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Asthma Health Disparities Collaborative Coalition Guide

Background and Purpose of This Guide

Introduction

This Asthma Health Disparities Collaborative Coalition Guide discusses the scientific foundation for the Michigan Asthma Health Disparities Collaborative (HDC) and provides practical examples, tools, and materials that can be easily used or adapted by asthma coalitions in developing partnerships with federally qualified health centers (FQHCs).

This guide is a living document that presents information specific to activities by Michigan's Asthma HDC project at both the State level and coalition level. Examples of health systems changes are featured, using the Chronic Care Model as the framework. Available tools, resources, and materials are identified for potential health system changes. Evaluation information and evaluation tools are presented, as is information to spread and sustain change.

In preparing this guide, an extensive review was conducted of the scientific literature, other resources, and tools. (Many of these resources are available on the Health Disparities Collaboratives Web site.) Appendix A provides a list of sources used for this guide as well as other helpful Web sites. It is hoped that the efforts described in this document may serve as a guide for other coalitions seeking to implement process and outcome improvements for asthma care in their States and communities.

Asthma in Michigan

The Asthma Initiative of Michigan (AIM) was chartered to improve the quality of asthma care delivered to children and adults with asthma who are served by federally qualified health centers. This goal is important because^a:

Asthma is a significant challenge in Michigan. There are over 230,000 children and over 700,000 adults who currently have asthma.
Asthma is costly. The disease costs approximately $224 million in direct medical costs alone, and an additional $170 million in indirect costs.
Not all people with asthma in Michigan are receiving treatment according to the national guidelines. Consequently, preventable symptoms and events, like hospitalizations and death, continue to occur.
- Only 30% of adults with asthma in Michigan have the recommended minimum two visits per year with a health care provider for routine asthma care.
- In 2003, about 64% of people ages 5 to 65 in Medicaid with persistent asthma filled at least one prescription for appropriate asthma medicine—a long-term controller medicine.
People with asthma in Michigan frequently experience symptoms.
- Among children of middle and high school age who have been told in their lifetime that they have asthma, about 35% have had an asthma attack in the past year.
- For adults who currently have asthma, 53% have had an attack in the past year and about 20% experience symptoms daily.
The burden of asthma in Michigan is disproportionately distributed across age, race, income, and geographic region. Efforts to reduce the burden of asthma in Michigan must address these dramatic health disparities. These disparities include the following^b:
- Among children (under age 18):
  - Males are hospitalized for asthma at a rate 60% higher than females.
  - Blacks are hospitalized for asthma at a rate 4.2 times that for Whites.
  - Children living in low income areas are hospitalized for asthma at a rate 4.3 times that for children living in high income areas.
  - Asthma deaths for Black children occur at a rate 6 times that for Whites.
- Among children in Michigan's Medicaid population:
  - The prevalence of persistent asthma is 40% higher for males than females.
  - The prevalence of persistent asthma is 23% higher for Blacks than Whites.
  - Blacks visit the ED for asthma at a rate 2.7 times that for Whites.
  - Males are hospitalized for asthma at a rate 48% higher than females.
  - Blacks are hospitalized for asthma at a rate 2.4 times that for Whites.
- Among adults (age 18 and older):
  - The rate of asthma hospitalization for females is 2.4 times that for males.
  - The rate of asthma hospitalization for Blacks is 4.2 times that for Whites.
  - The rate of asthma hospitalization for adults living in low income areas is 4.1 times that for adults living in high income areas.
  - Asthma deaths for females occur at a rate 50% higher than that for males.
  - The rate of asthma deaths for Blacks is 4 times that for Whites.
Asthma cannot be cured, but it can be controlled. People whose asthma is adequately managed should not experience sleep disruption, miss days of school or work, or have minimal need for emergency department visits or hospitalization because of their asthma.

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Michigan Asthma Health Disparities Collaborative

State-Level Efforts

In 2005, the Asthma Initiative of Michigan, under the leadership of the Michigan Asthma Program, began to explore opportunities to support implementation of the Asthma Health Disparities Collaborative. At that time, there was only one Michigan-based FQHC that had implemented the Asthma HDC.

Over the course of a year, Michigan developed a model to expand the reach of the Asthma HDC, especially in areas with high asthma burden. This model used Michigan's existing infrastructure of regional/local asthma coalitions in combination with FQHCs that had existing experience with the Health Disparities Collaboratives. The model's strength is in linking these coalitions, which have asthma expertise, experience, and community linkages, to the FQHCs. The coalitions:

Encourage the FQHCs to implement the Asthma Health Disparities Collaborative.
Provide technical assistance, consultation, and other support to the FQHCs as they expanded into this new arena.

The Michigan Asthma Program provides the technical assistance, consultation, training, and other resources to assist the coalitions. The coalitions provide asthma-related technical assistance, consultation, and resources to the FQHCs to assist them in planning, testing, sustaining, and spreading^c health system changes to improve the quality of asthma care.

The AIM charter sets the goal of creating partnerships between three asthma coalitions and six FQHCs to expand the Asthma Health Disparities Collaborative implemented from in three centers in 2007 to nine by August 30, 2009.

Michigan's approach to facilitate implementation of the Asthma Health Disparities Collaborative is decentralized and uses its existing infrastructure of regional and local asthma coalitions to serve as the primary liaison with the FQHCs. Diagram 1 illustrates this approach.

HDC overview. The Health Disparities Collaboratives national effort is administered by the Health Resources and Services administration (HRSA) to improve the quality of primary health care by changing the health care system. These changes affect how providers deliver care; consumers manage their disease or condition; and communities partner to facilitate self-management and behavior change. By focusing on system-level changes, the HDC creates informed, activated consumers; prepared, proactive teams; a coordinated delivery of care; and information systems that track improved outcomes.

Since 1998, over 450 HRSA-supported health centers, primarily FQHCs, have participated in HDCs. Health centers select the track they would like to address, which may include a focus on diabetes, cardiovascular disease, asthma, cancer, depression, business redesign, or prevention. In Michigan, more than 160 federally qualified health center clinics participate in the Health Disparities Collaborative. In 2006, three FQHCs were the first to begin the Asthma Collaborative in Michigan.

The HDC uses three health care improvement models: Learning Model (adapted from the Breakthrough Series Model), Chronic Care Model, and Improvement Model. Collectively, these three models produce health system changes that ultimately improve the quality of care. Each is described more fully below.

Learning Model. Figure 1 illustrates the Learning Model. It combines pre-work, learning, and action periods. Implementation of this model takes approximately 13 months. Participating health centers:

Identify a multi-disciplinary team of 3-5 staff members.
Dedicate at least 3 to 4 hours per week for team members to work on the HDC.
Participate (team) in three Learning Sessions and a National Forum.
Track national and local measures.

The time between the learning sessions are called the action periods. During these periods, the health centers complete Plan-Do-Study-Act (PDSA) cycles. These cycles help the health centers "test" small changes, learn from their experience, and use what they learned to try new changes or continue and expand the existing change. During the action periods, health center teams also collect and submit data and progress reports, and participate in conference calls and listserv discussions. Throughout the action periods, the health centers receive technical assistance from HDC experts; in Michigan, the Michigan Primary Care Association, as the Midwest cluster leader, provides this assistance.

Chronic Care Model. The Chronic Care Model (Figure 2) works in six areas or components to achieve effective and sustainable health system change. Each of these components must be addressed for maximum results, and it is not recommended that any one component be addressed in isolation. The components are:

The health care organization.
Community resources and policies.
Self-management support.
Decision support.
Delivery system design.
Clinical information systems.

At the learning sessions, teams are introduced to and explore possible health system changes that can be made within each area.

Improvement Model. During the action periods, health system changes are tested by way of the Improvement Model (Figure 3), which uses PDSA cycles to answer these questions^d,e:

What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?

The health center uses the PDSA process to guide them to make small changes in a short period of time. Using this process, the health center can determine the feasibility and effectiveness of each change. Successful health system changes are then continued and expanded. Changes that are sustained and spread ultimately result in transforming the health care system and improving overall quality of care.

Asthma Collaborative measures. Measures were identified using a process consistent with determining measures for all of the Health Disparities Collaboratives. A planning group comprised of asthma care providers, academicians, and other asthma experts was convened. They were given the charge to identify measures that would indicate whether or not health center staff had made effective system changes to improve care for patients with asthma. Using information and data from the scientific literature, asthma guidelines, and other consensus documents, the planning group identified one asthma outcome measure—number of symptom-free days in the past 2 weeks—and three process measures—current severity assessment, appropriate treatment with anti-inflammatory medication, and current self-management goal.

The three process measures reflect evidence-based practices that lead to improved health outcomes. In addition, because self-management is a key component of the Chronic Care Model, the self-management goal measure is common across all Health Disparities Collaboratives. Collectively, improvements in all the required measures would reflect improvements in the health care delivery system and improved quality of care.^f The goals (or targets) represent achievable levels by well-organized health centers or come from evidence-based guidelines.^g

To keep the data collection system manageable, only four core measures were required. Seven additional measures were identified as reflecting improvements in the health care system; these were recommended but were not required. Required and recommended measures are:

Required:

Current severity assessment (Goal: 90% or more).
Appropriate treatment with anti-inflammatory medication (Goal: 95% or more).
Current self-management goal (Goal: 70% or more).
Number of symptom-free days in previous 2 weeks (Goal: 10 or more days).

Recommended:

Exposure to environmental tobacco smoke.
Evaluation of environmental triggers.
Emergency department/urgent care visits for asthma.
Average lost workdays and/or school days.
Establishment of personal best peak flow.
Influenza immunization annually.
Depression screening (12 months)

Further information on these measures—including definitions, data gathering plans, and reference sources—is available from the Health Disparities Collaboratives Web site at http://www.healthdisparities.net/hdc/html/collaboratives.topics.asthma.aspx.

Learning Partnership for decreasing asthma disparities. In 2005, the Agency for Healthcare Research and Quality (AHRQ) developed an initiative to address the disproportionate burden and work toward the elimination of disparities in pediatric asthma. Michigan was one of six States that participated in this initiative.

The foundation of the initiative was the formation and maintenance of a Learning Partnership. This Partnership had several purposes including:

Creating and reinforcing relationships among key stakeholders and other leading States.
Providing forums that encourage the use of evidence-based knowledge and strategic decisionmaking.
Identifying measures, indicators, and data sources to assist States in measuring progress towards reducing disparities in pediatric asthma.
Assisting State asthma coalitions to understand, document, and share experiences and lessons learned.

Involvement in the Learning Partnership included conference calls, site visits, a learning institute, various forms of technical assistance, and a milestone meeting. Michigan's participation helped the Michigan Asthma Program to improve its critical thinking about asthma disparities, possible evidence-based strategies, and ways in which addressing disparities could be integrated into existing programming. The Learning Partnership heightened the Michigan Asthma Program's interest in working to expand the Asthma Health Disparities Collaborative within Michigan FQHCs.

Simultaneously, the Michigan Asthma Program was reviewing Michigan's Diabetes Prevention and Control Program's model of supporting the Diabetes Health Disparities Collaborative. This model features six regional diabetes outreach networks that form partnerships with the FQHCs that implement Diabetes Collaboratives. These networks work with participating FQHCs to examine their data and identify opportunities for health system changes. Depending on the proposed changes, the networks provide consultation, technical assistance, and resources to help the health centers implement the Collaborative. The Michigan Asthma Program decided to replicate this model by working through the regional asthma coalitions to create a partnership among the Michigan Primary Care Association, the Michigan Asthma Program, the asthma coalitions, and FQHCs that builds health center capacity to implement the Asthma HDC. In addition, this partnership will enhance the spread of the Asthma Collaborative within the health center as well as into other health centers.

In 2007, two asthma coalitions will assist a FQHC in their catchment area to initiate the Asthma HDC. Each of these FQHCs had prior experience with implementing the Diabetes Collaborative but had not yet moved toward the Asthma Collaborative. This effort is expected to increase the number of Michigan-based FQHCs implementing the Asthma Collaborative from 3 to 5 in 2007 with further expansion expected in 2008, as an additional coalition becomes involved and new FQHCs are recruited.

Although each center will be responsible for implementing the Asthma HDC and making the health system changes, the asthma coalitions and Michigan Asthma Program have important facilitating roles which are consistent with those defined over the past 5 years by the 50 State Diabetes Prevention and Control Programs^h and include:

Training—Provide individual technical assistance, support for learning sessions, conference calls, and listservs on the asthma HDC, each of its components, and related quality improvement strategies.
Resources—Identify or provide resources and tools to facilitate health care system changes.
Clinical information system support—Provide technical assistance or training to assist with tracking, interpreting, and reporting asthma HDC data.
Community linkage—Provide consultation and linkages to community resources and policies.
Sustainability and spread—Provide technical assistance and support to maintain and expand center staff understanding the collaborative process.ⁱ

Examples of Asthma HDC system improvements documented in the literature are presented in Appendix C.

Coalition-Level Efforts

This section highlights information, examples, and tools to determine how coalitions can best partner with a FQHC. One of the primary guiding documents is the Asthma Health Disparities Collaborative Module, illustrated in Table 1, developed by the Michigan Asthma Program. Coalitions working with the Asthma HDC can use this module to define their scope of work and track their progress.

Coalition role. As previously described, the FQHCs will be responsible for implementing the Asthma HDC though health system changes. Given this charge, what is the role of the asthma coalition? The coalition's role is to coach and guide the FQHCs to make health system changes most likely to result in improvements. The technical assistance provided by coalitions to FQHCs will further increase the likelihood that FQHCs will reach their targets and achieve their objectives. In addition, coalitions can provide asthma expertise and work with the Asthma Initiative of Michigan to facilitate the FQHCs in learning from each other.

Developing charter and aim statements. The Health Disparities Collaboratives Web site provides extensive information on the reasoning behind developing a charter and aim statement and the steps to take in doing so. Each asthma coalition is encouraged to work with the FQHC to develop a written charter and/or aim statement as one of the first steps to implementation of the Asthma HDC. This effort will help the asthma coalition and FQHC to focus on specific actions and defines the health care providers and patients with asthma that will participate.

The charter or aim statement should be time specific and measurable. The aim and measures should be realistic but not too easy to achieve, and they should reflect targets that are not possible given the current system of care. The aim should cover the components of the Chronic Care Model (described more fully below) and emphasize that health system change is the purpose.

A team's charter should include the following^j:

What is expected to happen?
- System to be improved.
- Setting or subpopulation of patients.
- Timeframe.
Why is it important to do this?
- How does it impact patients?
- Why is important for the organization (e.g., mesh with organization's strategic plan)?
- What data/analysis supports the choice?
What does the team want to accomplish?
- Anticipated outcomes.
- Specific, numerical goals to be attained.
- Business case (financial, throughput, cost, productivity impact).
Guidance for the activities, such as strategies for the effort and limitations (optional).

Below are two examples of charter statements:

The clinic practice initially will redesign the system of care of our asthma population patients by implementing the six components of the care model. We will focus on decision support so that 95% will have a severity assessment at last contact, 95% of patients with persistent asthma are on a respiratory anti-inflammatory medications, 70% will have a written asthma action plan, half of our patients will decrease exposure to environmental tobacco smoke, the average number of symptoms free days will increase by 10 days out of 14 days.
Redesign the system of care to provide improved care to our patients with asthma so that 90% of the pediatric asthma patients have a documented current severity assessment and 95% have appropriate treatment with anti-inflammatory medication within 6 months of implementation. We will accomplish this goal by implementing the components of the Care Model.

Below are two examples of aim statements^k:

Implement components of the Chronic Care Model to show a 40% increase in symptom-free days, 50% decrease in emergency department visits, 90% of patients with persistent asthma to be treated with anti-inflammatory medications, and at least 90% of patients to have a written asthma action plan.
An organizational approach to caring for the population of patients with asthma will be implemented using the Chronic Care Model so that there are 90% of patients with persistent asthma being treated with maintenance anti-inflammatory medications. At least 90% of clients with asthma will have an asthma flow sheet and action plan in their chart and 50% of clients with asthma will have an asthma trigger avoidance plan.

Project tree diagram. Once the asthma coalition and the FQHC have identified a health system change, they may want to construct a project tree diagram (Diagram 2). A tree diagram is used to break a project down into tasks or activities that must be carried out to complete the project or achieve an objective. When the tree is carefully and thoroughly constructed, it provides a better understanding of the true scope of the project—in this case, a proposed health system change. It also helps the team focus on specific tasks that are needed to get something done.

The steps in building a tree diagram are^l:

Be sure everyone agrees on main goal before beginning.
Be succinct.
Think of the main tasks involved in accomplishing the goal. Add them to the tree.
For each task node, think of the subtasks that will be required, and add them to the tree.
Determine if anything has been forgotten.
As the team works through the project toward the goal, change the colors of nodes that are finished, so an indication of progress is clear.

Among the benefits of a project tree diagram are:

It facilitates a view of several strategies for achieving the aim of the improvement project.
The likelihood that essential items will be omitted is reduced.
It provides an opportunity for dialogue and agreement among team members.
Information can be used in charter development.

^a.Asthma Initiative of Michigan. Asthma in Michigan 2010: A Blueprint for Action. A Strategic Plan for Improving Asthma Self-Management and Treatment through System Level Intervention, 2005-2010. Lansing, MI: American Lung Association of Michigan; 2006.
^b.Wasilevich EA, Lyon-Callo S, Dombkowski KF. Disparities in Michigan's Asthma Burden. Lansing MI: Bureau of Epidemiology, Michigan Department of Community Health; 2005.
^c.The theory and application of spread is part of the theory on diffusion of innovations. See: Rogers EM. Diffusion of Innovations, 5th ed. New York: Free Press; 1995.
^d.Langley G, Nolan K, Nolan T, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass, 1996.
^e.The Model for Improvement was developed by Associates in Process Improvement. Further information is available at: http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/; and in The Breakthrough Series: IHI's Collaborative Model for Achieving Breakthrough Improvement. Boston: Institute for Healthcare Improvement; 2003, pp. 6-7.
^f.Kevin Little, Informing Ecological Design, LLC. Personal communication May 10, 2007.
^g.Measures Webcast for the 2005 Diabetes Collaborative. Downloaded from the Health Disparities Collaboratives Web site (http:// www.healthdisparities.net). Accessed May 10, 2007.
^h.Martin M, Larsen BA, Shea L, et al. State diabetes prevention and control program participating in the Health Disparities Collaborative: evaluating the first 5 years. Prev Chronic Dis [serial online] 2007 Jan. accessed March 5, 2007. Available at: http://www.cdc.gov/ped/issues/2007/jan/06_0027.htm.
^i.Centers for Disease Control and Prevention. Opportunities for State Heart Disease and Stroke Prevention Programs to Improve Health Outcomes through Cardiovascular Collaboratives. 2006.
^j.Hupke C. The Model for Improvement. Presentation at the Chronic Care Model, the Model of Improvement, and Their Application to Reducing Disparities in Pediatric Asthma: A Faculty Workshop. Providence, RI, December 13-15, 2006.
^k.Institute for Healthcare Improvement. Setting Aims. Available at: http://www.ihi.org/IHI/Topics/ChronicConditions/AllConditions/HowToImprove/ChronicSettingAims.htm. Accessed May 19, 2007.
^l.Skymark Corporation: Project Tree Diagram. Available at: http://www.skymark.com/resources/tools/tree%20diagram.asp. Accessed May 20, 2007.

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