- 3.1. Develop and promote statewide implementation of "standards of asthma care" for the diagnosis and management of asthma in collaboration with California’s public and private health care delivery and payer systems.
3.1.1. Convene representatives from the major public and private health care delivery and payer systems to establish, adopt, and promote statewide consensus "standards of asthma care". Establish standards that, at a minimum, are consistent with the National Asthma Education and Prevention Program’s (NAEPP) newly updated Guidelines for the Diagnosis and Management of Asthma (Expert Panel Report-3), the NAEPP's Key Clinical Activities for Quality Asthma Care (Figure 6), and the Chronic Care Model (Figure 7).
3.1.2. Promote comprehensive care (or case) management as the standard of care for individuals with poorly controlled persistent or high-risk asthma (those with frequent ED or hospital visits) (Figure 8: Comprehensive Care Management for Asthma).
3.1.3. Translate consensus "standards of asthma care" into companion public education materials and disseminate widely to promote consumer awareness.
- 3.2 Facilitate coverage and reimbursement for a comprehensive chronic disease management approach to asthma within public and private health care payer systems.
3.2.1. Identify and develop long-term funding for a comprehensive care management approach to asthma care and for health information technology in support of high quality asthma care (Figure 9: Health Information Technology Report Summary).
Figure 6. Key Clinical Activities for Quality Asthma Care*
Assessment and monitoring
- Establish initial severity of asthma
- Classify initial severity of asthma
- Schedule routine follow-up care at 1-6 month intervals to monitor asthma control, including spirometry every 1-2 years
- Assess for referral to specialty care
Control of factors contributing to asthma severity
- Recommend measure to control asthma triggers
- Treat or prevent comorbid conditions
- Prescribe medications according to initial severity and adjust accordingly to level of control
- Monitor use of ?2-agonist drugs
Education for partnership in care
- Develop a written asthma management plan
- Provide routine education on patient self-management
*Adapted from NAEPP Key Clinical Guidelines for Quality Asthma Care and EPR-3.
Figure 7. Overview of the Chronic Care Model
The Chronic Care Model identifies the essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise. The model can be applied to a variety of chronic illnesses, health care settings, and target populations. The bottom line is healthier patients, more satisfied providers, and cost savings.
3.2.2. Facilitate coverage and reimbursement for comprehensive care management by public and private health care payer systems in California for individuals with persistent and high-risk asthma. Facilitate the establishment of a comprehensive current procedural terminology (CPT) code to be used when billing for comprehensive care and management.
3.2.3. Facilitate coverage and reimbursement for the following services and supplies for individuals with asthma: annual flu vaccine, lung function tests (spirometry) for asthma diagnosis, and monitoring for individuals over four years of age; allergen sensitivity assessment (either skin tests or in-vitro blood tests) for at least those patients with persistent asthma; individualized asthma self-management education; relevant prevention supplies (e.g., pillow and mattress encasements); duplicate medications for children if needed (i.e., one each for home and school/child care use); durable medical equipment (e.g., inhaler spacers and peak flow meters); and medically necessary specialist consultations and home visits.
Figure 8. Comprehensive Care Management for Asthma
Includes the following:
- Case management or care coordination for individuals with poorly controlled and high-risk asthma.
- Self-management education for all individuals with asthma.
- In-home asthma environmental assessments as determined to be medically necessary.
- Coverage for asthma management and prevention supplies (e.g., inhaler spacers, pillow/mattress encasements, etc.).
- Patient tracking over time in a series of asthma preventive care clinic visits.
- Multidisciplinary asthma care teams consisting of a physician/nurse practitioner, a clinical care coordinator (typically a registered nurse or respiratory therapist), and a community health care worker, health educator or public health nurse.
Figure 9. Health Information Technology Report Summary
Potential Quality and Efficiency Benefits of Health Information Technology (HIT)
The movement toward establishing new HIT systems has been motivated in large part by expectations that these new technologies will improve the quality of patient care and help contain health care costs. When implemented successfully, the use of HIT should help physicians and other providers make decisions about patient care in ways that improve the quality and efficiency of care. Some examples of the benefits afforded by HIT applications are the following:
- Fewer unnecessary medical tests.
- Higher quality patient care.
- Improved emergency care outcomes.
- More efficient prescription drug processing.
- Fewer patient burdens, such as repetitive paperwork.
- Better disaster preparation.
- Increased public health monitoring.
Source: Promoting Health Information Technology in California: A State Policy Approach (www.loa.ca.gov/2007/health_info_tech/health_info_tech_021307.aspx)
3.2.4. Promote public awareness of consumer rights laws and regulations regarding state health plan coverage for asthma drugs, devices and services* including requirements for coverage of outpatient prescription drug benefits (for inhaler spacers, nebulizers, and peak flow meters when medically necessary for the management and treatment of pediatric asthma).†
3.2.5. Design and post a model universal drug formulary for asthma medications, supplies and devices as a complement to the consensus "standards of asthma care."
- 3.3. Expand quality improvement (QI) for asthma care within public and private health care delivery and payer systems to assess, improve, and sustain the provision of high-quality asthma care within and across systems.
3.3.1. Explore the potential to require all commercial and non-commercial health care plans in California to adopt and report on the same Healthcare Effectiveness Data and Information Set (HEDIS®) performance measures on asthma care‡ to assess and improve performance across all commercial plans.3.3.2. Develop recommendations for standardized/comparable and validated QI measures (beyond HEDIS®) that assess and evaluate both quality of care and outcomes associated with care (for example, emergency room visits and hospitalizations). Formulate recommendations for data specifications for electronic medical records to ensure that asthma-related measures can be captured.3.3.3. Facilitate use of standardized/comparable and validated QI measures (beyond HEDIS®) by public and private health care delivery and payer systems to assess, improve and sustain the provision of high quality asthma care within and across systems.§3.3.4. Develop health care provider QI incentive and reward structures taht encourage quality asthma care.*The California Department of Managed Health Care maintains a website to address consumer and health care provider problems and complaints regarding health plan benefits and patients' rights at www.dmhc.ca.gov† Health plans are required to provide coverage for pediatric asthma equipment and supplies: California Health and Safety Code Section 1367.06‡ The quality-of-asthma-care measure developed by HEDIS® identifies health plan members (age five and older) with "persistent" asthma if there was one ED visit or inpatient discharge listing asthma as the primary diagnosis, >4 outpatient asthma visits with two medication-dispensing events, or four medication-dispensing events in the year before evaluation. To pass the measure, members with "persistent" asthma must fill a prescription for qualifying medication (inhaled steroid, leukotriene modifier, etc.) in the year of evaluation.§ Recent publications have ifentified limitations in teh reliability of the HEDIS® criteria. Currently, DHCS only requires its contracted Medicaid managed care pland to submit audited HEDIS® data.
- 3.4. Ensure seamless/integrated asthma care and enhance communication among primary care providers, emergency departments/urgent care centers, hospital inpatient settings, and community settings within public and private health care delivery systems.
3.4.1. Facilitate the use of chronic disease case registries in primary care to improve case finding and patient monitoring and to track improvement.3.4.2. Facilitate the establishment and improvement of mechanisms to support timely sharing of patient date between primary care providers, emergency departments, urgent care centers, and hospital inpatient settings -- including mechanisms for primary care provider notification of emergency/urgent care treatment and completeness of patient discharge instructions.3.4.3. Facilitate the establishment and improvement of mechanisms that support communication between primary care providers and community settings -- including mechanisms to share patient pharmacy utilization and to improve communication between primary care providers and schools, child care centers, other institutional settings such as mental health facilities and prisons, and foster care settings.
- 3.5. Improve asthma knowledge and competency of health care practitioners, allied health professionals and community health workers, with a high priority on those serving underserved populations.
3.5.1. Increase the number of physicians, nurses, and physician assistants who complete nationally or state recognized asthma training programs, with a high priority on those serving underserved populations. Facilitate trainings and offer continuing education credits (CEUs) for participation.3.5.2. Work with California medical colleges and residency programs to integrate education about consensus standards of asthma care into the physician training curriculum (see Goal 3: Objective 1).3.5.3. Work with the Department of Corrections an Rehabilitation to ensure that all prison health care providers are aware of consensus standards of asthma care to provide appropriate clinical asthma care for youth offenders and inmates (see Goal 3: Objective 1).3.5.4. Increase the number of Asthma Educators-Certified (AE-C) in California, with a high priority on those serving underserved populations. Encourage public and private health care payers to reimburse for patient education provided by AE-C.3.5.5. Establish a state community health worker (CHW) certification exam on patient asthma education. Encourage public and private health care payers to reimburse for the services of CHWs who have a current certification.3.5.6. Create opportunities for health care providers to share knowledge, experiences, and best practices, including establishing a statewide internet portal to support an online community for asthma care providers; developing collaborative quality improvement learning networks; and promoting asthma research symposiums for health care providers.3.5.7. Promote improved recognition of asthma during pregnancy by health care providers, allied health professionals, and CHWs; and enhance their capacity to maintain excellent maternal asthma control for the health and well being of both the mother and her baby.*3.5.8. Develop and promote statewide standing order protocols for emergency medical technicians (EMT) and other "pre-hospital providers" (consistent with the California Emergency Medical Services Authority EMT-II Model Curriculum for the administration of short acting beta-agonists for individuals experiencing asthma exacerbations).* NAEPP Working Group Report on Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment -- Update 2004 (NIH Publication No. 05-3279), which is available at http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg/htm.
- 3.6. Increase access to high quality asthma care for underserved populations in California by implementing best practice policies and strategies to reduce the following barriers to care: cost, culture, language, and location/distance.
3.6.1. Support the elimination of health insurance denial practices for individuals with asthma as a pre-existing condition.3.6.2. Support legislative and policy initiatives that expand or guarantee health care and drug coverage for all Californians.3.6.3. Convene representatives within public and private sectors at state and local levels to develop a set of California recommended best practices for improving cultural, linguistic and geographic access to care for chronic conditions including asthma. Facilitate the implementation of the recommendations.