Asthma program cuts ER, hospital visits
Guideline implementation emphasized
A year-long asthma care management pilot program for Boston-based Blue Cross & Blue Shield of Massachusetts (BSBSMA) based on national guidelines resulted in a 90% decrease in emergency room visits, a 59% decrease in hospital admissions, and a 64% decrease in missed days of school or work.
The program, developed by Broomfield, CO-based Access Health, also resulted in significant improvements in symptoms (52% reported improved functional status) and in knowledge about asthma (62% reported medication knowledge they did not possess before the program, and there was a 33% increase in use of peak flow meters).
"To improve the quality of life for our members who suffer from asthma, we looked for a scalable, integrated disease management program," says Shannon Sayles, RN, MS, director of quality and health improvement programs for BCBSMA. "Access Health's program offers that, as well as incorporates members' physicians, has clear evaluation and tracking, and is based on published clinical standards of care."
After the success of the pilot project, BCBSMA has decided to roll out the program to all members. Sayles says the keys to the program are:
· a 24-hour phone line that gives patients immediate access to nurses;
· follow-up monitoring calls;
· in-depth assessment and reinforcement of patients' knowledge of asthma.
· A case manager who coordinates services and delves into complicating issues such as family support, mental health, and comorbidities.
The program begins with a health resource counselor placing a 45-minute call to each patient to collect information about their health status, symptom control, medications and devices used, and knowledge of the disease, says Margaret Flaum, RN, BSN, director of disease state management delivery for Access Health. Based on that information, each patient is stratified to one of four severity levels that determine the number of follow-up calls. A level four (severe) patient, for example, receives monthly calls, while a level one (mild) patient gets a packet of educational material and the number for the 24-hour line they can call with questions.
Nurses make the follow-up calls with specific educational objectives based on national guidelines in mind, depending on what the patient already knows. At the end of the call, for example, the patient should be able to give three early warning signs of an asthma attack. If the patient can't do that, the next call (made by the same nurse) will address the same issue. The patient's status and knowledge base is tracked on a specially designed computer program. "It makes a strong impact on the patient to develop this relationship with a highly skilled nurse over the phone," Flaum says. "There is a strong emotional component that pulls the patient and provider together."
Physician follow-up
After each contact with the patient, a report is sent to the physician. "It provides a good check against the system," says Rufus Howe, RN, MN, FNP, vice president of disease state management for Access Health. "If the patient self-reports taking two different inhalers, but the physician prescribed three, the physician can talk to the patient and confirm instructions."
Each patient gets a letter detailing a customized self-management plan, and physicians get a summary of the major points of the national asthma guidelines from the Bethesda, MD-based National Heart, Lung, and Blood Institute. "Our objective is to narrow the gap between the guidelines and actual practice," Howe says. "I don't believe any physician intentionally withholds proper treatment, but their day is filled with tons of diseases. And there are things that get in the way. You may be coming in for asthma, but you've got an ingrown toenail, or your brother just died. You could be seeing the world's best expert on asthma and get everything you need for that ingrown toenail but get only half of what the chart says you should get for your asthma."
The other problem is that physicians don't always know whether the patients are complying with instructions. "When patients go in to see their physician, generally they over-report their compliance with treatment," Flaum says. "Physicians are being asked to do a lot more with less, and it's very hard for them to ask the question in enough different ways to get the true answer. If they ask if the patient is taking their medications and the answer is yes, they'll move on instead of probing further."
It's important to get patients involved in their own care, Howe says. "We treat patients as consumers who should be able to get what they deserve. We give them an owner's manual for the asthmatic body. They learn about so many things they didn't even know existed, like special mattress covers that control dust mites."
[For more information on asthma management programs, contact:
· Shannon Sayles, RN, MS, director of quality and health improvement programs for Blue Cross & Blue Shield of Massachusetts, 100 Summer St., Mail Stop 0107, Boston, MA 02110. Telephone: (617) 832-5633.
· Margaret Flaum, RN, BSN, director of disease state management delivery or Rufus Howe, RN, MN, FNP, vice president of disease state management, Access Health Inc., 310 Interlocken Parkway, Suite A, Broomfield, CO 80021. Telephone: (303) 466-9500.]
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