Pursuing Perfection: Report from Cambridge Health Alliance on Improving Asthma Care

The Challenge: Cambridge Health Alliance (the Alliance) wanted to take a more proactive approach to caring for children with asthma. Although only about five percent of asthma patients visited the emergency department (ED) or were hospitalized during the first quarter of 2002, Alliance leaders knew that with more aggressive care and asthma management, they could reduce that number, keeping kids out of the emergency department, in school and engaged in other daily activities.
The Background: Cambridge Health Alliance is a Massachusetts-based integrated health system that provides care in Cambridge, Somerville, and Boston’s Metro-North communities. It includes three hospitals, more than 20 primary care practices, the Cambridge Public Health Department, and the Network Health Plan. Through this unique and innovative model, the Alliance offers clinical care as well as academic training in community-based medicine.
The Alliance also works to improve public health through advocacy, outreach, and a wide range of community programs. About 150,000 people receive their health care through the Alliance, including some 24,000 children.
The Situation: According to a recent report by the New England Asthma Regional Council asthma affects one in eight children in New England, eclipsing all other chronic illnesses of childhood and flooding EDs and clinics with asthmatic children. The report found that more than 400,000 children have been diagnosed with the condition, and that its consequences fall disproportionately on the poor. 
In the cities of Cambridge and Somerville — just west and north of Boston — this picture is especially evident. From 1994 through 1996, asthma was the leading preventable cause of hospitalization for children through age five, leading to 32 percent of hospitalizations for this age group. For 6- to 17-year-olds, the case was even more dramatic, with asthma comprising 48 percent of preventable hospitalizations. Asthma is also prevalent in school children in nearby Everett, one of the Alliance’s primary service areas.
“No single childhood illness causes more school absenteeism or is a greater impediment to a child’s health and sense of well-being,” says David Link, MD, Chief of Pediatrics and Program Director of the Alliance’s Pediatric Asthma Program. “We can’t cure asthma, but we are increasingly successful at treating it.”
The Alliance cares for approximately 1,500 children with asthma and had already been working to improve asthma care when it was selected to participate in Pursuing Perfection in 2002. “We have a history of innovation, and we embraced the Pursuing Perfection challenge because it was consistent with our culture,” says Link. “The seeds of our asthma improvement work had already been planted.” Pursuing Perfection provided more fertile soil in which those seeds would grow.
The Solution: With the resources available through Pursuing Perfection, the Alliance made better management of pediatric asthma a priority. Like many organizations working to improve chronic illness care, the Alliance put in place the key elements of a system to support young asthma patients and their providers, including a registry of patients, severity assessments, use of controller medications, and regular monitoring of lung capacity. But what distinguishes the Alliance’s program is a broad and integrated patient support system that encompasses clinic, home, and school settings, as well as an incentive program that rewards providers for improving care and outcomes.
The Alliance began its effort to implement the Planned Care Model for children with asthma by creating pilot programs in two of its busiest pediatric sites. (The Planned Care Model, also called the Chronic Care Model, was developed by Ed Wagner, MD, and colleagues at the MacColl Institute in Seattle, Washington).
One of the first steps in the Planned Care Model is to create a registry, a computer-based program that contains key information about a child’s asthma, including a record of emergency room visits, hospital admissions, medications, and other relevant information. “The registry is one of the key elements that Pursuing Perfection helped us develop,” says Laureen Gray, Program Director for Planned Care. “The knowledge, training, and funding in the program helped bring our ideas to fruition.”
The information in the Alliance’s Childhood Asthma Registry is made available to parents and, with their permission, a wider circle of adults who could also benefit: primary care physicians, teachers, school nurses in approximately 30 local schools, emergency department staff, and a network of health providers. The thinking then and now is that no matter where a child enters the health care system — at the pediatrician’s office, through the school nurse, or the ED — providers should have access to his or her asthma information. 
The registry classifies children according to the severity of their asthma: Intermittent, Mild Persistent, Moderate Persistent, or Severe Persistent. These categories help determine the appropriate care plan for each patient. The classifications also help the Alliance track how successful providers are at reducing the severity of asthma among the pediatric target population.
The Planned Care Model advocates a comprehensive change from the way asthma patients have been cared for in the past, shifting from reactive care following acute episodes to aggressive daily management to prevent attacks. Alliance care teams, which consist of pediatricians, nurses, and others as necessary, work with patients to create an Asthma Action Plan that outlines regular steps to prevent and/or treat asthma attacks.
The Alliance also organizes school-based peer support groups for children with asthma as well as support groups for families so they can exchange information and advice. Peer groups help patients and families learn from each other the best ways to avoid environmental factors that exacerbate asthma, such as dust, smoke, pets, and other potential allergens.
A Cambridge Health Alliance pediatric patient and her mother learn how to self-manage their asthma at home with nebulizer treatments
Patients also benefit from the Alliance’s unique connection with the Cambridge Public Health Department, operated by the Alliance under a municipal contract with the City of Cambridge. The Health Department oversees Healthy Homes, a program that sends nurses and environmental health experts into the homes of young asthma patients to work with families to identify and mitigate asthma triggers.  Families are given items that can help modify the home such as mattress and pillow covers and cleaning supplies; safety equipment — smoke detectors and fire extinguishers — are also distributed.  Special vacuum cleaners are also loaned to families to help clean away pollen and dust mites. Healthy Homes is free to all Cambridge and Somerville residents with an asthmatic child under age 12.
Another key partnership is with the Cambridge Public Schools, says Laureen Gray. “We get permission from parents to share asthma information with the school nurses, and we build our relationships with the nurses around the Asthma Action Plan. In the old days when a child was wheezing on the playground, the school nurse would send them to the emergency department. Now, she has access to the registry and the care plan, and she  can offer an appropriate medication. It gives kids a better chance to stay in school.”
The registry provides Alliance pediatricians with regular updates that include both organization-wide data and provider-specific data regarding care of asthma patients. “This type of feedback is very motivating for physicians,” says the Alliance’s Dr. Link.
Additional motivation will come from a quality-based compensation package to be introduced in the summer of 2005. “Physicians will be compensated for doing the right thing,” says Link. “Are their asthma patients in the registry? Is their severity rate classified? Do they all have Asthma Action Plans? Are their patients with persistent asthma on controller medications? And what are the emergency department visit rates for their patients?”
The Results: The Planned Care Model for asthma has now been spread to all sites in the Alliance. All pediatric asthma patients throughout the Alliance are now listed in the Childhood Asthma Registry. The percentage of patients with a designated severity classification and an Asthma Action Plan is increasing. Most important, visits to emergency departments for asthma-related episodes are down, as are hospital admissions.
 Cambridge Health Alliance
% Patients With Asthma Admissions, Pilot Sites
What Team Members Say: “The registry is the foundation of Planned Care work. You have to know who your patients are, what they’ve had done, what their utilization is, what our performance is. Over time the registry helps us identify the factors that make a difference in emergency department visits and in hospitalizations. It is a critically important tool in caring for any population with a chronic condition.”
David Link, MD, Chief of Pediatrics and Program Director of Cambridge Health Alliance’s Pediatric Asthma Program
“Improving quality and safety is one of our strategic goals. Our tagline is ‘From strategy to action to accountability.’ We’ve become more process literate and are thinking about things more systematically. Our work to improve asthma care is a good example of that. Now we are looking forward to spreading the Planned Care Model across all conditions.”
Laureen Gray, Program Director for Planned Care
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