By M. Laurie Cammisa, vice president for child advocacy and Elizabeth R. Woods, MD, MPH, director of the Community Asthma Initiative

 

Boston Children’s Hospital does not have a community “benefits” mission. It does, however, have a community “health” mission that takes the hospital’s community partnerships and activities beyond compliance with state and federal regulations for community benefits and creates health and social impact by addressing the most pressing health needs facing the children of Boston and beyond.

Community Asthma Initiative By the Numbers in FY11

• CAI has reached 908 families since the program was established.
• Conducted 39 educational workshops for 683 parents and providers in the community.
• 76 percent of the families participating in the program have received home visits.
• 80 percent reduction in the percent of patients with any (one or more) asthma-related hospital admission.
• 60 percent reduction in the percent of patients with any asthma–related emergency department visits.
• 41 percent reduction in the percent of patients with any missed school days.
• 46 percent reduction in the percent of parents/caregivers with any missed work days.
• For every $1 spent on the program, $1.46 is returned to society/insurers and $1.73 to society.

An innovative approach

In the early 1990s, the Attorney General for the Commonwealth of Massachusetts (MA AG) released new guidelines that called for hospitals to rethink their roles in meeting the health needs of their local communities. The processes of assessment and planning that were outlined in the MA AG’s guidelines were recently mandated for all tax exempt hospitals in the federal 2010 Affordable Care Act and in guidance from the Internal Revenue Service (IRS). While the regulations specify the actions that nonprofit hospitals throughout the country must take to achieve compliance, they also leave room to explore the ways in which hospitals can contribute to a changing health landscape.

At Boston Children’s, what started as a response to regulatory requirements has evolved and matured into an innovative approach to advancing the hospital’s community mission. This process began with the hospital’s decision in 1994 to make community the fourth part of its mission in addition to clinical care, research and teaching.

The goal of the hospital’s community mission today is two-fold: (1) partner with key community-based organizations to focus our collective resources in addressing the most pressing health needs of children and families in the local community, and (2) provide services through program models that not only benefit children locally but will also lead to systemic change. The hospitals seeks to accomplish these goals with an emphasis on promoting innovation to achieve social and health impact locally and contribute to systemic change throughout the health care system.

Since the very beginning, conversations and input from community residents and stakeholders have formed the backbone of Boston Children’s approach to identifying and understanding which local and health-related issues are most important for families today. The hospital’s formal needs assessment, conducted every three years, includes a review of best practice literature, an analysis of health data, and an assessment of current community needs and strengths. It also involves focus groups with community residents and interviews with key stakeholders.

In its last formal needs assessment in 2009, Boston Children’s interviewed 29 stakeholders, held focus groups with 91 community residents, and conducted these activities in two languages.

Ultimately, the community needs assessment enables Boston Children’s to focus on how the hospital’s clinical expertise and resources can most effectively address the most pressing needs of children and families, as well as reduce gaps in current services and programs.

One of the major challenges faced by any hospital in fulfilling its community mission is how to leverage limited resources to meet an almost limitless amount of need. Over time, Boston Children’s determined that it could provide the greatest impact if it focused its efforts on a select few health issues in which it could work to produce measureable results. The hospital chose to focus its strategy on those issues that fall at the intersection of identified community needs, existing hospital expertise and available community partnerships.

Based on this principal, the hospital’s priority focus areas are the health issues of asthma, obesity, child development and mental health. Central to the hospital’s efforts to carry out its community mission is its collection of programs and partnerships referred to as the Portfolio to Achieve Health and Social Impact. This portfolio consists of four programs that seek to bring innovation to some of Boston’s most pressing health issues: asthma, child development, mental health and obesity. It also includes three strategic partnerships with key organizations in the city of Boston — the Boston Public Schools, the Boston Public Health Commission and community health centers — to strengthen the infrastructure for child health throughout Boston. The hospital manages and measures these programs and partnerships with the goal of demonstrating new models to improve child health throughout the city, state and beyond.

The hospital manages this Portfolio with a triple focus. One focus is to guarantee that the hospital’s investment of resources (human and financial) is targeted to programs that address local needs, alleviate health disparities, partner and engage with our community and provide services through models that lead to systemic change.

Another is to ensure that, by employing a uniform set of standards and criteria, these programs measure value and social impact —things like improving health outcomes and quality of life, proving cost-effectiveness and building community capacity.

A third is to align with the hospital’s overall need to excel in a changing health care environment. The hospital fits our focus areas and interventions into a continuum of care model that looks for ways to prevent short- and long-term illness and eliminate or avoid medical costs. By doing so, the community health programs are setting the stage for a number of key elements of national health care reform, including reductions in medical costs, the patient-centered medical home and population heath management.

One program in the Portfolio, the Community Asthma Initiative (CAI), provides an illustration of this innovation—addressing a health need, delivering services locally and then measuring health and social outcomes to initiate changes that will affect the broader community.

Community mission in action: The Community Asthma Initiative

Boston Children’s had been tackling the issue of asthma for years through clinical services and community-based efforts to help educate families and caregivers on how to best manage the disease. Asthma is the most common admitting diagnosis for children, not only at Boston Children’s but across the nation in pediatric settings. Analysis of admission rates revealed that 70 percent of patients with asthma-related hospitalizations at Boston Children’s came from the neighborhoods immediately surrounding the hospital. In those communities, Black and Latino children had four to five times the admission rate of white children.

Results from Boston Children’s 2003 community needs assessment confirmed what the hospital and other providers and experts already knew first-hand. Asthma was taking a toll on families in Boston neighborhoods.

More needed to be done to better manage this condition in order to prevent its damaging consequences—poor health status, loss of work for parents and caregivers and missed school days for children, not to mention additional stress and poor quality of life for the whole family.

Drawing on lessons learned in the clinical setting and earlier community-based intervention efforts, the hospital implemented the CAI in 2005 to provide more intensive support to improve the health of children with moderate to severe asthma in the Boston neighborhoods of Jamaica Plain, Roxbury and Dorchester. CAI began serving patients from the targeted neighborhoods who visited the emergency department or who were hospitalized because of an asthma exacerbation, as those children were most likely to have poorly controlled asthma. The program was not meant to replace the role of primary care providers, but rather be an additional partner and support in helping a family to manage their child’s every day asthma care and connect patients more closely with their Medical Home.

CAI, which is a nurse and community health worker model, establishes a close relationship with the participating families and provides case management services depending on a child’s unique medical and social needs. The initiative provides a home environmental assessment and asthma management and medication education, while working with the family and child’s health care providers to remove barriers to improved asthma control. The CAI staff truly partners with the families—answering questions, listening to concerns, reinforcing the child’s Asthma Action Plan, which outlines medications to give when the child is well, when symptoms develop and in case of emergency. They also provide education, materials and supplies to reduce home environmental triggers including High-Efficiency Particulate Air (HEPA) vacuums, which remove 99.97 percent of particles that are at least 0.3 micrometers, to every family.

In addition to working with families in the home, a nurse provides asthma education out in the community for parents and caregivers by partnering with community organizations, day care centers and schools. Through education and support, the nurse helps families understand that children with asthma can stay physically active with proper control of their symptoms.

After only one year, CAI was able to show that the model could improve health and quality of life outcomes, and it has sustained those results each subsequent year. Participating children in CAI experienced fewer asthma-related hospitalizations, emergency department visits and missed school days. Parents and caregivers also reported fewer missed work days. Equally important, the model proved to be cost-effective. In the March 2012 Journal Pediatrics, CAI reported its program costs as $2,529 per child for the first year of services.

Because of the reduced hospital visits and admissions, CAI was able to save $1,621 per child in year one and $2,206 per child in year two. Essentially, for every $1 spent on the program, $1.46 is returned to society/insurers. Factoring in the savings due to the reductions in occupational or school absenteeism, CAI is helping to return $1.73 to society.

Changing asthma care beyond Boston

From the program’s inception, Boston Children’s formed partnerships with asthma advocacy and community organizations to not only address the issue but show that this type of intervention could reduce hospitalizations and emergency room admissions, saving money for the community and insurers.

As the program began to demonstrate success, Boston Children’s looked for ways to expand CAI’s reach to benefit more children than it could through its own direct services. Thus in 2007, the hospital’s Office of Government Relations partnered with the Asthma Regional Council (a coalition of federal and state health, environment, education and housing agencies) to develop a white paper for cost-effective asthma interventions. Based on experiences and outcomes from CAI, “Investing in Best Practices for Asthma: A Business Case” was written and disseminated urging payers to provide children with access to asthma services such as CAI. This sparked further work with other key partners, the Boston Healthy Homes and Schools Collaborative (BHHSC) and the Massachusetts Asthma Advocacy Partnership (MAAP), to use the business case to advocate for policy changes that would help ensure that all children in Massachusetts could benefit from enhanced asthma care.

After three years of advocacy, the efforts were successful in persuading the legislature to earmark $3M in the FY11 Medicaid budget to fund and evaluate a demonstration project that would provide case management services for children with poorly controlled asthma.

Medicaid then set up an Asthma Bundled Payment Advisory Committee to develop the plan with Boston Children’s and other advocacy partners serving on the committee. Recently, the Medicaid office approved funding for the proposed pilot program and plans to issue a request for proposals to select six pediatric practices to participate.

The impact of CAI is now poised to reach children and families beyond Massachusetts. CAI is providing technical assistance to the American Academy of Pediatrics which is preparing to replicate the model in Alabama. Ohio is also investigating the approach and plans to implement a similar type of intervention. CAI represents what Boston Children’s hopes to accomplish with its community mission, providing services locally in partnership with others to address health needs, while also validating that community-based models can be cost-effective solutions for public health problems. Through all of its community efforts, Boston Children’s aims to show how a hospital can go beyond compliance with its community benefit investments, using its community mission as a way to unite other providers, community organizations, advocates, policymakers and families to initiate long-lasting and significant changes for the greater good.

For more on Boston Children’s unique approach to its community mission and the Portfolio for Health and Social Impact, visit www.BostonChildrens.org/community.

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