Breathing easier

Asthma project at Children’s Hospital in Boston is redefining care and sharply reducing costly emergency room visits and hospital admissions

Izaeyah French of Dorchester is an energetic 7-year-old who loves kickball—and loves knowing asthma won’t keep him on the sidelines while other kids play. In the past, “my head would hurt and I’d have to stay home,” he says. But, thanks to a pilot program at Children’s Hospital Boston that addresses environmental factors in kids’ homes that can exacerbate asthma, Izaeyah’s condition is largely under control.

His mother, Lolanda Randal, says the hospital’s Community Asthma Initiative has helped her to understand the need for changes in her home and helped her with expenses. “I was the type who’d use air freshener in every room,” says Randal. “When [a case worker] came in, they said, ‘That’s an asthma trigger.’”

So Randal, a leasing officer with the Boston Housing Authority, stopped using air freshener. She stopped using bleach as a household cleaner. The initiative paid for the family to have a vacuum cleaner, since allergens were collecting in the carpets, as well as an air conditioner, since Randal’s windows must stay closed to keep out pollen. While Randal says she used to make frequent trips to the emergency room with Izaeyah and his older brother due to asthma, the family hasn’t been back since joining the initiative about three years ago. Today, the boys are leading increasingly normal, active lives.

“I never took my boys anywhere because I was worried they’d exert themselves,” says Randal. “Last year, they were able to do a program for swimming and they loved it. It was so nice. That got me to thinking that boys can be boys.”

The premise of the initiative is simple: Asthma is the leading cause of admissions at Children’s. In both Massachusetts and the nation, the condition is most common in low-income, urban communities. (While 11 percent of children statewide have asthma, the figure rises to 14 percent in Boston, 23 percent in Holyoke, and 17 percent in Spring­field and New Bedford, according to the Depart­ment of Public Health.) The reasons for the geographic and income disparities are uncertain, but, according to a hospital spokeswoman, are likely due to a combination of factors including outdoor air pollution, poor indoor air quality caused by an aging housing stock, and inadequate access to both medication and assistance managing medications. What is certain is that hospital visits aren’t much fun for patients, they’re expensive for taxpayers if the children are covered by Medicaid, and, often, they are preventable.

But preventing inpatient hospital stays and emergency-room visits for asthma means redefining what we consider medical care and even medical devices. It means recognizing that for a child with asthma, paying $200 for a new vacuum cleaner can mean not paying $2,000 for a hospital stay. If that recognition were to come on a broad scale—and officials at Children’s Hospital hope it will—it could have important implications both for pediatric asthma treatment and for a much larger health care challenge facing the state and the country: reforming the way providers are paid.

Children’s Hospital began the asthma initiative in 2005 and has since served 544 Boston children. Funded through the hospital, private donations, and a grant from the Centers for Disease Control and Prevention, the initiative provides medical care, help with pest management and other environmental hazards, and asthma education. The program has no in­come eligibility guidelines, although 70 percent of participants are on Medi­caid. The initiative’s director, Dr. Elizabeth Woods, says the hospital exercises discretion when it comes to assisting patients financially and that many families—even those with employed parents—struggle with the co-payments for their medication. “We certainly try to be judicious in providing the more expensive items, like vacuum cleaners and AC units, to families in greatest need,” she says.

As a result of the initiative, kids are spending less time in the hospital. Among the 544 children enrolled in the program since its inception, total visits to the emergency department dropped 65 percent, falling from 482 visits during the six months preceeding enrollment in the program to 170 over a six month period after beginning the program. Total hospital admissions decreased 81 percent, declining from 350 to 68. Kids served by the initiative also missed 39 percent fewer school days; their families reported a 49 percent decline in missed days of work. And for every dollar the program spent on asthma management, it saved $1.49 in hospital visits.

While the causes of asthma aren’t well understood, doctors do know what helps patients keep it under control: taking medication regularly, and keeping their environments as free from irritants as possible. “If someone has asthma and doesn’t take preventative medicine, they chronically have more mucus. Whereas if you have control of it on an everyday basis, then when you face an irritant, there isn’t as extreme a response,” says Woods.

Woods says that when hospital social workers—who work with physicians and nurses in the asthma initiative —began visiting local families, they were startled by the high levels of what are considered environmental “triggers” for asthma, such as dust, and the droppings of cockroaches and mice. “We also didn’t realize that most families couldn’t afford vacuums and filter bags,” says Woods. “We often have to supply cleaning materials.”

Woods and other members of the initiative would like to see MassHealth, the state’s subsidized insurance program, cover items such as cleaning supplies and vacuum cleaners—tools almost as important as inhalers in keeping asthma under control. The hospital successfully lobbied for language in the current state budget to replicate its program elsewhere in the state and explore what are known as “bundled payments” for the management of asthma and other chronic diseases: Instead of reimbursing hospitals on a per-visit basis, Mass­Health would pay a lump sum for a patient’s asthma care. (Bundled payments are related to, but different from, the concept of global payments, in which providers receive a lump sum for a patient’s overall care.)

With bundled payments, providers could use that money to pay for items such as air conditioners and vacuum filters, as well as inpatient treatments. Staff could also spend time working with school nurses to coordinate a child’s asthma management and be available for phone consultations with parents, both of which the Children’s program now does.

On a steamy August afternoon, Lolanda Randal brings her sons into Children’s Hospital’s Primary Care Center to meet with Linda Haynes, a nurse practitioner and asthma specialist. Both boys feel fine—in the waiting room, Izaeyah races around with a toy car while his older brother, Javaun Dawkins, 10, im­merses himself in a hand-held computer game—and need to have prescriptions refilled before heading off for camp.

“Which medications have they been using?” Haynes asks as the family settles into the examination room.

“I know them by colors,” says Randal. “They’re on the purple one, two puffs a day. And the orange one. And he” —she gestures at one son—“takes the tablets for allergies.”

“The Claritin?” Haynes asks.

“Yes,” says Randal.

For much of the rest of the 30-minute visit, Haynes spends time quizzing the boys and their mother on when to use which medication and how much, making sure they’re sticking to a system that would befuddle many adults, never mind a 7-year-old. “Which are the controller meds?” she asks Randal, who points to the correct inhaler. “And which are for relief?” Randal points again as her sons look over her shoulder. Each boy takes a turn on the exam table, shows Haynes which inhaler he uses when and for how many puffs, and then gets a high-five from Haynes as he jumps back down.

Later, Haynes says that making environmental changes, as the program helped Randal do, are often straightforward. The harder part of her job is getting kids to believe in the importance of taking their asthma medication even when they’re feeling good. “If someone told you that you had to take medicine twice a day for the rest of your life and you’re seven years old, how compliant would you be?” she asked.

The Patrick administration is exploring ways to pay for education, counseling and environmental makeovers—and, ideally, to avoid paying for expensive trips to the emergency room. Reducing asthma-related ER trips and individualizing care is also a priority on a federal level, where it’s estimated asthma costs the US $19 billion in health care costs and lost productivity. Last year, the Centers for Disease Control and Prevention gave grants to asthma-management efforts in 34 states.

David Martin, the director of health policy at the Execu­tive Office of Health and Human Services, says, “This is an example of where we as a state, where Gov. Patrick and Secretary [JudyAnn] Bigby, want to go as far as getting a handle on health care costs. Right now, no one is paying you to simply take care of the patient. If they were, you’d try to prevent them from coming in to the ER.”

His office is now in the process of finding hospitals interested in replicating the Children’s program, and determining how MassHealth might reimburse providers. He expects conversations will result in a bundled payment, but says the details are uncertain; he hopes a plan will be in place by early 2011.

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Martin says he expects that if MassHealth begins providing bundled payments for asthma, children with private insurance are likely to be affected as well. “The hope is that by embarking on this pilot, private payers will follow along because it’s also in their interest,” he says. But even if they don’t, hospitals that establish a protocol for asthma treatment—say, sending a caseworker to the home to look for environmental triggers—are unlikely to vary it for patients with different kinds of insurance. “You get to a critical threshhold where if 60 percent of kids are being paid for in a certain way, and another kid comes in, you don’t say, ‘Well, we won’t send a caseworker out,’” he says. “As doctors tell us all the time, you seldom know the source of payment. So once you have a system in place, it becomes the norm.”

Martin does not yet have an estimate on how much money the state might save if the Children’s approach expands to other hospitals. “Once we’ve defined the hospitals and know how many kids, and know what the bundled payment will be, we can establish an estimate,” he says. “But I want to caution that the focus isn’t just saving money. We also want to treat kids better.”