Module 3: Learning From Current State Quality Improvement Efforts

States are currently involved in many efforts to improve the quality of asthma care. These actions can inform other State efforts. This module provides examples of current State efforts to improve the quality of asthma care within the context of a State-led model of quality improvement.

Key Ideas in Module 3: A variety of quality improvement initiatives at the State level are sparking change in health systems across the Nation. States can use this module to identify examples and resources for asthma care quality improvement.

The Introduction to this Resource Guide described a new, strategic role for States in leading quality improvement for asthma. A State-led quality improvement framework that States could use in playing this role was described in Module 2. Building on lessons from industrial and clinical models for quality improvement, it adapted the Plan-Do-Study-Act cycle of quality improvement for the policymaking context to a Plan-Do-Assess approach illustrated in Figures 2.1, 2.2, and 2.3.

This framework identifies the three stages in which States can play a key role—provide leadership, work in partnership, and implement improvement. Many States are already active in these areas, so Module 3 also provides specific examples of what States are doing currently at each of the three stages presented above.

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Current State Efforts To Improve the Quality of Asthma Care

States have typically viewed their role in quality improvement from a public health perspective or, more narrowly, as a buyer of health insurance for state employees. However, as outlined in the introduction, States can play a broader and more strategic role. Some States are already doing this, at least in part, with respect to asthma.

States have undertaken a variety of asthma initiatives over the years. Many of these have been funded by the Centers for Disease Control and Prevention (CDC). States have used CDC funding to establish creative programs to address asthma prevention and control. As attention to health care quality has increased, State asthma programs have also adopted quality improvement aims. States also initiate other programs. States have established asthma disease management programs in Medicaid and have partnered with the private sector on quality improvement for asthma care. Many States also have tried to integrate CDC-funded efforts with private sector and Medicaid efforts.

Appendix C lists over 100 separate programs in 48 States that target improvement in some aspect of asthma care and include efforts at the Federal and State/local levels, joint private/public efforts, and efforts by private national organizations with Internet links to more information.

A significant number of these programs are targeted to specific populations—such as children, minority communities, or Medicaid recipients—or on public health approaches toward asthma mitigation. However, it is difficult to generalize about these programs, given their diversity and heterogeneity. Therefore these programs are divided into 12 categories that relate their relevance to some of the important aspects of quality improvement:

• Advisory bodies and councils.
• Coalitions.
• Collaboratives.
• Cross-agency work.
• Data measurement and reporting.
• Developing and enforcing guidelines.
• Disease management.
• Minority and rural outreach.
• Public service/education efforts.
• Self-management (of asthma).
• Provider training.
• Use of technology.

Note that these categories cut across the three stages of activity highlighted in the State-led model. The number and range of State activities make it difficult to present all instances. Therefore this module presents some examples of specific programs in States that fit these stages:

• In Stage 1, States are providing leadership by championing quality, convening partnerships, and providing support.
• In Stage 2, States are working in partnership on various activities—planning for quality improvement, developing and complying with asthma guidelines, and supporting measurement and data collection.
• In Stage 3, States are implementing improvement by supporting activities that implement asthma care quality interventions of various types, evaluating their effectiveness, and spreading success.

Most of the information provided below and in Appendix C was derived from a review of State health department Web sites, CDC resources, Internet research, and in-person interviews with State agency officials. Examples below provide a sampling of State efforts that reflect regional, size, and funding differences among States. Although not an exhaustive list, it demonstrates a range of State efforts related to asthma quality improvement.

Stage 1: Provide Leadership

A Champion for Quality

Having a champion for quality improvement is critical to the success of any asthma quality improvement initiative. Champions provide consistent leadership, give greater visibility to issues, and spur others toward greater strides in quality improvement. In some cases, asthma quality improvement initiatives have received recognition and support from the highest leaders of State government. The involvement of an influential, recognizable leader, such as a governor or other high-level elected official, can enhance stakeholder engagement in the process and heighten the attention given to quality improvement initiatives in the media and within the public and private sectors.

In other cases, dedicated staff within an executive agency, such as the asthma control program staff in the State's health department, are instrumental in providing the leadership needed to pull together diverse stakeholders and influential elected officials to promote quality. For example:

• In New York, Governor George Pataki championed improving asthma care. Following his 1999 State-of-the-State speech, New York launched an aggressive asthma prevention and control agenda. New York has developed clinical treatment guidelines for asthma, provided funding to regional coalitions to improve asthma care, and implemented a Medicaid disease management and quality improvement initiative related to asthma.
• Staff in Oregon's Asthma Program established a Workgroup on Improving Asthma Care with representatives from health plans, health care providers, medical professional groups, and advocates. Through a consensus process, the workgroup developed guidelines for asthma care in the State based on NHLBI guidelines that were then published and distributed by Oregon's Asthma Program to providers, medical professionals, and others.

Convene Partners and Develop Support

Quality improvement leaders cannot accomplish their task alone. Creating networks of support has been critical for State programs that address asthma quality improvement. States have used various methods to convene parties interested in improving asthma care, including creating or assembling broad coalitions or networks of multiple stakeholders as well as using advisory bodies, councils, or State workgroups that are smaller and authorized by statute or regulation.

State advisory bodies, councils, and workgroups. A number of States have established through legislation or executive action, advisory boards, councils, or workgroups on asthma that assist with statewide asthma planning and quality improvement efforts. Advisory bodies, councils, and workgroups are generally led by State officials and typically include a variety of experts and stakeholder groups from the public and private sectors, such as the American Lung Association, State health professional associations, hospital associations, and provider organizations. Other stakeholders may include large businesses, employer groups, and other community leaders. These advisory bodies, usually housed within the State's health department, are often supported through CDC Asthma Prevention and Control Programs.

• The Minnesota Department of Health developed the Commissioner's Asthma Advisory Workgroup to provide direction and assistance in forming a statewide plan to address the rising health and economic burden of asthma in Minnesota.
• Connecticut established its Asthma Advisory Council in 2003 to assist in the implementation of the State asthma plan. The council consists of 15 members appointed by the State Commissioner of the Department of Public Health.

Coalitions and networks. Coalitions and networks are broad-based, voluntary efforts, in contrast to advisory bodies or other State-sanctioned entities. These groups are generally formed by private initiative; elected State officials or executive agency staff may participate. Coalitions and networks bring together a broad variety of stakeholders in a State to work together to identify areas of strength, common objectives, and gaps in services. They also develop plans to assure that the essential treatment and educational services for managing asthma are in place in a community.

Coalitions may also include community representatives and nontraditional partners such as the corner grocery store owner, faith communities, health organizations, social service agencies, and more. Coalitions and networks can be important allies in quality improvement efforts in the State because of their broad membership and natural interest in improving the quality of care for asthma. For example:

• Ohio's Asthma Coalition is an association of medical and public health professionals, business leaders, various government agencies, community activists, and others dedicated to improving the quality of life for people with asthma through information sharing, networking, and advocacy.
• The Colorado Asthma Coalition is a group of health care professionals and community members committed to working together to improve public awareness and education, data collection and research, and provider education.

Stage 2: Work in Partnership

Planning for Quality Improvement

Convening a State advisory body or a coalition of stakeholders or both is just the first step in the improvement process. The group must then develop a strategy and plan of action for asthma quality improvement.

In many States, the State's asthma plan will be the guiding document for group action. A State asthma plan is required by the CDC for States that receive funding from its National Asthma Control Program. These plans provide an overview of the asthma prevention and control issues within the State that need to be addressed. The plan also articulates goals and identifies strategies the State will use to achieve the goals. Thirty-five States received fiscal year 2004 funding from CDC for asthma prevention and control. (More information on State asthma plans is available on the CDC Web site at http://www.cdc.gov/asthma. The CDC Web site provides links to State asthma programs and their State plans.)

State asthma plans generally include most of the traditional public health activities such as education and awareness, data collection, disease surveillance, and partnership activities with State and community groups. Some State asthma plans also include improving the quality of care for asthma, although this varies. States have used the State asthma plan process to develop evidence-based asthma treatment guidelines, collect data on quality of care measures, improve asthma self-management education and practice, and train providers on asthma management training.

In other cases, asthma quality improvement initiatives may develop apart from the State's asthma program, such as with Medicaid disease management or pay-for-performance initiatives. Provided below are examples of different ways that States have worked in partnership with others to develop and implement asthma quality improvement plans.

Developing and Complying With Asthma Guidelines

To help translate research-based evidence into practice, several States are promoting the use of evidence-based clinical guidelines for asthma care. Like Oregon, many States have adopted guidelines established by the National Heart, Lung, and Blood Institute, while others have worked through the process of developing State-specific asthma treatment guidelines.

• New York released its Clinical Guidelines for the Diagnosis, Management, and Evaluation of Adults and Children with Asthma—2003 along with a call to action to the State's health care professionals to participate in regional conferences for physician education.
• Missouri's Center for Asthma Treatment at Children's Mercy Hospital has worked to fully implement the 1997 NHLBI guidelines for diagnosis and management of asthma by creating an integrated program for asthma treatment and standardizing the education and medical treatment of people with asthma.
• The Texas Medicaid Managed Care Asthma Project is a pediatric asthma pilot program for Medicaid enrollees.The program provides standardized patient and family asthma management education and supplies best practice guidelines to providers.

Quality Measurement and Data Collection

The development of quality measures and data collection and analysis are fundamental steps in quality improvement. States have used CDC asthma program funding to improve data collection, including information about prevalence, death rates, and other statistics. Other data sources include managed care plan or Medicaid program data. (More information on identifying and using asthma data sources for quality improvement plans is presented in Module 4.)

• The Colorado Asthma Program is developing a statewide surveillance data system to determine the prevalence, mortality, and morbidity of asthma in the State and to assess any associated morbidity and mortality.
• Wisconsin's Asthma Plan includes objectives to use (by 2007) the NHLBI guidelines for diagnosis and management of asthma statewide and to build the capacity of health care organizations in the State to monitor and measure asthma care quality.

Partnerships Beyond Health Care

Effective asthma interventions can leverage partnerships beyond the health care setting. Asthma interventions can involve leaders in businesses, employer groups, schools and day care centers, and organizations of caretakers, social workers, and others. Comprehensive asthma interventions should address environmental issues that affect people with asthma and support self-management for patients in the context of their communities and daily lives.

• The National Cooperative Inner-City Asthma Study Intervention is a social-worker-based education program that focuses on environmental control. Social workers are trained as asthma counselors and work with the child's caretaker to improve communications between family and physician (Sullivan, et al., 2002).

Stage 3: Implement Improvement

Implementing Asthma Care Quality Interventions

States use a variety of interventions to affect asthma care. Some examples of ways that States seek to improve the quality of care for asthma are listed below.

Self-management/patient education. Patient self-management is critical for good asthma outcomes. Patient education programs can be conducted in a variety of settings that are accessible to target populations, including: churches, neighborhood associations, schools, and community-based organizations that are well recognized in a community. These programs can be conducted in small groups, or one-on-one, based on the identified needs of the population.

• Alabama's Inner-City Asthma Intervention program at the University of Alabama at Birmingham provides patients with individualized treatment plans and education based on evaluation from physicians, nurses, and educators to improve self-management skills.
• In North Carolina, the Inner-City Asthma Intervention program provides individualized and group educational sessions on asthma for children. The sessions provide a basic understanding of asthma, its triggers, environmental control, warning signs, and medications.

Collaboratives. Improving the quality of care for asthma is a systemic issue. The entire health care system and all its actors need to be mobilized to improve the quality of care received by persons with asthma. Building on the successes of the Health Disparities Collaboratives funded by the Health Resources and Services Administration (HRSA), a number of States have started or participated in collaboratives that bring together teams of practitioners to develop quality improvement strategies for clinical settings. Collaboratives typically use a PDSA model to bring together teams over a period of time, develop an improvement idea, test it on a limited basis, study the effect, and then implement the change more broadly.

• California Medi-Cal officials and a group of health plans, providers and community-based organizations that serve the Medi-Cal population have participated in the Plan/Practice Improvement Partnership, a quality improvement effort aimed at developing clinical and administrative approaches to improve asthma care. The collaborative is funded through the Center for Health Care Strategies Best Clinical and Administrative Practices program.
• The New York State Medicaid Asthma Disease Management and Quality Improvement Initiative promotes disease management interventions in the treatment of asthma. Community Health Centers in the greater NYC region provide patient education to improve health outcomes for Medicaid recipients.

Provider training. Because health care providers are a key element in improving asthma quality care, many States have actively sought their involvement in developing programs. In addition, States are providing outreach, training, and support to health care professionals as they seek to implement new evidence-based care guidelines.

• Arkansas Asthma Coalition offers primary care physicians, health care providers, school nurses, and physician office staff training that spotlights diagnosis, evaluation, and treatment of asthma as well as skills for managing, educating, and communicating with asthma patients. In addition, approximately 1,200 staff of public schools receive the American Lung Association's Asthma In-Service Training.

State disease management programs. Because States are looking for ways to control Medicaid costs while maintaining or improving quality, 38 States are implementing disease management programs, many of them targeting asthma. Medicaid disease management programs seek to increase patient knowledge and self-management skills, improve provider adherence to clinical guidelines, and implement computer technology to track patients more effectively in clinical settings for provider awareness and for system-wide evaluations of the effectiveness of the intervention. Improved care management for asthma helps patients get their asthma under control and ensures that care provided meets accepted standards.

• The Virginia Health Outcomes Partnership established a training program for physicians in the Medicaid Primary Care Case Management program that focused on reducing emergency care for asthma through better education for physicians on disease management and communication skills. The program resulted in overall savings for Medicaid, even when the training costs and higher drug costs were factored in.
• The Florida Agency for Health Care Administration's Medicaid Disease Management Program has contracted with experienced disease management organizations to provide disease management services to Medicaid recipients who have been diagnosed with asthma.
• The Indiana Chronic Disease Management Program (ICDMP) was developed after legislation required the Office of Medicaid Policy and Planning to implement a disease management program for people with asthma and other chronic diseases. The ICDMP provides information on asthma for Medicaid recipients as well as all other patients.
• The Missouri State Medicaid Disease Management program is targeted toward patients enrolled in the fee-for-service Medicaid program. This program focuses on disease management tactics for asthma patients determined to be at high risk for adverse outcomes. The goal is to slow the progression of asthma and avoid medical crises.

Pay-for-performance initiatives. Quality improvement experts have long recognized that providers have little incentive to improve health care quality in an environment where every health care organization is paid for quantity of services rather than quality. While the effectiveness of pay-for-performance on quality improvement is still being studied, an increasing number of private and public payers are exploring use of financial incentives to spur quality improvement (Dudley, 2005). CMS is conducting a number of Medicare demonstration projects that include pay-for-performance. As of January 2006, CMS had a new voluntary program on quality measure reporting to help providers assess their performance in anticipation of the trend to implement pay-for-performance in both the public and private sector. Some private insurers have already begun implementing pay-for-performance to improve quality, including Blue Cross/Blue Shield, Wellpoint Health Networks, and others. (More information can be found at The Leapfrog Group Web site at http://www.leapfroggroup.org/leapfrog_compendium.)

States, too, are implementing pay-for-performance initiatives, particularly through Medicaid managed care contracts. Pay-for-performance initiatives are still in early stages of development. Currently, most pay-for-performance initiatives have a broad focus and use quality measures for several chronic conditions including asthma.

• Iowa and Massachusetts have included financial incentives to contractors that deliver behavioral health services. One study found that the contractors involved in pay-for-performance initiatives showed improvement in the specific areas where financial incentives were provided (Dyer, et al., 2002).
• Medical groups in California have agreed to use common data and performance measures for their quality improvement incentives. The pay-for-performance initiative is a collaboration of seven California health plans which use the same survey instrument for patient satisfaction and some HEDIS^® measures for cancer screening, asthma, diabetes, coronary artery disease, and immunizations. More information on this initiative can be found at http://www.iha.org.

Evaluating Effectiveness

Interventions to improve quality of care need to be evaluated for clinical effectiveness as well as cost effectiveness. State leaders, however, need a clear definition of success. Demonstrating real cost savings in a short time frame can be difficult. What may be more readily demonstrated is improved quality of care, cost avoidance, and improved quality of life for patients. With diligence, careful planning, and longer time to evaluate a program, States can also evaluate the cost effectiveness of quality improvement efforts.

One study (Rossiter, et al., 2000) offers a good example of how to design and evaluate an asthma intervention program. The Virginia Health Outcomes Partnership targeted low income asthma patients in a Medicaid primary case-management program. The program aimed to reduce the rate of emergency care visits for asthma. An intervention group and a control group were used to assess the effectiveness of the intervention in a real world setting where other factors can be expected to change. The study provided statistics on the reduction in emergency care visits as well as the projected direct savings to Medicaid that accounted for the cost of the physician training and the costs of increased prescribing of drugs to control the asthma symptoms. (Go to Module 1 for information about estimating potential cost savings from quality improvement.)

Spreading Success

The experience of success should not be isolated to a single program or clinic. Successful programs and strategies need to be disseminated in order for quality of care to be improved overall. It is important to adapt existing models for quality improvement and to spread their success to other communities and health care settings.

• The federally sponsored Health Disparities Collaboratives, developed by HRSA with the Institute for Healthcare Improvement, aim to transform the delivery of care in community health centers. The program improves the care for certain chronic conditions by targeting providers, patients, and communities to support provider-patient partnerships. Participants in the Health Disparities Collaboratives have worked to improve care for their patients with asthma and spread the changes and improvements throughout their health center.
• Organizations such as the National Initiative for Children's Healthcare Quality (NICHQ) have formed other learning collaboratives to spread success in asthma care improvement as well (http://www.nichq.org/nichq). States can use this model with other programs to spread the success of these programs.
• In North Carolina the Center for Children's Healthcare Improvement (CCHI) has worked with the State's Division of Medical Administration and Area Health Education Centers (AHECs) on a variety of quality improvement projects aimed at improving the care for asthma among the Medicaid population. Building on its past successes working with clinical practices, CCHI plans a multi-tiered policy, community, and clinical approach to spread quality improvement statewide, beginning first in two AHEC regions.

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Summary and Synthesis

Successful programs of current asthma quality improvement activities provide State leaders with examples, useful resources, lessons learned, and approaches for enhancing initiatives and partnerships. State programs have been successful in improving asthma care. Even so, much remains to be done. States have a unique role to play in championing improvement for asthma care, forging partnerships to address approaches to change, and implementing those approaches to help providers deliver the best care and to help people with asthma enjoy optimal quality of life. Whether a State is building the infrastructure for improving asthma care or already has a well developed set of partnerships in place, there are a variety of approaches in place that can inform State efforts.

Resources for Further Reading

• Institute for Healthcare Improvement stories for asthma. Available at: http://www.ihi.org/IHI/Topics/ChronicConditions/Asthma/ImprovementStories/.
• Rossiter LF, et al. The impact of disease management on outcomes and cost of care: A study of low-income asthma patients. Inquiry 2000;37:188-202.
• Rust GS, Murray V, Octaviani H, et al. Asthma care in community health centers: A study by the Southeast regional clinicians' network. Journal of the National Medical Association 1999;91(7):398-403.
• Stanton MW, Dougherty D, Rutherford MK. Chronic care for low-income children with asthma: strategies for improvement. Rockville, MD: Agency for Healthcare Research and Quality; 2005. Research in Action Issue 18. AHRQ Pub. No. 05-0073. Available at: http://www.ahrq.gov/research/chasthria/chasthria.htm.

Associated Appendix for Use With This Module

Appendix C: National and State Asthma Programs
Appendix C lists asthma quality improvement programs by State and Web site links for further information.

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