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					 Amending the State Health Plan to
create a Targeted Case Management
  Reimbursable Service for Healthy

                            Lila Wickham, Director
            Multnomah County Environmental Health,
                                  Portland, Oregon
 Community Needs Assessment
The goal is to:

Include the community in the
prioritization of needs and                   Mold
development of meaningful plan
Protocol for Assessing Community             like an
Excellence in Environmental Health          Ignored
                                      Lead Community” Trash
Similar to MAPP, PATCH

Note: Health Care Reform and Public
Health Accreditation require
Community Health Assessments.
 Health equity
Health equity is the assurance that all
 populations have the same health outcomes

Health inequities result from the social
 determinants of health that unfairly distribute
 access to healthy homes, walk able
 communities, educational and social supports
 Why Asthma?
Asthma is a chronic disease that disproportionately affects
people of color, people in poverty
The community told us that housing was a health issue of
concern to them
Children spend 90% of their time indoors
Asthma is complex to manage and parents and children
need help identifying asthma triggers and management
 Our Healthy Homes Programs
Low-income children with asthma
through our Healthy Homes
Asthma Program

Landlords and Tenants through
landlord tenant education and mediation

Doctors and nurses with pediatric asthma patients through
Asthma Inspection and Referral Program (AIR)

Policy makers through various initiatives that address root
causes of environmental justice issues
What is the goal of policy change?
To define or change policies that improve health
  for the overall population.

Examples of policy
• A city habitability code that guides neighborhood
  inspectors in citing violations on rental housing.

• A state law that allows tenants to be evicted
  within 30 days without cause.
Create a Targeted Case
Management Code for Healthy Homes

Goal: Amend the State Health Plan to
provide sustainable funding and
  opportunities for other Health
  Departments to provide this
Phase I
• Educate yourself on “policy making basics”
• Research legislators and key issues
• Connect with your Government Relations
• Identify organizations that can be allies
• Engage Public Health colleagues
• Schedule meetings and listen, listen, listen
Phase II
• Set a clear policy goal
• Revise key points
• Directly advocate and educate
• Engage the media
• Tell the facts and personal testimony of
• Carefully plan and hope for good luck
“New Program Highlights Household Asthma Triggers”

PORTLAND, OR 2006-08-10 The Multnomah County
Health Department has started a new program to raise
awareness about asthma and to help struggling families.

Asthma is becoming increasingly common in the U.S. It's a             Media
disease that leaves people wheezing and panting for breath.
Those who live in cities are at higher risk, but asthma is growing
even faster among minority populations, who often live in older
homes and closer to large industrial areas.

Maribel Correa, who moved to the U.S. from Colombia 7 years
                                                                      Getting your
ago, lives in Northeast Portland with her husband and four kids.
Her two youngest have had problems with asthma. Last spring
                                                                      message out
one got sick with a cold.                                             to decision
"It started to fill up his throat and she went to the hospital and    makers and
they said he had bronchitis, and it had never happened before
and she got scared," translates Correa's 11-year-old daughter,
                                                                      the public.
Melissa. "They gave her some medicine to give to the kids and in
three days it got worse and so she took him to the hospital."
Correa says eventually they found out it wasn't bronchitis - it was
asthma. Doctors told her that her son's respiration was half the
level it should be.

and support

Educating and
makers on
public policy.
Set a clear policy goal – Pass legislation for
  funding for Healthy Homes
Analyze and frame the issue – Asthma is a
  health disparity
Gain input through advocacy – Meet with
  legislators, lobbyists, allies
Engage media and influence policymakers –
  Coordinate state briefing, press releases
Set new goal – Amend Health Plan, Acquire
  Medicaid Funding
Start new advocacy – Educate Managed Care
  plans, Medical Assistance Programs
               … and you keep doing it all over again…
Key steps to final policy goal

• Convene the Directors of Managed Care Plans

• Re-vise talking points

• Identify a champion within DMAP to help carry
  our work forward

• Research national efforts
Key steps to final policy goal
• Research statewide existing Targeted Case
  Management groups and core functions

• Adapt core functions to Healthy Homes

• Identify key steps to implementing a TCM

• Develop a plan and timeline and coordinate
  monthly meetings with DMAP staff.
Key steps to final policy goal
• Submit a State Plan Amendment (SPA) waiver to
  Center for Medicaid Services

• Implement immediate time study

• Analyze policy to determine billable activities

• Negotiate rate with DMAP

• Begin TCM!
TCM Healthy Home - Risk Criteria

The target group is Medicaid eligible children with
poorly controlled asthma or a history of environmentally
induced respiratory distress which can result in a life
threatening asthma exacerbation or exacerbation of
respiratory distress.

Risk factors could include, but are not limited to:
• (a) Unscheduled visits for emergency or urgent care;
• (b) One or more in-patient stays;
• (c) History of intubation or Intensive Care Unit care;
• (d) A medication ratio of less than or equal to .33;
• (e) Environmental or psychosocial concerns raised
  by medical home;
TCM Healthy Home – Description of services
Comprehensive assessment and periodic reassessment
  of individual needs:

These annual assessment (more frequent with significant
change in condition) activities include:

• Taking client history;
• Evaluation of the extent and nature of recipient’s needs
  (medical, social, educational, housing, environmental,
  including assessment for risk of lead exposure and
  existence of second hand smoke and other specified
  asthma triggers and irritants, and other services) and
  completing related documentation;
TCM Healthy Home –
Provider Requirements

 The case manager must be a licensed
 registered nurse, registered environmental
 health specialist, asthma educator certified by
 the National Asthma Education and Prevention
 Program, community health worker certified in
 the Stanford Chronic Disease Self-Management
 Program, or worker working under the
 supervision of a licensed registered nurse or a
 registered environmental specialist.
         Questions and feedback:

               Lila Wickham
           503 988 3663 x 22404

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