Neighborhood Health Plan Asthma Disease Management Program
Neighborhood Health Plan (NHP) was one of the first health plans in the country created with the express purpose of addressing the health care needs of underserved populations. By working closely with the Commonwealth’s Medicaid program and commercial purchasers, and by partnering with community health centers (CHCs) and other providers, NHP grew from a few thousand members in the late 1980s to over 250,000 members today throughout Massachusetts.
Management and Operations
Integrated Health Care Services
Comprehensive Asthma Management Program
NHP is committed to improving the health care of its members. The health plan’s clinical program activities extend across the continuum of care and include disease prevention, health promotion and member education, disease management, care coordination, and complex case management. The goals of NHP’s programs are to promote improved health outcomes, increase member and provider satisfaction, and support appropriate resource utilization through member and provider focused initiatives.
NHP’s Asthma Disease Management Program (ADMP) is based on the assumption that, for most patients, asthma is a controllable illness and that much of asthma morbidity is preventable. The varied components of ADMP are geared to assist primary care providers (PCP) with proactively managing their NHP patients with asthma while providing them with tools to improve the asthma care they provide to all of their patients. The program focuses on reaching out to members at risk and engaging their providers with actionable, patient-specific data to improve outcomes related to appropriate medication use and reducing hospital-based utilization.
Management Structure and Operating Principles
In 1999, as a result of an increasing trend in asthma related utilization and hospitalizations, the Chief Medical Officer at NHP at the time, championed the establishment of an asthma disease management program. He hired Dr. James Glauber as Associate Medical Director to develop a program that would serve the health care needs of NHP’s predominantly inner-city, low-income, minority members. Dr. Glauber previously served as Pediatric Asthma Champion at Kaiser Permanente Medical Group in Hayward, CA and now practices on a part-time basis as an asthma specialist while serving as NHP’s Senior Medical Director. He has also authored and coauthored several peer-reviewed asthma health services research articles.
At the outset, Dr. Glauber determined that a systematic way of identifying and characterizing NHP’s asthma population was needed. He began by developing a registry from which meaningful medical and pharmacy claims data would be captured. The data would be used to generate key measures so that NHP and its providers could describe current performance and identify opportunities for improvement for the plan’s asthma population. Dr. Glauber implemented NHP’s formal ADMP in 1999 and the program has expanded incrementally and continuously since.
NHP worked in collaboration with community-based organizations to further improve the quality of life for members with asthma as well as members of the community. In 2000, NHP added home visits to its ADMP. A few years later, in response to results of the 2004 Inner City Asthma Study (ICAS) that bolstered the evidence of the effectiveness of home-based environmental interventions, and in consultation with Boston University School of Medicine experts in environmental determinants of the health, NHP established its Enhanced Asthma Home Visit Program (EAHVP) in 2005. NHP was the first health plan to contract with the Boston Asthma Initiative (BAI) (a community-based organization founded to address asthma and related environmental issues in some of the city’s minority neighborhoods) to provide asthma education, conduct environmental assessments in the home to identify triggers, and to offer advice on how to remove triggers. Besides its enduring relationship with BAI, NHP participates in community-based asthma initiatives such as the Greater Brockton Asthma Coalition, the Massachusetts Asthma Advocacy Partnership, and the Boston Asthma Home Visit Collaborative.
ADMP interventions are stratified according to member acuity and include generalized mailings, personalized mailings, reporting to clinicians, and targeted telephonic outreach. Specific goals of the program are to improve patient/family self management skills, enhance asthma management programs at primary care sites, improve the breadth and intensity of controller medication use, increase provider awareness of asthma treatment guidelines, decrease overuse of symptom relieving medications, and decrease asthma related emergency room (ER) and hospital utilization.
According to the Centers for Disease Control and Prevention, 16.2 million adults and 6.7 million children in the U.S. currently are diagnosed with asthma. The prevalence of asthma is higher in Massachusetts than in most states in the U.S., with the burden falling mostly in Black and Hispanic/Latino communities.1. The disproportionate prevalence in some racial/ethnic minorities and those living in impoverished, urban environments is well documented in the research literature, including collaborative research over the past decade involving the NHP pediatric asthma population.2. In addition, asthma is the most prevalent chronic disease among the NHP population, with approximately 10% utilizing asthma-related services in a given year.
Sources of identification of asthmatic members are both real-time and retrospective including hospital notifications, pharmacy claims trigger reports, health needs assessments upon member enrollment, provider referral, member self-referral, and NHP care manager referral from other clinical programs. The vast majority of members are identified proactively by NHP for stratified interventions. Members targeted for enrollment in the ADMP include those who evidence ineffective management of their disease process, as manifested by frequent utilization of the ER for asthma related problems, asthma related inpatient admissions, and high recent and chronic use of symptom-relief and crisis asthma medications. The EAHVP targets pediatric and adult non-smoking asthma members with poor asthma control despite compliance with adequate dose of controller medications, and that are likely to have significant environmental triggers in their home.
While NHP offers its members with complex chronic conditions a monetary incentive to complete a comprehensive Health Needs Assessment, results of a published study of its asthma population, in collaboration with researchers from Harvard Medical School, demonstrated that incentives did not increase member participation in its disease management program.3. As a result, NHP does not offer any other monetary incentives to members, instead relying upon other strategies for engaging members.
- Distinguishing Program Feature: Use of community-based services for home visits. NHP is the only Massachusetts Medicaid health plan that utilizes a community-based asthma service for the majority of its asthma home visits.
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Integrated Health Care Services
NHP has adopted the National Heart, Lung and Blood Institute Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma 2007 (NHLBI Guidelines) as a foundation for its multi-faceted ADMP. Central goals of this program are to identify and stratify members with asthma, establish site-based registries, improve prescribing practices consistent with established clinical asthma guidelines, improve continuity and coordination between acute care settings and primary care, and develop and disseminate multi-lingual, lower literacy educational material to support member/family self-management.
- Distinguishing Program Feature: Bi-Weekly Trigger Reports and Letters. NHP is the only health plan in Massachusetts that issues bi-weekly trigger reports and letters to practitioners. The frequency of the reports ensures that information is actionable so that interventions can be made in a time-effective manner. Members identified in the report also receive a mailing. NHP has received feedback from providers that this program feature is a ‘best practice’.
- Distinguishing Program Feature: Community involvement and provider focused interventions. Based on the Strategic Plan for Asthma in Massachusetts 2009 – 2014 (SPA), NHLBI Guidelines recommend that office-based physicians who care for asthma patients have access to spirometry for the diagnosis and monitoring of asthma. However, not all of Massachusetts office-based physicians have access to spirometry. Studies have shown that low income communities of color are often the last to benefit from medical technology. One goal of the SPA plan is to improve the diagnosis and assessment of asthma in Massachusetts through spirometry. In response to internal data indicating that fewer than 20% of NHP’s high and moderate risk individuals with asthma received spirometry in the past year, NHP recently implemented a pilot program with ten large network community health centers (CHCs) to adopt and incorporate pulmonary function testing in their clinical practice. NHP will fund the spirometry units, provide technical assistance from NHP respiratory therapist asthma case managers in choosing the spirometry equipment, and train appropriate staff (including physicians) on the performance and interpretation of spirometry, at no charge to the CHC. Participating sites have agreed to achieve the goal of performing annual spirometry on 50% of their high and moderate risk NHP asthma population. This program will not only benefit NHP members, but all of the asthma patients at the site.
- Distinguishing Program Feature: Low-literacy educational materials. One of the challenges NHP faces is low health and overall literacy of some of its members. To this end, NHP has created a number of educational materials that are pictorial in nature as well as a DVD to assist members in appropriate use of inhaled asthma medications.
With respect to qualitative return on investment (ROI), NHP is committed to reducing health care disparities in its member population as well as in the communities it serves. As noted previously, asthma is the number one chronic disease among the NHP population. NHP developed the ADMP to help its members take control of their asthma. Those interventions that may help ease the asthma burden in communities most at-risk are given the highest priority. Additionally, as an attestation of its commitment to reducing health care disparities related to asthma, NHP has made this the focus of one of its Community Benefits (a Commonwealth of Massachusetts program) initiatives for 2010.
In 2010, Neighborhood Health Plan was recognized by the U.S. Environmental Protection Agency (EPA) for best practices in asthma care by a health plan.
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1. Massachusetts Department of Public Health. (2007) Asthma Report for Massachusetts
2. Racial/Ethnic Variation in Asthma Status and Management Practices Among Children in Managed Medicaid, PEDIATRICS Vol. 109 No. 5 May 2002
3. Asthma self-assessment in a Medicaid population. Wu AC, Glauber J, Gay C, Lieu TA, BMC Public Health. 2009 Jul 16;9:244.