
> 35 percent of members with
asthma are in a commercial plan;
65 percent are in the Medicaid
HMO
* 70 percent of those with asthma
are children
In the mid 1990s, Optima Health staff noticed that despite
pharmacological advances in asthma therapy, hospital admissions for
asthma were increasing. Optima Health conducted a year-long pilot
study with 50 high-risk children, during which clinicians made home
visits to enrollees to develop asthma self-management practices. Optima
then compared post-study utilization of health services to pre-study
utilization and noted a dramatic improvement; based on these results,
Optima Health expanded the program to all its members with asthma.
Optima Health's comprehensive asthma management program includes
full recognition of the importance of managing environmental triggers in
addition to taking appropriate medications. The program educates all of
its members with asthma about environmental trigger management, and
provides more intense counseling for members with more severe asthma.
As part of its comprehensive asthma management program, Optima
Health provides unlimited home visits by "asthma life coaches," nurses
or respiratory therapists from contracted home health agencies, to
enrollees with severe persistent asthma. The goal of the program is to
"provide education and support to promote optimal independent
functioning, thus reducing the need for more intensive, higher cost
services," according to Janis Sabol, program coordinator for asthma
disease management at Optima. Home visits enable life coaches to
identify possible environmental asthma triggers during walkthroughs.
Multiple visits help patients and their families develop trust in their
coaches and enable gradual implementation of trigger avoidance
measures and home modifications, increasing the likelihood of long-term
compliance with trigger management. Life coaches also teach enrollees to
manage their asthma through consistent use of medication and
implementation of an asthma action plan. The life coach program is
offered only to higher risk members because, as the member's severity
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Optima Health
2005 Winner of EPA's National Environmental Leadership Award in Asthma Management
Optima's Community
Activities
* Outreach to major
employers
* Health fairs and classes
on asthma
level decreases, so does
their utilization of health
services, thus decreasing
the return on investment
for this higher level
intervention.
management
The life coach program
has achieved significant
reductions in
hospitalizations and
emergency department
visits among participants.
Overall health care costs decreased by 35 percent for
participants in the life coach program. Optima has also
realized cost savings as a result of these reductions.
"Community relationships, visibility, cost containment
they're all important factors," said Janis Sabol. "Certainly,
creating good will in the community is a key motivation."
The Asthma Management Program
Optima's asthma management program provides
interventions based on their enrollees' asthma severity.
Members with asthma are placed into one of three categories
based on medical and pharmacy claims information. These
categories are similar to guidelines issued by the National
Institutes of Health but are modified slightly, since Optima
has access only to medical and pharmacy claims information
and not to results of medical tests. New health plan
members are assigned to a category based on responses to a
questionnaire on asthma. Optima uses these categories to
determine the types of asthma services members should
receive, as shown in Figure 1 below. Because members of the
mild and moderate persistent categories often have a
sufficient understanding of their disease and how to manage
it, interventions offered to these members reinforce positive
behavior primarily through mailings and case manager phone
calls. Members in the severe persistent category, however,
often require more intensive interventions provided through
Figure I: The Asthma Management Program
Mild Persistent
Moderate Persistent
Severe Persistent
Characteristics
> Physician office visit with
primary diagnosis of asthma
> With or without minimum
use of asthma-related
medications
> No emergency department
visits or hospitalizations
> Also includes mild
intermittent patients
> I or 2 emergency
department visits in 6
months with primary
diagnosis of asthma, and
> Use of 4 or more canisters
of inhaled asthma rescue
medications in 6 months
> Hospitalization for primary
diagnosis of asthma, and/or
> Use of 6 or more canisters
of inhaled asthma rescue
medication with little or no
inhaled steroid use
% of Asthma Members
80 percent
12 percent
8 percent
Education
> Education materials mailed
> Invitation to free group
classes offered twice a
month
Same
Same
Case Management
Phone number of asthma
case manager
> Screening phone call from
asthma case manager about
symptoms, medication use,
triggers, and doctor visits
> The case manager conducts
the same screening for
environmental triggers as the
life coach does for severe
asthma cases, except no
walkthrough is conducted.
> Additional follow-up by
telephone to achieve patient
self-management
> Referral to life coach if not
successful
> Life coach program,
including visits from a
trained health professional
(the "life coach"), home
walkthrough, and I year of
follow-up calls and visits.
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2005 Winner of EPA's National Environmental Leadership Award in Asthma Management
Optima Health
the life coach program to help develop self-management skills
necessary to manage asthma.
The Life Coach Program for Severe Asthmatics
Members in the severe persistent category receive free visits
from a life coach, who is a trained nurse or respiratory
therapist from a home health agency. When the member
enrolls in the life coach program, Optima notifies the
enrollee's physician by phone or letter and provides a profile
of the enrollee's asthma history and services provided. During
the initial visit, the coach reviews the member's medical
history, performs a physical and psychosocial assessment, and
assesses asthma severity and triggers. The coach also discusses
medication use patterns, peak flow meter use, and when to
visit a physician as opposed to the emergency department.
The coach then determines issues to be addressed in future
visits and works with the member's physician to develop a
treatment plan. Life coaches spend at least one full visit on
environmental triggers. The visit includes:
> A review of known triggers.
> Identification of additional possible triggers through
discussion of symptoms and results of allergy testing, if
available.
Home walkthrough to identify possible triggers.
Suggestions for modifications in the home to reduce
exposure to triggers; referrals to resources for obtaining
allergen-proof bedding or smoking cessation materials.
Discussion of other places where triggers may be present
and how to avoid them.
Discussion with other care providers to encourage trij
avoidance outside the home.
rer
Coaches may visit as many times as they believe necessary;
the average is four visits. Visit frequency may range from
once every 23 months to 23 times a week. Once the
enrollee is effectively self-managing his or her triggers,
coaches stop making home visits but continue to follow up
by phone, more frequently at first, to ensure continued
compliance with the treatment plan and with trigger
avoidance. Life coaches define self-management as successful
use of the treatment plan, successful behavior or lifestyle
changes, and decreased use of high-cost services. Phone calls
continue for at least one year after the completion of home
visits; if asthma severity changes for the worse, coaches may
reinstitute home visitation.
Figure 2: Total Pre- and Post- Enrollment Health Care Costs for Patients Participating in the Life
Coach Program
Product Claim Type
Commercial ( 1 36 members) Primary care provider visits
Emergency room visits
Home health
Inpatient admission
Specialist referrals
Medicaid HMO (354 members) Primary care provider visits
Emergency room visits
Home health
Inpatient admission
Specialist referrals
Total (490 members) Primary care provider visits
Emergency room visits
Home health
Inpatient admission
Specialist referrals
Total
Cost Pre-Enrollment
$26,378.34
$27,379.30
$3,696.43
$224,122.64
$29,758.62
$33,835.29
$53,667.02
$3,587.55
$294,685.64
$44,799.30
$60,213.63
$81,046.32
$7,283.98
$518,808.28
$74,557.92
$741,910.13
Cost Post-Enrollment
$19,885.56
$17,795.33
$6,458.66
$101,846.04
$46,44 1 .87
$29, 1 60.42
$51,673.65
$17,066.60
$139,627.30
$50,569.85
$49,045.98
$69,468.98
$23,526.46
$241,473.34
$97,0 1 1 .72
$480,526.48
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Optima Health
2005 Winner of EPA's National Environmental Leadership Award in Asthma Management
In addition to home visits and phone calls to members, life
coaches may contact their schools and employers to
encourage them to take steps to reduce levels of
environmental triggers in their buildings. Coaches also
communicate with enrollees' physicians regarding possible
triggers and the need for changes to prescriptions and
treatment plans.
Optima Health has contracts with several home health
agencies to provide life coaches for its members. The
program expectations are included in the contracts. The
home health agencies are paid the same amount ($425 per
member per year) for each member enrolled in the life coach
program, regardless of the number of home visits a member
requires.
Results Achieved by the Life Coach Program
Optima Health has noted significant improvements in
asthma management over the last few years, based on the
following indicators to measure improved health
performance:
> Hospitalizations per 1,000 members with asthma
> Emergency department visits per 1,000 members with
asthma
> Ratio of inhaled rescue medication use to inhaled steroid
use
> HEDIS (Health Plan Employer Data and Information
Set) measures for use of appropriate medications for
people with asthma
How to Get Started
* Consider a pilot home visit program. A pilot can
help you determine the most effective approach
while minimizing the initial investment required.
A successful pilot will help persuade plan
managers and the board of directors of the cost-
effectiveness of a home visit program.
* Determine an approach based on logistics,
budgetary restraints, and the needs of your
members. For example, contracting with home
health agencies may provide your plan the
flexibility to reach members throughout the state
and to reach more members as your program
expands. In Optima Health's case, it was
convenient to work with an agency that it was
already affiliated with.
> Calculate baseline utilization rates and costs so
you will be able to track the effectiveness of your
home visit program.
Between 1999 and 2004, hospitalizations for asthma
decreased by 54 percent in the commercial health plans and
32 percent in the Medicaid HMO plan. Emergency
department visits decreased 18 percent in commercial plans
and 33 percent for Medicaid patients during the same time
period. There was some fluctuation in rates during the time
period, probably due to variations in climate. (Extreme heat
or cold can trigger asthma attacks, and weather can also
affect levels of triggers such as smog, pollen, and mold.)
However, the overall result was a decrease in use of high-
cost services.
The ideal ratio of rescue medication to inhaled steroid use is
1:1, with the assumption that regular use of steroids
decreases the chance of an asthma episode, thus decreasing
the need for rescue medication. Based on pharmacy records
for both commercial and Medicaid plans, between 2000 and
2004, the ratio had decreased from 2.63:1 to 1.58:1.
HEDIS measures for appropriate use of asthma medication
increased 1.5 percent from 2002 to 2004 to 70 percent.
As a result of the decrease in hospitalizations and emergency
department visits, overall costs decreased by 35 percent in
enrollees participating in the life coach program, as shown in
Figure 2 on the previous page. This decrease occurred in
spite of increases in home health costs associated with life
coaches and increases in visits to specialists. This number is
based on a comparison of pre-enrollment costs to post-
enrollment costs for 490 participants in the life coach
program, where the pre-enrollment period and post-
enrollment period are the same amount of time (although
the length of these periods varies for each patient). "Post-
enrollment" costs are measured beginning 6 months after an
enrollee begins the life coach program; in some cases
enrollees may still be participating in the program.
Approximately 500 additional enrollees in the life coach
program were not included in this analysis because their pre-
enrollment or post-enrollment data were insufficient.
Prescription costs were not included in the costs shown on
the previous page, but did increase 53 percent overall with
improved adherence to inhaled steroid medication, from
$132,292 to $202,625. However, this increase was more than
offset by the decrease in utilization costs. The savings help
to pay the administrative costs of the program.
Optima Health has calculated a return on investment of
4.4:1, where return on investment is defined as total health
plan cost savings divided by total program costs, and
program costs include materials, mailing costs, and asthma
management staff. In addition to achieving a financial return
on investment, part of Optima Health's mission is to be
proactive and quality-oriented. Optima's quality initiative is
to "provide disease management programs that help to
manage health issues before they become major problems,"
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2005 Winner of EPA's National Environmental Leadership Award in Asthma Management
Optima Health
said Janis Sabol. Improving health is as important as being
cost-effective.
Lessons Learned
Optima Health has learned several lessons over time. Since
the inception of the asthma management program, the focus
on management of environmental triggers has increased.
Initially, asthma case managers and life coaches emphasized
the importance of taking asthma medication as prescribed.
However, they noticed that adherence to a treatment plan
alone often did not result in decreased asthma severity. Two
years into the program, they determined that trigger
avoidance was necessary and that modifications had to be
made gradually to avoid overwhelming members. The
coaches suggest "small changes that the patients feel they
can make quickly and without too much cost or effort," said
Sabol. "Most patients cite cost and inconvenience as the
main reasons they do not make requested changes to their
homes." For example, instead of recommending that
families give away pets, coaches might first recommend that
the dog sleep on the floor instead of on the child's bed, and
at the next visit recommend having the dog sleep outside the
child's room. Similarly, coaches might initially recommend
vacuuming and dusting once a month. At the next visit, they
might suggest vacuuming and dusting every two weeks, and
so on.
In addition, Optima streamlined the home visit curriculum.
The coaches noticed that only some of what they taught was
being retained, so they and Optima worked together to
determine what information absolutely had to be transmitted
to members. The amount of time spent with members
remained the same, but the lessons were simpler and more
focused.
Optima Health also learned that persistence is necessary to
achieve good results. Members in the Medicaid HMO are
particularly difficult to track because they move frequently.
Case managers and life coaches must work hard to contact
members initially and to follow up with them. In addition,
some members become complacent about their asthma and
are less willing to participate in the life coach program.
Members whose hospitalization or emergency department
visits begin to increase are re-enrolled and start to receive
visits again from a life coach. Optima Health's continuous
attention to its members with asthma supports their goals of
having all asthma patients maximize their treatment options,
reduce acute episodes, and improve their overall quality of
life.
For more information on Optima Health's asthma
management program, contact Janis Sabol, program
coordinator for asthma disease management, at
jsabolfg.sentara.com or (757) 552-8934.
This document provides information on an organization's
comprehensive asthma management program. The content
of the document does not represent official EPA policy or
guidance.
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