Form 0920-0853 AIRS Performance Measure A. Health Care Reform Opportuni

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Overview

A. HC Reform Opportunities
B. Meetings
C. Schools covered by agreement
E. Surv. Use
F. Eval. Use
G. SME
H.Skills increase
I. Referral to PCP
J. Policies
K. Use of long-term control med
L. Improved asthma control
M. Reduce Hospitalization & ED
N. QI Process in HC Orgs
O. Team-based Approach in HCOs
P. Reimbursement
Q. HCOs Implement Referrals
R. Referrals from HCOs
S. Health Care Utilization

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Sheet 1: A. HC Reform Opportunities

A. Health Care Reform Opportunities:

List and description of priority opportunities for expansion of comprehensive asthma control services by leveraging health care reform

Purpose: Encourage broad, strategic thinking about the asthma program's place in the new health care reform context; to support program planning

Instructions: Identify and describe top 4-6 opportunites for expansion of comprehensive asthma control services by leveraging health care reform.

Your state (Select one)

Funding Year (Select one)

Opportunity related to...

Anticipated outcome of the Opportunity (check (x) all that apply)

Brief description of opportunity (250 characters limit)

Status (Select one)

Comments (750 characters limit)

Opportunity related to... (Select one)

If "other" is selected in column C, describe here

Improve quality of medical services through training, QI, or decision support

Encourage provision of or reimbursement for asthma SME and/or home visits

Develop, include, or collect asthma quality measures

Include asthma in training or certification of CHWs

Develop or implement mechanisms for linking PH-HC services

Advance the evidence base for implementation of comprehensive asthma services

Other

Description of "Other" anticipated outcomes of the opportunity (250 characters limit)

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Sheet 2: B. Meetings

B. High-level meetings: Number and description of meetings to educate high-level decision makers  about asthma burden and evidence-based strategies

Purpose: To encourage state programs to engage partners across multiple sectors and at a high level to expand comprehensive asthma control services

Instructions: List all high-level meetings for which an asthma "ask" is on the agenda. For recurring meetings, list those with a significant outcome.

Your state (Select one)

Funding Year (Select one)

High-level decision maker(s) at the meeting (title not name)

Person(s) representing the State Asthma Program (title, not name)

Sector(s) represented by high-level decision makers (check (x) all that apply)

Meeting outcomes (check (x) all that apply)

Desired outcome(s) of collaboration (check (x) all that apply)

Level of proposed outcome

Meeting Date (mm/dd/yyyy) Separate multiple meeting dates with ";"

Comments (1000 characters limit)

SHD

State Medicaid agency

Other payers

Health Care (HC) Organizations

Dept of Ed

Housing agencies

NGO/Foundation

Other sector

Description of "other" sector (250 characters limit)

Info shared

Info gathered

Agreed to pilot interventions

Declined to participate in pilot

Agreed to share costs of intervention

Other specific actions identified (specify)

Plan to meet again

Other

Description of "Other" meeting outcomes or specific actions (250 characters limit)

Reimburse-ment of asthma services

Clinical quality improve-ment

Certifica-ton/trai-ning of non-clinical providers

Quality measures

Expansion of services

Other

Description of "Other" desired outcome (250 characters limit)

Level (select one)

Description of "Other" level (250 characters limit)

FQHCs/Safety Net

Other HC Orgs

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Sheet 3: C. Schools covered by agreement

C. School Enrollment Covered by Formal Agreements: Total enrollment, including racial, ethnic, and SES breakdown of students in schools or districts covered by MOAs, MOUs, or other formal agreements

Purpose:To encourage state asthma programs to formalize relationships, processes, and protocols supportive of asthma control with appropriate educational entities at the highest administrative level possible. To estimate program reach (both overall and to groups experiencing a disproportionate burden of asthma).

Your state (Select one)

Funding Year (Select one)

Name or Brief Description of Formal Agreement (250 characters limit)

Topic of Formal Agreement (check (x) all that apply)

Level of agreement

Description of "Other" level

School/District/Other Entity Name

Date agreement went into effect (mm/yyyy)

Total enrollment of students covered by the agreement

Number of schools covered by agreement

Number of school districts covered by agreement

Provide a brief description of the racial/ethnic characteristics of the student population (limit 250 characters)

Percent of students receiving free or reduced school lunches (if available)

Percent of students with asthma in participating schools (if available)

Comments (750 character limit)

SME

Linkages to care

Education of school personnel

Policy

Data sharing

Other

Description of Other topic

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Sheet 4: E. Surv. Use

E. Alignment between program activities and burden data:

Map, chart, or other tool demonstrating the overlap between existing program activities and areas or populations with poor asthma outcomes as indicated by most recentsurveillance data avialable

Purpose: Ensure program resources are focused on areas and populations with poor asthma outcomes

Instructions: Submit to project officer a map(s), chart(s), or other tool(s) documenting alignment between burden data and program focus. Provide additional information below. Disinguish currently implemented from activities that are in the planning stage.

Your state (Select one)

Funding Year (Select one)

Map, chart, or tool submitted to project officer? (Y/N)

Measure(s) of asthma outcome used (check (x) all that apply)

Map, chart, or tool covers the entire state population? (Y/N)

Rationale for selection of sites for program activities (1250 characters limit)

Comments (750 characters limit)

Asthma hospitalizati-ons (population-based)

Asthma hospitaliz-ations (risk-based)

ED visits for asthma (population-based)

ED visits for asthma (risk-based)

School absenteeism due to asthma

Other

Description of "Other" measure of asthma outcome used (250 characters limit)

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Sheet 5: F. Eval. Use

F. Use of Evaluation Data: Descriptions of actions taken during the reporting period to improve program activities and increase program effectiveness based on evaluation findings.
Purpose: Encourage a feedback loop for use of evaluation data in program decision making.
Instructions: Describe the actions taken during the reporting period that were based on evaluation findings, regardless of when the evaluation was done. Include only those actions or changes that have already been implemented and that you believe have had or will have a significant impact on your program. You may cut and paste from the evaluation action plan.
Your state (Select one)	Funding Year (Select one)	Type of action taken	Actual programmatic action (1250 characters limit)	Recommended programmatic actions based on findings (1250 characters limit)	Evaluation finding on which action was taken (1250 characters limit)	Main evaluation question(s) that produced findings (750 characters limit)	Evaluation name (200 characters limit)	Comments (500 characters limit)

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Sheet 6: G. SME

G. Self-management Education: Number and demographics of participants (a) initiating and (b) attending at least 60% of sessions of guidelines-based intensive asthma self-management education

Purpose: To monitor and document the success of state asthma programs and their partners in enrolling people with asthma in intensive self-management education and in sustaining their participation

Your state (Select one)

Funding Year (Select one)

Partner delivering intensive asthma self-management education

SME curriclum name (limit 250 characters)

Curriculum setting

Description of "Other" setting (limit 250 characters)

Number of sessions (use numeral)

Type of instructors

Description of "Other" instructor

Does the SAP provide funding?

Contributions of the SAP other than funding (limit 250 characters)

Test used to measure asthma control

Description of "Other" test of asthma control (limit 500 characters)

Number of participants initiating intensive asthma SME

Number of participants attending at least 60% of sessions

Number of participants attending 100% of sessions (optional)

Age of participant (person with asthma) upon enrollment

Provide a brief description of the racial/ethnic characteristics of the participants (limit 500 characters)

Asthma control status on enrollment

Number of participants (upon enrollment) with any hospitalizations OR ED visits for asthma in the 12 months prior to enrollment

Comments (750 character limit)

Number of participants aged 0-4

Number of participants aged 5-11

Number of participants aged 12-17

Number of participants aged 18-65

Number of participants aged 65+

Number of participants with well-controlled asthma

Number of participants with poorly controlled asthma

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Sheet 7: H.Skills increase

H. Demonstration of basic asthma self-management knowlege and skills: Number of participants attending at least 60% of intensive asthma self-management education sessions who successfully complete a return demonstration of basic asthma self-management knowledge and skills
Purpose: To monitor whether asthma self-management education programs as administered by the states or their partners are successfully teaching basic asthma self-management knowledge and skills.
Your state (Select one)	Funding Year (Select one)	Partner delivering intensive asthma self-management education	SME curriculum name (limit 250 characters)	Number of participants initiating intensive asthma SME	Number of participants attending at least 60% of sessions	Number of participants attending 100% of sessions (optional)	Number of participants attending at least 60% of sessions who successfully demonstrate basic knowledge and skills	Number of participants attending 100% of sessions who successfully demonstrate basic knowledge and skills (optional)	Knowledge and skills test/instrument submitted to project officer?	Comments (750 character limit)
		0	0	0	0	0
		0	0	0	0	0
		0	0	0	0	0
		0	0	0	0	0
		0	0	0	0	0

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Sheet 8: I. Referral to PCP

I. Referral to a primary care or specialty care provider: Number of participants attending at least 60% of intensive asthma self-management education sessions who are without a primary care provider at the time of enrollment and are a) referred to (required) and b) access (optional) primary or specialty care for asthma
Purpose: To assure that groups implementing intensive asthma self-management education refer participants without a primary care provider to primary or specialty care for asthma.
Your state (Select one)	Funding Year (Select one)	Partner delivering intensive asthma self-management education	SME curriculum name (limit 250 characters)	Number of participants initiating intensive asthma SME	Number of participants attending at least 60% of sessions	Number attending at least 60% of sessions who are without a PCP at enrollment	Number attending at least 60% of sessions, without a PCP at enrollment, and are provided a referral	Number attending at least 60% of sessions, w/out PCP at enrollment & referred to & access care for asthma (optional)	Brief description of referral process to PCP or specialty care (limit 250 characters)	Brief description of the mechanism of tracking access to care (optional) (limit 1000 characters)	Type of provider to which participants are referred	Description of "Other" type of provider	Comments (750 character limit)
		0	0	0	0
		0	0	0	0
		0	0	0	0
		0	0	0	0
		0	0	0	0
		0	Err:509	0	0
		0	Err:509	0	0
		0	Err:509	0	0
		0	Err:509	0	0
		0	Err:509	0	0

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Sheet 9: J. Policies

J. Asthma-related Educational or Housing Policies: Description of existing (for year 1) and new (for years 2-5) policies supportive of comprehensive asthma control adopted by educational or housing agencies prior to/during the reporting period and influenced by the state asthma program

Purpose: To monitor and report on the contribution of state asthma program efforts to the adoption of policies supportive of asthma control by housing and education agencies

Instructions: Describe each adopted policy and the SAPs contribution to its adoption.

Your state (Select one)

Funding Year (Select one)

Educational or Housing agency? (Select one)

Focus of policy (Select one)

Description of "Other" focus of policy (limit 250 characters)

Group(s) affected by policy

Level of policy

Name of agency adopting the policy (250 characters limit)

Policy name (250 characters limit)

Template or language available to share? (Y/N)

Brief narrative description of policy (1000 character limit)

Policy effective date

Role of SAP in influencing agency (check (x) all that apply)

Status

Comments (750 characters limit)

Level (select one)

Description of "Other" level (250 characters limit)

Provided surveillance data

Provided information on evidence base

Provided sample policies

Commented on request

Other

Description of "Other" role of SAP (250 character limit)

In development, passed, implemented, or discontinued?

If implemented, describe

Evaluated (Y/N)

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Sheet 10: K. Use of long-term control med

K. Use of long-term control medication: Number of participants who: had poorly controlled asthma and were not using a long-term control medication regularly on enrollment; who reported better adherence to long-term control medication a month or more after attending at least 60% of intensive asthma self-management education sessions
Purpose: To assess whether participation leads to an increase in the use of long-term control medication among participants with poorly controlled asthma.
Your state (Select one)	Funding Year (Select one)	Partner delivering intensive asthma self-management education	SME curriculum name (limit 250 characters)	Number of participants attending at least 60% of sessions who had poorly controlled asthma on enrollment	Number of participants attending 100% of sessions who had poorly controlled asthma on enrollment (optional)	Number of participants attending at least 60% of sessions who, on enrollment, had poorly controlled asthma and were using long-term control medication less than 7 days per week	Number of participants attending 100% of sessions who, on enrollment, had poorly controlled asthma and were using long-term control medication less than 7 days per week (optional)	Number of participants attending at least 60% of sessions who had poorly controlled asthma on enrollment who self-report better adherence	Number of participants attending 100% of sessions who had poorly controlled asthma on enrollment who self-report better adherence (optional)	Comments (750 character limit)
		0	0
		0	0
		0	0
		0	0
		0	0

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Sheet 11: L. Improved asthma control

L. Improved asthma control: The number of participants with poorly controlled asthma on enrollment who report their asthma is “well-controlled” one month or more after attending at least 60% of intensive asthma self-management education sessions
Purpose: To document the effectiveness of the asthma self-management education together with medical management In improving asthma control in participants
with poorly controlled asthma.
Your state (Select one)	Funding Year (Select one)	Partner delivering intensive asthma self-management education	SME curriculum name (limit 250 characters)	Number of participants attending at least 60% of sessions who had poorly controlled asthma on enrollment	Number of participants attending 100% of sessions who had poorly controlled asthma on enrollment (optional)	Number of participants with poorly controlled asthma on enrollment who reported well-controlled asthma one month or more after attending at least 60% of sessions	Number of participants with poorly controlled asthma on enrollment who reported well-controlled asthma one month or more after attending 100% of sessions (optional)	Comments (750 character limit)
		0	0	0	0
		0	0	0	0
		0	0	0	0
		0	0	0	0
		0	0	0	0
		0	0	Err:509	Err:509
		0	0	Err:509	Err:509

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Sheet 12: M. Reduce Hospitalization & ED

M. Reduction in hospitalizations and ED visits: Number of participants attending at least 60% of intensive asthma self-management education sessions who report a decrease in the number of asthma-related hospitalizations and ED visits during the 12 months following the program. (supplemental measure/encouraged but not required)

Purpose: To document the effectiveness of the self-management education program in reducing the number of asthma-related hospitalizations and emergency room visits.

Your state (Select one)

Funding Year (Select one)

Partner delivering intensive asthma self-management education

SME curriclum name (limit 250 characters)

Number of participants attending at least 60% of sessions

Number of participants attending at least 60% of sessions with any asthma-related hospitalizations or ED visits in the 12 months prior to enrollment

Number of participants attending at least 60% of sessions with any asthma-related hospitalizations or ED visits in the 12 months prior to enrollment for whom 12 month follow up is available

Number attending at least 60% of sessions who had any asthma-related hospitalizations or ED visits in the 12 months prior to enrollment who report a decrease in the number of these events in the 12 months following the program

Number attending at least 60% of sessions who had any asthma-related hospitalizations in the 12 months prior to enrollment who report a decrease in the number of hospitalizations in the 12 months following the program (if available)

Number attending at least 60% of sessions who had any asthma-related ED visits in the 12 months prior to enrollment who report a decrease in the number of ED visits in the 12 months following the program (if available)

Number attending at least 60% of sessions who had any hospitalizations or ED visits 12 months prior to enrollment who report no change in these events in the 12 following the program (if available)

Number attending at least 60% of sessions who had any hospitalizations or ED visits 12 months prior to enrollment who report an increase in these events in the 12 months following the program (if available)

Source of information on hospitalizations/ED visits

Comments (750 character limit)

Source (select one)

Description of "Other" source of information (250 characters limit)

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Sheet 13: N. QI Process in HC Orgs

N. QI Processes in HC Organizations: Number of health care organizations (HCOs) influenced by the State Asthma Program to implement an asthma quality improvement process

Purpose: To encourage state asthma programs to assure that health care providers and organizations serving populations with a disproportionate burden of asthma provide guidelines-based asthma care

Your state (Select one)

Funding Year (Select one)

Type of HCO

Brief description of population served by the HCO (limit 500 characters)

Name/description of QI process (limit 1000 characters)

Asthma-related QOC measures collected (if available) (Limit 1500 characters)

Health outcomes collected (if available) (check (x) all that apply)

Role of SAP in influencing organization

Comments (limit 750 characters)

Type (select one)

Description of "Other" HCO

Asthma control

Hospitalizations/ED visits

Satisfaction with care

Asthma-related quality of life

Other

Description of "Other" health outcome

Role (Select one)

Description of "Other" role of SAP (250 characters limit)

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Sheet 14: O. Team-based Approach in HCOs

O. Team-Based Approach in Health Care Organizations: Number of health care organizations influenced by the state asthma program to implement a team-based approach to asthma
Purpose: To promote more efficient, comprehensive, and patient-centered care so as to align services across the asthma care continuum
Your state (Select one)	Funding Year (Select one)	Type of HCO		Name of HCO	Brief description of population served by the HCO (limit 500 characters)	Composition of teams and roles of team members (500 character limit)	Method of sharing information among team members (500 character limit)	Role of state asthma program in influencing organization (500 character limit)	Measures taken to ensure cultural appropriateness (if available)	Comments (750 character limit)
		Type (select one)	Description of "Other" HCO

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Sheet 15: P. Reimbursement

P: Plans Reimburse for SME and Home Visits: Number of health plans influenced by the state program to cover or reimburse for (a) intensive asthma self-management education, or (b) home-based trigger reduction services, or (c) both (a) and (b)
Purpose: To monitor and increase the efforts of SAPs in promoting system-level changes to increase availability of intensive asthma self-management education and home-based trigger reduction services for people whose asthma is not controlled with medical management alone.
Your state (Select one)	Funding Year (Select one)	Name of Health Plan	Type of Plan		Services covered or reimbursed	Description of services (limit 500 characters)	Eligibility for services		If services are contracted, what is the amount of reimbursement? (limit 500 characters)	Role of state asthma program in influencing health plan (limit 500 characters)	Comments (750 character limit)
			Type (select one)	Description of "Other" type of plan (limit 250 characters)			Eligibility (select one)	Description of "Other" eligibility criteria (limit 250 characters)

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Sheet 16: Q. HCOs Implement Referrals

Q. HC Organizations Implement and Improve Referral Systems: Number of health care organizations influenced by the state asthma program to implement or improve systems to refer to home-based intensive self-management education and trigger reduction services or other community-based intensive asthma self-management education
Purpose: To monitor and improve the efforts of the state asthma program in promoting system-level changes to create a continuum of asthma services across the health care facility, school, home and community settings
Your state (Select one)	Funding Year (Select one)	Type of HCO		Name of HCO	Description of referral process and the services referred to (limit 500 characters)	Description of the assessment of referral timeliness and completion (if available)	Brief description of population served by the HCO (limit 500 characters)	Role of state asthma program in influencing organization (500 character limit)	Comments (750 character limit)
		Type (select one)	Description of "Other" HCO

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Sheet 17: R. Referrals from HCOs

R. Referrals from HCOs: Number and percent of participants in intensive asthma self-management education sessions who were referred by a health care organization or provider
Purpose: To document progress in promoting linkages between intensive asthma self-management education providers and health care organizations at the local level.
Your state (Select one)	Funding Year (Select one)	Partner delivering intensive asthma self-management education	SME curriclum name (limit 250 characters)	Number of participants initiating intensive asthma SME	Number of participants referred from HCOs or providers	Comments (limit 750 chatacters)
		0	0	0
		0	0	0
		0	0	0
		0	0	0
		0	0	0
		0	0	0

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Sheet 18: S. Health Care Utilization

S. Health care utilization in populations served by partnering health care organizations and health plans: Number of health care organizations (HCOs) or health plans in the state that are implementing comprehensive asthma control services (CACS) and sharing information on asthma-related hospitalizations and/or ED visits with the state asthma program. (supplemental measure/encouraged but not required)
Purpose: Promote engagement of the state asthma program with health care organizations and health plans around sharing of information about the provision of comprehensive asthma control services and health care utilization. Provide information toward a business case for the implementation of CACS
Your state (Select one)	Funding Year (Select one)	Type of HCO or health plan		Name of HCO or health plan	Description of CACS provided (limit 500 characters)	Did the state asthma program have some influence on the HCO's or health plan's approach to asthma care? If "yes," describe.	Description of state asthma program's influence on the HCO's or health plan's approach to asthma care (500 character limit)	Describe actual changes in asthma-related hospitalizations and/or ED visits reported, including decrease, increase, or no change. (limit 500 characters)	Other outcomes (if any) tracked by HCOs or health plans that are implementing CACS (limit 500 characters)	Comments (750 character limit)
		Type (select one)	Description of "Other"