State Financing and Delivery Innovations to Address Disparities in Uncontrolled Childhood Asthma
The high prevalence of uncontrolled asthma among child populations served by Medicaid programs and the associated rising costs often are the impetus for states to improve the quality of care provided to children with asthma. New opportunities to comprehensively address asthma and its triggers are emerging through state and national health care delivery system and payment reform initiatives. NASHP identified state initiatives underway in Arkansas, Iowa, Michigan, North Carolina, Oregon, and Rhode Island that aim to address disparities and improve outcomes for children with uncontrolled asthma through innovative health care—particularly Medicaid—financing or delivery system strategies. The initiatives originate at either the state or community level and address the disease through a combination of clinic and community-based interventions, some of which focus on social determinants of health. The below table provides a cross-state analysis of the key strategies these six states are implementing to address childhood asthma and the accompanying case studies offer a more in-depth examination of each model. These resources are excerpts from a recent report released by MDRC in partnership with NASHP, “The Effectiveness of Interventions to Address Childhood Asthma,” which has more information on state and local efforts to improve asthma management among children in low-income families.
Comparison of Key State Asthma Program Features
| Arkansas Health Care Payment Initiative (episodes of care and PCMHs) | Iowa Health Homes Program |
Michigan Asthma Network of West Michigan | North Carolina CCNC Asthma Disease Management Program |
Oregon Healthy Homes | Rhode Island Home Asthma Response Program |
||
| Intervention Elements | Setting (Community or Clinic-based) |
Clinic | Clinic | Both | Both | Community | Both |
| Asthma action planning, education, care coordination | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Home visits | ✓(up to 32) | ✓ | ✓ | ✓ (3) | |||
| Referrals | ✓(e.g., smoking cessation) | ✓ (e.g., smoking cessation) | ✓(e.g., housing, transportation, counseling, prescriptions) | ✓(e.g., child care, health consultants, transportation) | ✓(e.g., food, housing, weatherization, legal, transportation, medical and mental health) | ✓(e.g., WIC, adult education, weatherization, smoking cessation, mental health) | |
| Other services | Visits to school, child care, extended family | Supplies (e.g., vacuums, humidifiers, encasements, green cleaning kits) | Supplies (e.g., vacuums, filters, bed coverings, green cleaning kits) | ||||
| Program Overview | Target population | Children and adults with qualifying events (episode of care); all Medicaid patients (PCMH) | Medicaid-eligible adults and children with 2 chronic conditions or 1 and at risk for second | Children and adults with moderate-severe uncontrolled asthma | Medicaid-eligible children and adults with asthma, prioritizing high-risk patients | Children <19 with asthma diagnosis, living in specific county, meeting Medicaid income requirements | Children ages 2-8 with recent ED visit or hospitalization residing in 3 specific cities |
| Providers | Hospital physicians, PCP, or Pulmonologist | Designated practitioner, care coordinator, health coach and clinic support staff | Certified asthma educator (RN or respiratory therapist), licensed master social worker | Care manager (e.g., nurse, social worker, pharmacist), PCP | Nurse, CHW, environmental health and safety worker | Nurse educator, CHW | |
| Strategies to address disparities | Medicaid population focus; specific strategies vary | Medicaid population focus; specific strategies vary | Interpreters available; action plan in native language; target inner cities | Medicaid population focus; educational materials available in Spanish and English | Low-income population focus; bilingual staff, interpreters available; CHWs in disadvantaged areas |
Diverse staff who receive cultural awareness training, offered in English and Spanish | |
| Financing | Medicaid reimbursement | Retrospective episode-based payment | Tiered PMPM payment | Skilled nursing visits (4 Medicaid managed care plans) | PMPM payment | Targeted Case Management (specific counties) | N/A |
| PCMH PMPM payment | |||||||
| Other sources | Private insurer (separate episode of care initiative) | N/A | Local grants | Varies by Network | County funds; federal grants | Federal grants | |
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
