Community based approaches for optimal asthma outcomes and accountable population health

The United States health care system has begun a significant transformation toward a population oriented delivery model. Support for this transformation comes from reforms in how health care is paid for and regulated that are intended to address shortcomings in care today: rising costs, substantial gaps in quality, and increasing demand for services. While traditional medical care can have a tremendous impact on health outcomes, the social determinants of health also contribute substantially. Consequently, the shift toward population health improvement requires stronger collaboration and coordination between traditional health services, public health, and non-clinical services to achieve lower overall costs and improved patient outcomes. New models that link clinical, social, community, public health, and governmental programs are needed. To improve value, health system transformation that shifts the emphasis from health care to health is needed.

The opportunities and challenges for effective health care reform are particularly evident in pediatric asthma. Asthma is highly prevalent and is consistently one of the top five most costly health conditions. While effective clinical treatments have long existed, poor asthma control is strongly affected by factors largely outside the control of clinicians, including patient beliefs and behavior and environmental factors such as smoking, indoor air pollution, and household pests. Therefore, pediatric asthma represents an excellent example where improved outcomes will require greater coordination of clinical, non-clinical, and community resources than currently exists.  New payment models are needed to support these collaborations and to increase the value of healthcare spending.

To enable better outcomes for conditions where social determinants matter, the mechanisms used to reimburse providers, the types of services delivered, the roles of providers, and the expectations of patients need to change. These changes have already begun at the local, state, and federal levels. To succeed, they will require engagement and leadership by patients, clinicians, community organizations, government agencies, non-governmental agencies, patient advocates, and payers.  However, such potentially far-reaching changes can be very difficult to implement effectively.

This paper reviews the evidence on opportunities for improving outcomes and lowering costs by better addressing the social determinants of asthma.  It describes a broadened care delivery model that can be implemented through practical and incremental reforms.  It is based on a joint Brookings and Asthma and Allergy Foundation of America (AAFA) roundtable that was convened in March 2015 (see Appendix A for the agenda). The meeting brought together a diverse group of stakeholders to explore opportunities to improve the care of pediatric asthma patients through enhanced coordination of clinical services, community organizations, and public health entities (see Appendix B for a list of participants). Experts from the federal government, health and social agencies, successful community-based asthma programs, physicians, patients, school nurses, pharmacists, and payers met to discuss: (1) opportunities to improve care through community interventions; (2) improved access and efficiency of community interventions; and (3) the relationship between payment reform, health system transformation, and sustainability of community interventions. Although the discussion focused on asthma, the themes also apply to other chronic conditions. The findings of the roundtable are detailed throughout this paper and were also disseminated during a Brookings-AAFA webinar held in May 2015 (see Appendix C for the webinar agenda and a link to the recording).

The first section of this paper details the limitations of conventional asthma treatment, opportunities for improvement, and the major barriers to implementing these innovations. The subsequent three sections detail three broad themes that have emerged from Brookings and AAFA research and the roundtable discussion on how to improve care. The paper concludes with lessons learned and presents a path forward.