Kaiser Permanente: The Colorado Asthma Experience

Improving Gaps in Care 

Kaiser Permanente’s HealthTRAC Asthma Registry includes 42,000 members or about 8% of total Kaiser Permanente Colorado (KPCO) membership.  During 2010, the Kaiser Permanente Colorado (KPCO) 12-month average for emergency department (ED) visits for asthma was 35 per 10,000 members for pediatrics and 13.8 per 10,000 members for adults.  For asthma related inpatient discharges, KPCO’s 12-month pediatric rate is 11 per 10,000 members and 2.3 per 10,000 members for the adult population. Both KPCO’s asthma related ED and hospitalization rates were well below the published CDC and state rates. Hospitalizations and ED visits are seasonal. Lower income and African-American populations have higher hospitalization and ED rates than other socio-economic and ethnic populations. 

Research shows a linear association between increasing fills of short-acting beta-agonist use and hospitalization and ED visits for asthma; as fills for beta-agonist increase, so does the prevalence of hospitalization and ED visits.  For those patients with persistent asthma, data shows correlation between regular use of an inhaled corticosteroid (ICS) and decreasing hospitalization and ED rates.  Regarding the HEDIS 2011 rate, KPCO ranked #1 in the nation in persistent asthma patients filling an ICS. 

Learn  More: 

Program Overview
Value Proposition
Access and Support
Expansion Efforts 

Asthma Care Coordinators Key to Program Success 

Several studies correlate asthma disease management programs with lower costs resulting from decreased hospital and ED visits.  KPCO Asthma Management Disease Program is led by RNs known as Asthma/COPD Care Coordinators (ACCs) who work closely with primary care physicians to:

  • Outreach to patients overusing Albuterol or under filling inhaled coticosteroids;
  • Outreach to patients with an ED visit for an asthma exacerbation;
  • Provide patient education when requested by PCP, Allergy or Pulmonologym Department;
  • Perform spirometry to better assess asthma;
  • Provide education for staff to correctly perform and document spirometry;
  • Support implementation of the “Albuterol Refill Protocol”;
  • Develop Asthma Action Plans in collaboration with patients.

The ACC team also coordinates letter campaigns each year; two that are pediatric-focused and two that are adult-focused.  The letter campaigns strategically address issues such as ICS under use, beta agonist overuse, back to school asthma education, and promotion of the flu vaccine.  To date, the letter campaigns have shown a 23.8% response rate for prompting patients to pick up an ICS.

The asthma program is also supported by the Allergy Department, which sees patients who were hospitalized for asthma. In addition, the Clinical Pharmacy Department supports KP’s regional asthma program from a medication therapy and cost perspective.  A recent pharmacy initiative to outreach to patients on Advair and convert them to Dulera has saved KPCO 2.5 million dollars. Asthma medication cost is the biggest contributor to the overall cost of care for patients with asthma and the pharmacy has played an integral part in helping keep medication costs low.

The Asthma Governing Board oversees all asthma population management efforts.  The Asthma Governing Board establishes the annual program goals and objectives and monitors key asthma quality indicators to ensure that the organization is on track to meet goals.  When needed, the Asthma Governing Board will discuss challenges and opportunities that may impact the organization’s ability to provide evidence based care to KP members who have asthma.  In 2012, work is being done to solicit members’ perspective by addition of 2 KP members to the Governing Board.

The Board includes representation from the Clinical Informatics Decision Support team to ensure that the HealthTRAC asthma registry is accurately identifying and stratifying the asthma population so that resulting interventions, outreach, and in-reach can occur in a timely and appropriate manner.

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In 2011, the ACC team provided services for nearly 9,000 members with asthma who were identified as at-risk.

ACC’s outreach to asthma patients in high risk categories: those overfilling beta-agonist, those underfilling inhaled corticosteroids and patients who have been in ED with asthma exacerbation.  The asthma/COPD care coordinators utilize HealthTRAC reports to generate lists of names. In 2011 the ACC’s outreached to 3,754 members.  Approximately 5,000 letters were sent to patients who were in the high risk categories with a 23.8% rate of filling ICS. For 2012, the ACC’s are completing a questionnaire for each outreach in their Health Connect documentation. 


In addition to tracking patient interventions, the team has identified tasks that may contribute to patient care directly or indirectly, other tasks that support or educate staff or providers and miscellaneous tasks.  A tracking tool has been developed for them to monitor these items for 4-8 weeks.  This information will then be analyzed with the help of project coordinators to identify areas of opportunity for improvement in efficiency, productivity and/or quality.  Process mapping and other tools will be used by the team to streamline work flows and standardize processes.

Value Proposition (Optional in 2012)  

Literature supports KPCOs’ continued focus on increased use of inhaled corticosteroids in the persistent asthma population and interventions for those who are overusing rescue medication. These are key factors for improved asthma control and translates to lower ED and hospital utilization at cost savings.

By partnering with Pharmacy Operations, the Governing Board is seeking to decrease asthma medication costs. One strategy is the Dulera conversion and limits to the number of albuterol canister equivalents that are dispensed to patients in an effort to decrease overuse and medication waste. 

The Governing Board is researching use of spirometry to support step down therapy which will decrease medication cost for both the patient and KPCO.  A Canadian cost effectiveness analysis found 28% of randomly selected physician-diagnosed asthma patients were misdiagnosed. Of the patients who were misdiagnosed, 71% were on an asthma medication. In comparing the ongoing cost of asthma medication and the cost of secondary screening to confirm the diagnosis, the average cost saving per 100 individuals screened was $35,141 (Pakhale et al., 2011). A similar study in the U.S. used spirometry to confirm physician-diagnosed asthma in pediatric patients and found nearly one third of patients were misdiagnosed (Talwar & Leo, 2007).


Increasing Access and Support for Evidence-based Guidelines  

KP’s Colorado Community Benefit group has funded the Colorado asthma toolkit and training program.  The Colorado Asthma Toolkit Program (CATP) has successfully trained 100 primary care practices in Colorado, mostly in rural areas and all providing care to medically underserved patients.  The 6 hour training aims to increase knowledge of evidence-based guidelines.  A free spirometer and training in its use and interpretation is provided as well as an understanding of asthma care management strategies in underserved communities to help facilitate patient-provider interactions.  Led by National Jewish Health, the program has been in existence since 2007 and has resulted in increased use of spirometry, asthma action plans and inhaled corticosteroid medication.

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Kaiser Permanente Efforts Outside of Colorado 

Increasing Community-Based Care 

Kaiser Permanente has also funded The Breathmobile® (BMo) a project by the Prescott-Joseph Center for Community Enhancement, Inc. located in Northern California and Southern California.  BMo is a mobile asthma clinic equipped with an exam room, intake and waiting area, with capabilities to test for vital signs and allergen skin testing and spirometry.  The team consists of certified allergists – a pediatrician, registered nurse or nurse practitioner, respiratory technician and a patient service worker/driver.  The majority of the staff speak Spanish and all services are available in multiple languages (English/Spanish).

In Southern California, the BMo operates in the Los Angeles, Orange, San Bernardino and Riverside counties, and is governed by a partnership with the Asthma and Allergy Foundation of America, University of Southern California (USC), some medical centers, and County School Districts. These mobile asthma clinics can visit 22–23 school sites per month, seeing children with asthma.

In the Bay area, the mobile asthma clinic serves various counties and school districts as well as areas where gaps are seen in care. During the first year of operation, the Northern California team saw a significant reduction in asthma-related emergency room (ER) visits and school absenteeism from the previous year. ER visits dropped from 71 to 2, and absenteeism dropped from 101 to 7 among school children seen within a 4-6 week time period.

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