Managed Care, Medicaid, and Public Health: Building Collaborations That Work

Childhood Asthma Initiative

Presenters: Andrew K. Goodman, M.D., M.P.H., Associate Commissioner, Community HealthWorks, New York City Department of Health, New York, NY. Judith A. Cashman, R.N., M.P.A, C.P.H.Q., Vice President for Clinical and Provider Services, Neighborhood Health Providers, New York, NY. Louise Cohen, M.P.H., Director, New York City Childhood Asthma Initiative, Community HealthWorks, New York City Department of Health, New York, NY. Theodore Outwater, Environmental Specialist, Center for Occupational and Environmental Health, Hunter College School of Health Sciences, City University of New York, New York, NY.

To minimize asthma-related hospitalizations and emergency room (ER) visits, symptom days, and school absences, the New York City Childhood Asthma Initiative incorporates not only the patient/family and primary care provider but also the healthcare system and community environment.

The Initiative's partners include: the New York City Department of Health, Hunter College, Columbia University, the Centers for Disease Control and Prevention, the New York Academy of Medicine, the Medicaid Managed Care Community Health Workgroup, and the Hunts Point Childhood Health Promotion Initiative. The Initiative has a $6 million annual budget for the rest of the city's 4-year budget cycle.

From 1997 to 1998, asthma hospitalizations decreased 28 percent, in part due to the efforts of the Initiative; hospitalization rates decreased further in 1999.

Andrew Goodman described the Asthma Initiative's components, which include:

• Citywide education and awareness: This is accomplished using the media, written materials (including a successful subway poster campaign, which is being expanded to other public transportation areas), presentations, and the Medical Provider Education Campaign (offering onsite interactive training to practices in the South Bronx). As part of the Medical Provider Education Plan, an Asthma Action Plan form was developed, with copies for the physician, family, and school. The physician and family would complete plans for how to handle green ("go"), yellow ("caution"), and red ("danger") zones. The initially piloted form was revised following parent focus groups and provider surveys.
• Asthma program assessment and development: This builds capacity within city agencies, managed care organizations (MCOs), the Health and Hospitals Corporation, public schools, Head Start/day care centers, and other community-based organizations. This includes training staff, developing asthma policies and procedures, and establishing linkages among community programs.
• Comprehensive community-based programs: These are being developed in high-risk neighborhoods. For example, the Community Health Outreach Worker Program provides home visits, identifies system gaps, and provides leadership in the community because workers are hired from the neighborhoods served. The Critical Event Tracking and Response System is being piloted in one neighborhood to identify and ensure that appropriate care is delivered to symptomatic children. Anyone identifying such a child can contact the Data Center, which then notifies everyone involved with the child's healthcare. Five schools and three hospitals participate.
• Surveillance and evaluation: Both process and outcome measures are examined by looking at hospital discharge data and prevalence surveys.

Challenges for the Initiative include:

• Balancing service delivery with capacity-building.
• Using the Initiative as a foundation for other health issues affecting children.
• Having an impact on policies and systems.
• Measuring effectiveness.
• Obtaining resources.
• Equalizing the level of participation among the partners.

Judith Cashman explained that the collaborative behind the Initiative is the Community Health Workgroup, initiated in 1996 by the city's Department of Health. City Medicaid contracts with MCOs require that the medical director or a high-level designee participate in the workgroup, which seeks to identify priority issues and develop preventive programs. Asthma was chosen because of high hospitalization and ER rates, the fact that it is in the public eye, and that the Department had some funding to work on the issue.

Reasons for partners to collaborate include:

• MCOs want to decrease utilization of high-cost services, such as ER visits.
• There is a public health interest in decreasing the need for services.
• Preventable health problems, such as asthma, tend to occur in communities with high numbers of Medicaid beneficiaries.
• MCOs may have high penetration rates in certain communities where specific health problems are more prevalent.
• It's good public relations.

In addition to those pieces of the Initiative discussed above, the milestones of the workgroup include:

• The Department of Health's Asthma Action Line.
• MCO provider and member education about using the Asthma Action Plan (see above), and an assessment of the plan's use.
• The Asthma Services Directory, a resource for providers.
• An agreement between the city and MCOs on member education materials being distributed.
• Conference for nurses in 1999 and 2000, including providing information on how to navigate managed care systems.

Aspects of the workgroup that are positive or working include:

• City leadership and staff support.
• A collegial atmosphere as a result of the inclusion of MCO clinical personnel.
• Having a product.
• Having resources and expertise not readily available within MCOs.

Aspects that are not positive or not working include:

• A relatively slow pace.
• Not all MCOs participate and the contributions of those who do are uneven (the department is currently discussing ways to measure levels of participation for contract enforcement purposes).
• Uneven MCO senior management support.
• Difficulties in community implementation.
• Little public recognition.

The other panelists provided greater detail into various projects within the Initiative. One goal of each project is to create replicable strategies; therefore, the partners have sought to keep costs down.

Louise Cohen described a project in the Hunts Point area, a defined community of approximately 80,000 people. The department began the project in 1997 by holding focus groups with residents and assessing community assets. Hunts Point Childhood Health Promotion Initiative's components include:

• Medical Advisory Committee—a partnership of the department, MCOs, and providers—developed an action plan.
• Community Health Worker program (described above) has each worker case managing approximately 180 children.
• Work in schools started with training the nurse in one school to identify symptomatic children and to develop access to proper medications onsite. However, since that time, working with schools has been at an impasse, as school personnel already feel overwhelmed; one goal for next year is to work through this impasse by convening all the school-related players.
• The Community Planning Group has done a great deal of educating, both on asthma and on the realities of the political process. It developed two communitywide events, in which approximately 400 families participated.

In order to foster a greater "sense of self" in the community, the Hunts Point Initiative's new model will be led by contracted community-based organizations. These organizations will be responsible for convening a community coalition and facilitating its activities. The department will continue to be a partner in these activities. The department will also coach and work with these organizations over the next 2 years to help develop skills in community organizing, program development, and community health planning.

Ted Outwater described the Asthma and Pest Control Project in a four-building development in East Harlem. The partners are: the City Health Department, City Housing Authority, Hunter College, and the development's resident association. The goals of the project are to reduce cockroach and rodent infestations (common asthma triggers) using a least toxic approach that includes resident and staff training, and to change asthma-related behaviors through such activities as a children's poster contest and resident workshops. An evaluation of the pest control piece completed 6 months after the project had started found significant reductions in cockroach and rodent populations.

Mr. Outwater stressed that having a team that communicates well can work through the complexity of administrative realities, particularly when multiple city agencies are involved. It is critical to find and keep the right people, including helping them enjoy the process by celebrating goals achieved along the way. It is also important to fire or redirect the individuals and organizations that don't seem to be working.

References

Atkins FM. The asthma action plan: at the fulcrum of individualized asthma care. J Asthma 1997;34(1):1-3.

Etzel RA. Indoor air pollution and childhood asthma: effective environmental interventions. Environ Health Perspect 1995;103(Suppl. 6):55-8.

Fisher EB, Strunk RC, Sussman LK, et al. Accessibility and feasibility of a community approach to asthma management: the neighborhood asthma coalition. J Asthma 1996;33(6):367-83.

Flaum M, Lung CL, Tinkelman D. Take control of high cost asthma. J Asthma 1997;34(1):5-14.

Harris JR, Gordon RL, White KE, et al. Prevention and managed care: opportunities for managed care organizations, purchasers of health care, and public health agencies. MMWR 1995 Nov. Publication No. RR-14.

Hunter College Center for Occupational and Environmental Health. Cockroach inspection, monitoring and control tips. New York (NY): 2000 Jan.

Hunts Point Childhood Health Promotion Initiative: Community asthma program. Bronx(NY): The Initiative;1999.

National Center for Environmental Health, Centers for Disease Control and Prevention: Asthma prevention program at a glance. Atlanta(GA): 1999 Feb.

O'Brien KP. Managed care and the treatment of asthma. J Asthma 1995;32(5):325-34.

Public health and managed care: opportunities for collaboration. Washington (DC): U.S. Department of Health and Human Services, Office of the Inspector General;1999 Jul. HHS Publication No. OEI-01-98-00170.

Stout JW, White LC, Rogers L, et al. The asthma outreach project: a promising approach to comprehensive asthma management. J Asthma 1998;35(1):119-27.

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