Aetna’s Asthma Program for Medicaid Members in Delaware
Asthma is among the top chronic lung diseases afflicting adults and children in the United States. Asthma disproportionately affects racial and ethnic groups. The medical literature notes that asthma emergency room (ER) use is highest for both African Americans and Hispanics when compared to non-Hispanic Whites.
Aetna assessed asthma ER utilization over a one year period to determine if there were differences in ER utilization by race and ethnicity in its insured population. For African Americans, ER utilization was more than three times higher for both adults and children when compared to Whites. For Hispanics, ER utilization was nearly two times higher for both adults and children when compared to Whites.
Based on the striking differences in asthma ER utilization by race and ethnicity, Aetna sought to address and reduce this disparity by developing a culturally appropriate, evidence-based program targeting high-risk populations. Its goal was to impact ER asthma utilization by improving the quality of asthma care for this population while simultaneously reducing avoidable ER visits in a specific state or region.
According to the American Lung Association, the prevalence of asthma in adults in Delaware is more than 9.8 percent, while the national average is 8.4 percent (as of 2009). Based on this information and in consultation with Aetna’s Medicaid team, Delaware Physicians Care (DPC), Aetna selected Delaware as the pilot site for this program, which began during first quarter 2011.
In partnership with DPC and Disease Management, Aetna identified a high-risk target population. The target population was comprised of Delaware members with an asthma diagnosis and at least one ER visit. The age ranges of members were from five to 50 years old.
To address chronic condition management, Aetna has a centralized disease management (DM) program that includes asthma care.
Aetna’s current asthma disease management program offers:
- Asthma health coaching
- Culturally competent training for Aetna clinical staff
- Coverage and encouragement of primary care provider and specialist visits
- Physician education and engagement
- Controller and rescuer medications
- Asthma-related medical supplies including spacers, peak flow meters, nebulizers, etc.
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For its evidence-based, culturally appropriate program, Aetna leveraged this strong foundation that existed and then augmented it to make it more focused on the targeted population of Delaware Medicaid members to increase member participation in its program. The augmented program was enhanced and strengthened to include the following specific elements:
Targeted Member Outreach and Collaboration
The clinical nurses are the first point of contact to the member. In addition, the members and their physicians receive welcome letters and educational materials. The goal is to provide the best medical and environmental management by engaging as much of the target population as possible.
Validated Tool to Assess Asthma Control
In order to assess a member’s asthma severity during these calls, nurse case managers utilize the Asthma Therapy Assessment Questionnaire, which is a validated tool that assesses asthma control. This tool generates indicators of potential care problems in several categories, including: symptom control, behavior and attitude barriers, self-efficacy barriers, and communication gaps.
Culturally Appropriate Member Education Materials
The member receives culturally and linguistically appropriate asthma education materials that were developed by allergy specialists specifically for the African American population and are consistent with current asthma care recommendations. These materials are available in both English and Spanish.
In order to appeal to all ages, there are specific materials created for children, teens, adults and parents. The content of these materials includes a review of the disease process, use of medications, appropriate use of an asthma action plan, environmental triggers, and common myths about asthma.
All Delaware Medicaid members are provided with a toll-free phone number in case they have additional questions.
Home Environmental Assessments
Several home care agencies in the Delaware area were selected to perform home environmental assessments. The home care agencies had to agree to use the U.S. Environmental Protection Agency (EPA) Asthma Home Environment Checklist and attend training on the use of this EPA tool. Home care agency personnel assess the sensitivity of the patient to indoor and outdoor environmental triggers based on their findings and reinforce these learnings during subsequent visits. Additionally, nurse telephonic outreach was created as a substitute for the in-person visit if the person did not want anyone entering their house. The nurses use the EPA home assessment tool during telephonic outreach.
The home care agency or telephonic nurse provides a comprehensive report to the member’s PCP and Aetna.
Community Health Workers (new for 2012)
For members who did not want strangers in their homes, Aetna will be using community health workers, who are considered known and trusted advisors in their community. Aetna is developing standardized asthma training for community health workers using the EPA home assessment tool as a guide.
Incentives (new for 2012)
Aetna has also developed a three-tiered incentive strategy that is being implemented to improve member recruitment, uptake of home environmental assessments, and overall completion of its comprehensive asthma program.
The program evaluation assessed both process and outcome measures. The primary outcome measure is program impact on avoidable asthma ER visits.
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In order to determine the impact of this initiative in reducing avoidable ER admissions, Aetna analyzed two comparison groups using two methods that accounted for asthma seasonality by comparing similar time frames. Early results are as follows.
- The first comparison group is Delaware Medicaid members ER utilization in 2010 vs. 2011. This comparison showed a 19 percent reduction in ER admissions in 2011 compared to 2010.
- The second comparison group is 2011 Delaware Medicaid members vs. Delaware Commercial members. This comparison resulted in a 13 percent decrease in ER visits for Medicaid members vs. Commercial members.
Aetna’s program is a comprehensive approach to addressing disparities by improving asthma management for Delaware Medicaid members in which asthma environmental management activities are one element of this comprehensive program. The plan believes that it is the combination of all the evidence-based elements that have favorably impacted asthma ER admissions described above.