Community Asthma Network
Community Asthma Network
- Lone Star Circle of Care, Georgetown, TX
Please note that all data below was derived from the collaboration's nomination for the Collaboration Prize. None of the submitted data were independently verified for accuracy.
The Seton Family of Hospitals d/b/a Seton Asthma Center (Seton) and Lone Star Circle of Care (LSCC) came together in 2008 to create an integrated approach to the education and treatment of those suffering daily with asthma and asthma-related diseases. Many of these patients were using Emergency Rooms to find treatment for their asthma and asthma symptoms, and there was a growing need to find them a medical home. Independently, Seton and LSCC handled specific parts of the continuum of care, but realized in order to truly impact the quality of life for patients there needed to be an integrated, multi-system approach.
Seton worked with various coalitions, professional groups and individual interest groups, such as the Central Texas Asthma Coalition, to find an organization that would be most aligned to create a synergistic partnership. Because the missions of Seton and LSCC were so aligned, the organizations were able to engage quickly to create the Community Asthma Network, with a management system that reflected the values of each facility and allowed for immediate action and care delivery to underserved asthmatic patients.
Seton and LSCC immediately realized that in order to establish efficient implementation of services, the collaboration’s management system would need to integrate the two systems while also keeping many internal processes unchanged. By allowing the Executive Directors within each partner organization to jointly manage the collaboration, their commitment of support to each other has allowed for direct and daily planning and management of operations. The resulting open dialogue helps resolve differences in patient care from each partner organization and promotes a standard process which enhances efficiency, reduces cost, and increases the quality of care for patients who originally received duplicate care across the region.
The collaboration’s management structure has also allowed for sharing of vital data and patient information across systems, which is typically unheard of between organizations. This shared information removes redundancies that normally require patients to receive duplicate tests and treatment, and ultimately allows for improved patient care and increased access for patients who previously had limited or no access to asthma care.
Coordinating and integrating operations was an initial challenge, especially in the area of information technology and information sharing. While Seton and LSCC had minimal operational integration issues, finding the right technology that allowed the two systems to ‘talk’ to each other proved slightly more difficult. By working with teams from both organizations and implementing data exchange technology, we have been able to create a more streamlined system for patient and data information management.
As funding is always a challenge for nonprofit entities, the collaboration has been dedicated to researching and obtaining donations and grants from individuals, businesses, foundations, and organizations. The collaboration also recently applied for a Beacon Grant from the federal government for its pioneering work in asthma education and care delivery.
Managing staff resources is always initially difficult, but staff confidence in the collaborative partnership and open communication with the Executive Directors has helped us develop a good working system. When challenges arose, data and information was collected and discussion was encouraged, which has led to solutions and specific actions taken that have improved processes and our understanding of the resources needed for success. This “Data-to-Action” cycle has proved invaluable to resolve the communication and staff challenges the collaboration has encountered.
The Community Asthma Network collaboration measures impact in how we have been able to improve the quality of life of those served. Many patients come in for treatment complaining that, in 14 days, they only have an average of four days free of asthma symptoms. This number is staggering. Following education and treatment, which includes setting a patient up with a primary care provider, we have seen those symptom-free days increase by 40%. This translates to adding an average of two months of symptom-free days per year to each patient. The collaboration has also recorded a dramatic 39.5% decrease in Emergency Room utilization, a 94.5% reduction in hospitalizations after education and treatment, and an average of more than $1,000 in cost savings to the healthcare system per patient.
While the collaborative shows positive measurable outcomes through percentages and dollars that impact the counties and communities we serve, feedback from patients measure the true success of the program.
Meet Daniel, an eighth-grader who almost decided to give up playing the French horn in the school band due to his asthma. He and his parents received education about and learned how to manage his asthma with help from the Community Asthma Network. By his six-month follow-up, Daniel had decreased his absences at school and his parents had decreased days off from work needed to care for him because of his asthma. Daniel has been actively competing for “first chair” within the band.
Kim is a 40-year-old mother of two who was afraid to go out of her house and could not get a job because her asthma had worsened since moving to Texas. She did not qualify for coverage through her spouse’s insurance, yet their household income prevented her from qualifying for government medical assistance. The Community Asthma Network provided Kim with temporary funding and a primary medical home close to her rural location, giving Kim the tools she needed to manage her asthma. At her last follow-up, Kim felt her asthma was controlled enough that she has started applying for work.
Seton and LSCC have learned that through a careful and coordinated integration of services, the collaboration can effect change in patients’ lives and control asthma to a point where it is truly making a difference --- not just alleviating symptoms, but offering people, like Daniel and Kim, a better quality of life.
Due to the dynamic changes in health care affecting many organizations, attempting to balance the cost, access, and quality of that health care has become more difficult to sustain. Collaborations that involve integrating care elements from two healthcare networks within a single community are already rare, and have not existed with an asthma care focus. The pioneering collaboration between the Seton Asthma Center and LSCC to create the Community Asthma Network has adapted current partnership models to instill a greater focus on patient self-management across all areas of patient care, including prevention, education and treatment. By combining resources, we have been able to meet community goals, reduce duplication of services across the same population of patients, and improve the quality of life of the patients and families served.
The Community Asthma Network formed between the Seton Asthma Center and Lone Star Circle of Care showcases a collaboration of healthcare providers working together to develop a community intervention to improve chronic disease outcomes in patients. Economic and operating efficiencies achieved through the collaboration’s asthma program have been impressive. We have seen both positive cost savings to the healthcare system, as well as a significant decrease in the utilization of unnecessary emergency care services for the treatment of asthma, and decreased hospitalizations for patients in the program.
Operating and Economic Efficiencies Achieved:
Evaluation of outcome measures demonstrated significant decreases in the utilization of hospital and emergency services for enrolled patients following the program’s primary asthma intervention. Described in rates of utilization of services as visits per 1,000 people, analysis shows the rate of emergency department use falling by 37%, inpatient hospital visits decreasing by 63%, and total length (days) of inpatient stays decreasing by 46%. Visits to the patient’s primary health care clinic in the enrolled group increased by roughly 10%.
The control group of statistically similar patients not enrolled in the program also showed a decrease of 14% in emergency department use in that same year, with 442 visits per 1,000 people the year before, and 384 the year after. However, within the control group, the number of inpatient hospital visits increased by 16% (from 56 to 65 per 1,000 people), total length of stay for inpatient visits increased by 46% (from 150 to 220 days per 1,000 people), and clinic visits decreased by 17% (from 729 to 604 visits per 1,000 people).
Our analysis demonstrates that the change in utilization of services, such as emergency department and inpatient hospital visits, in the control group are in opposite direction to the changes observed in pre-post-intervention in the enrolled group. There is an impressive net 27% increase in primary health care clinic utilization with a 23% and 79% decrease in emergency department and inpatient hospital visits, respectively, in enrolled patients compared to control patients.
In the absence of cost data, we use estimated expenditure based on national averages to calculate the return on investment of the asthma program. The actual cost of providing the program on a per patient basis is received from program staff. This mainly includes salaries of the staff, benefits, and other operating costs. For estimating the benefits on utilization, we use average direct medical costs for different visit types for asthma nationally, as reported by the most recent Medical Expenditure Panel Survey conducted by the National Institute of Health’s Agency for Healthcare Research and Quality.
This analysis shows that the net benefit to the healthcare system is $559,872 when the intervention is provided to 229 patients on an annual basis. For each dollar spent in the delivery of the asthma program, the system gains $5.30. Without accounting for economies of scale, the net savings from the same program for 1,000 enrolled patients will be almost $2.4 million a year.
Methodologies for Evaluation:
The program was evaluated using pre- and post-enrollment utilization of services in a retrospective cohort study design. We identified both process and outcome evaluation measures. Outcome evaluation data were extracted using the ICare database – a clinical data repository for uninsured and underinsured patients in Central Texas. We utilized the ICare database to not only track enrolled patients’ utilization of services over the study period but to also create a control group of patients meeting eligibility criteria for enrollment. We sampled only those patients who had at least 12 months pre- and post-history in the database, meaning their first visit in the database was before 12 months from their enrollment and their last visit in the database was after 12 months since the date of enrollment in the program. We used the same criteria for the control group, using the midpoint of the study period as the index date.
Process evaluation assesses procedural or operational aspects of the program and measures how well the program was implemented. Outcome evaluation focuses on measurable outcomes assessing improvements in health status and quality of life of the enrolled patients. We conducted in-person interviews with program staff and evaluated interim operational reports. The process evaluation measures are based on reports obtained from the program staff and generated through their clinical information system. The outcome measures, which are the main focus of this evaluation, are based on rates of emergency department visits per 1,000 people per year, as reported in the database.
For this analysis, we identified 229 enrolled patients in the asthma program that showed a referral from the ICare database and who also had a medical record number in the ICare system. For the control group we identified 4,706 patients who met the inclusion criteria. Patients with less than 12 months of pre- or post-history were removed, as well as those enrolled in the program. The remainder was 2,623 patients. Rather than work with averages overall for the control group and then age-adjust it to match the enrollment group, we divided this group into three age groups and identified, randomly, a number of patients in each age group equivalent to the proportions in the enrolled group. We chose the largest age category in the enrolled group as our reference group in order to maximize the number in the comparison group. This resulted in a control with 1,010 patients.
Benefits to the Community:
Our collaboration has focused on eliminating duplicate services and inefficiencies in the healthcare system, as well as establishing care coordination that is needed to help increase positive health outcomes for asthma patients in the community. Benefits to the community and area patients have been significant. We have increased healthcare access for asthmatic patients and decreased the utilization of unnecessary and expensive emergency services. More patients are connecting to asthma resources and treatment through primary health care clinics, rather than turning to the emergency room for emergency care that could have been prevented entirely through earlier diagnosis and treatment. This has not only provided cost savings to patients and but has also reduced the overall cost of care delivery for healthcare providers. Most importantly, through the collaboration we have helped improve quality of life for our patients and enable them to participate more fully as members of our community.
The impressive results from our collaborative efforts suggest the establishment of a system of chronic disease management in the community that involves continual monitoring and education of patients. The key role of the ICare database as a clinical data repository derived from a health information exchange is a unique feature of this program in identifying eligible patients, tracking the use of services, and evaluating program outcomes. The successful use of the ICare database in the asthma program provides a template for other communities that are facing rising asthma prevalence among the uninsured and vulnerable populations. It could also help identify and be applied to other areas in which chronic disease care can be coordinated and made more effective through similar collaborative efforts.
The Community Asthma Network collaboration between the Seton Asthma Center and Lone Star Circle of Care was born from a shared recognition of the significantly high prevalence of asthma in our community and the inordinately high utilization rates of acute services (such as the emergency department and inpatient hospitalization) for the treatment of asthma. The partners recognized that although each had processes and procedures in place to provide access and treatment for asthma, these silo systems were largely ineffective at implementing the processes necessary to provide the patient care coordination that is needed to reduce reliance on acute care and improve health outcomes.
The collaboration began with a discussion between organizational leaders regarding our mutual interests and desired outcomes. From this conversation, a framework for collaboration was established and a memorandum of agreement was achieved. The “merged governance-separate structure” model was chosen for this collaboration to ensure that our mutual interests with respect to asthma would be achieved while maintaining the autonomy needed for each organization to accomplish its unique objectives in exigent service lines.
The Community Asthma Network collaboration has faced some challenges during its progression. One such challenge was the need for staff to be able to document patient encounter-related information in the electronic medical record (EMR) systems in each respective organization. Though concerns about the security and privacy of patient health data were addressed in our guiding governance documents, it became apparent that technology limitations would not allow for the transfer of certain patient intervention data across systems. This challenge was addressed and resolved with relative ease. Each member of the collaboration agreed to provide access for staff to the internal EMR systems in both organizations regardless of where the staff was actually employed. This was a unique resolution as ordinarily, an employment relationship would typically be necessary for a health care provider organization to grant access to EMR systems. The novel approach to resolving this issue demonstrates both the commitment and ingenuity inherent in this collaboration.
The collaboration has resulted in better healthcare access and improved quality of life for asthmatic patients, decreased utilization of unnecessary and expensive emergency and inpatient hospitalization services, reduced overall cost of care delivery, and allowed for a significant return on investment shared between the partners and demonstrated in the community.
We feel that the Community Asthma Network collaboration is deserving of the Collaboration Prize because it demonstrates, both qualitatively and quantitatively, the synergistic power that is achievable when organizations combine efforts with a shared and mutual set of guiding principles, desired outcomes, and commitment to success. The award will be used by the collaboration to further the work that has been achieved thus far. Collaboration Prize funding will help us expand the scope and staff of the Community Asthma Network, and will ultimately increase the benefits the collaboration has brought to our patients and community.
Moreover, Seton has already applied this model internally to diabetes management and is working to form an area-based diabetes program and to expand the model to serve other chronic disease areas, such as congestive heart failure and chronic obstructive pulmonary disease. Efforts have also been made to work with other Central Texas health organizations to replicate the collaborative model and establish additional systems of chronic disease management throughout the community. The award will help us to advance, improve, and enhance our capacity to bring our successes to a broader population of patients who will benefit from our shared work.