Capital District Physicians’ Health Plan (CDPHP) Asthma Care Management Program


Capital District Physicians’ Health Plan (CDPHP), a non- profit health plan that operates a network of providers and practitioners to offer healthcare services in New York and Vermont, has developed a number of strategies to remove identified barriers related to knowledge and cost, and to ensure quality asthma care is delivered to their diverse members.  

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Removing Barriers
Deliver Community-Based Care
Identify those in Need
Prevent Onset of Asthma 


Removing Barriers to Delivery of Guidelines-Based Asthma Care  

In 2012, CDPHP introduced value based health plans.  To address a cost barrier, these plans waive co-pays and offer select maintenance drugs at zero cost, depending on the option track. 

In an effort to increase knowledge of asthma care guidelines, CDPHP developed and circulated measure specific HEDIS® tip-sheets for providers to enhance provider understanding of these measures. 

The plan has also set-up targeted outreach campaigns to members with asthma identified without a claim for a long-term control medication in the prior 12 months. Consumer messaging focuses on educating members on the importance of long-term control medication, and reinforcing the importance of taking medications as prescribed by a physician.


Building Local Capacity to Deliver Integrated Community-Based Care  

CDPHP works directly with providers through the Asthma Coalition of the Capital Region (ACCR). Gap reports are given to providers at coalition meetings, generating explanation and discussion.

CDPHP is partnering with select level 3 Medical Home practices that provide its Enhanced Primary Care (EPC) program, to facilitate payment and quality reform. These reforms drive integrated, high quality, affordable health care.   

CDPHP places nurse case managers in the EPC practices to allow for face-to-face interaction with members.  These opportunities help to educate, clarify and provide disease-specific materials directly to members. In addition, collaboration between physician office staff and CDPHP care management programs continues to increase.

Telephonic educational outreach is made to members with an emergency visit (ER) or in-patient hospital visit for asthma. The conversation includes the importance of a follow-up visit with the member’s primary care provider (PCP).

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Improving Capacity to Identify Those Most in Need 

At the end of 2011, CDPHP moved to a new Care Management application which allows the plan to build identification and stratification rules in-house. The system incorporates claims data as soon as it is loaded into its warehouse. Previously the plan relied on external vendor programs to identify chronic disease populations. This new system allows CDPHP to be more agile and quickly change target populations for care management outreach. 


Accelerating Efforts to Prevent Onset of Asthma through Varied Resources 

To accelerate efforts to prevent poor asthma outcomes, CDPHP’s embedded case managers at the EPC sites to promote and facilitate action plan completion.

CDPHP also institutes secure transmittal of e-referrals to New York State’s Smoker’s Quitline allowing a more timely transfer of member information and faster outreach to the member from Quitline professionals.

Lastly, providers are given a number of gap reports that identify high-risk members, number of inpatient stays, emergency visits, specialist visits, and frequency of PCP visits and potential gaps in care. Providers can use these reports to determine where to focus pro-active outreach and care.

All these multi-prong efforts have resulted in improved asthma care coordination and management among CDPHP’s members.


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