Vol. 18 • Issue 2 • Page 20
Asthma costs this country more than $16 billion each year. The health care sector bears more than 70 percent of those costs, which are largely preventable.
That is why, even in today’s depressed economy – and perhaps because of it – the health care sector should fund adequate asthma education services, especially those targeted at high-risk populations, declared Polly Hoppin, ScD, during a webinar hosted by the New York City Asthma Partnership in September.
“Savings from reduced health expenditures exceed the cost of asthma education and environmental intervention programs,” said Dr. Hoppin, program director of the Environmental Health Initiative at the University of Massachusetts Lowell School of Health and Environment.
It is a pitch that everyone fighting the asthma epidemic in America, whether on the frontlines as caregivers or in the background as administrators and organizers, would surely echo.
“The idea is if patients understand their asthma and control it, they’re not ending up in the emergency room and hospitalized,” explained Teresa Lampmann, coordinating manager for the Pediatric/Adult Asthma Coalition of New Jersey (PACNJ), which began in 2000 and now has 75 partners.
All community-based asthma education coalitions want the same thing, Lampmann explained. They all want to establish asthma management so thoroughly into schools and other social systems that “they become routine.” And they all need funding to make that happen.
When children suffer from asthma “they can’t sleep at night, they do poorly in school and in life,” observed another asthma education veteran, Lisa Gilmore, MSW, MBA. “Funding is important because asthma is so impactful to quality of life in every way, shape, and form. It has lifelong repercussions.”
Divvying the dollars
Asthma is highly complex, requiring education and intervention tailored to the individual, Dr. Hoppin said. Standard doctor’s visits leave insufficient time to cover all the details. Plus, insurance coverage for asthma education is limited.
Asthma education can vary in setting (clinic, telephone, hospital or home, individual or group), in number of visits (one up to eight), and in personnel (respiratory therapist, nurse, physician, medical social worker, health educator). Funding for asthma education initiatives comes from federal grants, state and local health departments, some private foundations, and some health plans.
One question has never seemed more important than it does today: How best to allocate those dollars? Funding coalitions comprised of many community-based asthma education “partners” is more cost-effective than funding a single asthma education effort, Gilmore said.
“In general, we are still trying to figure out how to do longitudinal care of chronic illness well,” she observed. “Coalitions have a unique perspective. They tend to be somewhat multidisciplinary, bringing people with different perspectives together to focus on a particular problem.”
Grants spent on intensive, one-time interventions to promote asthma care “produce good results, we learn a lot from them, they’re valuable, but then what?” she asked. “They often can’t replicate their results because it’s too expensive.”
Grant money for activities “without community buy-in limits its impact,” she emphasized. “If you don’t fund coalition work, you don’t engage collaborative partners that will shape and sustain effective services in their communities. Instead of leveraging resources, organizations compete on their own.”
Rolling with economic punches
Until recently, Gilmore directed a large asthma coalition that helped more than 10,000 children and 22,000 adults in Washington, D.C., who suffered from asthma but did not receive appropriate care.
It was not easy at first. “There was not a good history of collaboration and trust in D.C.,” Gilmore recalled. “It took a great deal of reaching out, doing asthma workshops in community settings, to generate sustained interest in asthma.”
Finally, in 1999, the nation’s capital had a bona fide community-based asthma education coalition. By 2004, with funding from the Robert Wood Johnson Foundation, the nonprofit National Capital Asthma
Coalition had grown to include more than 70 organizations, with Gilmore overseeing day-to-day operations as executive director.
In perhaps the coalition’s crowning achievement, it created a multidisciplinary Collaborative Care Management Demonstration Project to produce affordable intervention protocols for at-risk children and their families in three economically downtrodden areas.
By 2007, though, with the RWJ grant long evaporated, Gilmore and her board of directors agreed to dissolve the coalition as a nonprofit corporation. Yet many of the coalition’s programs still continue through its partners. Gilmore uses a listserv of 300 supporters and updates the coalition’s former website to maintain communication.
Making a business case
On the federal level, the U.S. Environmental Protection Agency provides small grants for home visits by asthma educators but also works to equip community-based asthma programs with the tools needed to secure other funding.
“Our role has been trying to bolster these ongoing community-based asthma education programs, the ones getting funding from the local health infrastructure: local hospitals, clinics, universities,” said Alisa Smith, PhD, asthma program team leader for the EPA’s Indoor Environments Division.
The EPA supports a national online network of 375 community-based asthma programs that enables them to interact with each other and share funding strategies. “We are trying to capture how they make their
business case to their funders,” Smith said. “We help them create a value proposition, figure out the best way to tell their stories, and to quantify their impacts, whether it’s to health plans, philanthropic organizations, or government officials.”
EPA also disseminates evidence from the literature supporting the cost-effectiveness of asthma intervention. Private sector insurers are starting to hear the message, Dr. Smith said.
“We’re partnering with America’s Health Insurance Plans, the organization that represents most private insurers, to get the message out to health plans, and provide them with grants to start up home visit programs,” she said.
“We’ve seen a real sea change within health plans. They want to provide services that support national asthma guidelines, and they are starting to adopt these more intensive services. We’ve uncovered
models across the country providingasthma education or contracting for these services.”
Recognizing success
Often the most persuasive evidence, Dr. Smith said, comes from people who have a “great passion” for improving the lives of families dealing with asthma, “from people actually doing this work who see the outcomes firsthand and share this information,” she said. “We allow these leaders to have a voice to be recognized through our awards program, and to participate online in our network.”
EPA officials awarded the Pediatric/Adult Asthma Coalition of New Jersey a 2007 Specialty Achievement Award for Healthy School Environments, for example. “Creating an asthma-friendly school environment is important because there is evidence that hospitalizations due to asthma spike significantly in the fall and spring, particularly among school children,” Lampmann said.
New Jersey school districts are already required by state law to take asthma management measures. Schools must have nebulizers on the premises. And school nurses and faculty members must have asthma education, so PACNJ created a three-hour asthma course for nurses and a one-hour course for faculty.
“We give schools the resources to comply with the law,” Lampmann said. She and her coalition colleagues just finished reviewing their 2007 survey of school nurses and are pleased with the results.
“Nearly 50 percent of nurses who conducted the faculty in-service said teachers had taken some asthma-related remedial action, like not wearing perfume, disallowing pets in class, reducing triggers in the classroom,” she said. “That was a wonderful response.”
Most reported that teachers “had improved their confidence levels on how to deal with asthmatic children in class. So we feel those programs provide a valuable service.”
The coalition also is revising an asthma treatment plan to be adopted statewide that will eliminate the frequent problem of illegible writing by physicians.
“In the revised version, all meds are listed, and physicians only have to check off which meds they are prescribing,” Lampmann said.
The asthma treatment plan “is, essentially, a tool for inter-communication among parents, physicians, and school staff,” she added. “It’s about keeping physicians, parents, and school caregivers in touch with each other.”
In addition to the treatment plan, the coalition generated a top 10 list of asthma triggers in the home and how to control them. “Together with the asthma treatment plan, we were able to have both translated into seven languages,” Lampmann said.
At the same time, the coalition is “taking steps to be more cost-effective,” given the economic times, Lampmann noted. “We used to print, store, and distribute our asthma treatment plan to 21 locations. Now we post a downloadable version on our website. So we’re not incurring those mailing and storage costs any longer.”
Michael Gibbons is senior associate editor of ADVANCE. He can be reached at [email protected].
Study: environmental intervention pays off for Patients with Asthma
A special form of asthma education called environmental interventions can range from telephone instruction about smoking cessation to structural remediation of the home, such as mold abatement.
Some environmental interventions work, some do not. “It varies,” Lisa Gilmore, MSW, MBA said. “And interventions that work in one community may not work in another.”
When they work, they pay off for patients and society.
A 2005 study involved respiratory therapists who entered the homes of patients with asthma for eight 30-minute education sessions. The sessions reduced asthma hospitalizations in subjects by 82 percent, intensive care unit days by 92 percent, emergency department visits by 86 percent, missed school days by 65 percent, and unscheduled doctor’s visits by 66 percent.1Translated into dollars and cents, the program cost $640 per patient. But it saved an estimated $13.30 for every $1 spent.
Reference
1. Shelledy DC, McCormik SR, Legrand TS, Cardenas J, Peters JI. The effect of a pediatric asthma management program provided by respiratory therapists on patient outcomes and cost. Heart and Lung. 2005;34(6):423-8.
