An update on Alameda County's Pay For Success Asthma Initiative

1. ALAMEDA COUNTY
PAY FOR SUCCESS
ASTHMA INITIATIVE
Community Update
April 27

2. Introductions and Background
• Asthma in Alameda County asthma rates
• Asthma hot spots and why we must look upstream
• Cost of care examples
• The impact of asthma on children
• The rate of uncontrolled asthma

3. The Impact of Asthma on Our County
• Average cost of pediatric hospitalization is now:
$23,248 (when we started that figure was
$16,545)
• Average cost of ED visit: $3,500
• Average cost of EMS Response: $2,944
• 17% of Oakland’s school children diagnosed
with asthma were chronically absent—missing
10% of the school year and reducing Average
Daily Attendance (ADA) by $894 per student and
greatly increasing a child’s chances of dropping
out of school

4. The Effects of Chronic Absence on
Dropout Rates Are Cumulative
Proportion of Students Dropping Out by Number of Years the Student was Chronically
Absent from 8th-12th Grades
http://www.utahdataalliance.org/downloads/ChronicAbsenteeismResearchBrief.pdf

5. 5
Asthma Impacts Quality of Life
*Note: Examples drawn from real Healthy Homes Program anecdotal evidence. Photographs are fictional
Jenny
8 years old
(Only child in
family of 3
adults)
Impact of Asthma:
7-day overnight hospital stay.
Mother was not giving controller
medication because she did not
understand the concept of
preventative medication.
Symptomatic twice a week.
Environmental Triggers: Raw
sewer smell, mold in bathroom,
leak under kitchen sink,
household clutter, smoking by
adults in home
Ryan
2 years old (1
of 5 children in
family of 2
adults)
Impact of Asthma:
15-day overnight hospital stay,
Mother was not priming inhalers,
did not know how to use inhaler
with spacer and was not
administering QVAR.
Environmental Triggers: Mold
on walls, cockroach infestation,
inadequate heat, lead in
bedroom, deteriorated paint, use
of harmful pesticides

6. Asthma in the East Bay
Disease Burden in the East Bay
In 2015 there were 2102 unique
patients who visited the Emergency
Department or were admitted for
ASTHMA at the Alta Bates Summit,
Delta and Eden Medical Centers.
Of these patients:
• 45% of patients were Black
• 22% of patients were White
• 19% of patients were Hispanic
Hispanic
American Indian or
Alaska Native
Asian
African American
Multiple Races
Native Hawaiian or
Pacific Islander
Other
White
Antioch
Berkeley
Castro Valley
Oakland
Grand Total
Antioch
Berkeley
Castro Valley
Oakland
Grand Total
939
357
393
441
2101
Unique Asthma Patients by Race
Unique Asthma Patients by Facility
Unique Asthma Patients Included in Data Set
In 2015, Sutter Health East Bay facilities saw:
• 2,567 ED visits for asthma
• 239 hospital admissions for asthma

7. Diagnosis
Number of
Encounters
Total Number of
Encounters in ED
109,514
Total Number of
Encounters with Dx as
Asthma
1,812
Total Number of
Encounters Peds
Asthmatics
180
Pediatric Patients Seen
for Asthma in ED
( Primary Diagnosis Only)
Asthma Hotspots in Alameda County

8. Asthma START
• Conduct psycho-social
assessment of health needs
• Provide health education
• Insure Asthma management
plan is in place
• Check-in to affirm behavior
changes
• Refer to Healthy Homes for
environmental and home
remediation
Department of Healthy Homes
• Healthy home visual
assessment
• Conduct occupant health
and housing education
• Conduct environmental
treatment
• Removal of known asthma
triggers and address safety
issues
• Provide technical
assistance to property
owner and coordinate with
Code Enforcement as
necessary
Two Existing Interventions
Working Together

9. Project Target Outcomes
1. Improve quality of life indicators based on
Pediatric Asthma Survey
2. Reduce Asthma emergency department visits 70%
3. Reduce Asthma related hospitalization days 50%
4. Reduce missed days of school by 30%
5. Improve housing conditions through occupant
education and technical assistance
6. NO incremental cost to Alameda County; savings
demonstrated to Alliance for continued funding

10. Currently 65% of children with asthma will visit the ED at least once during a
12 month period. Even more troubling, 45% of children with asthma will
also be hospitalized. The real cost of care for a child with asthma may reflect
multiple contacts with the health care system.
$220-400 $100-120 $3,500 $100-120 $60-200 $100-120 $23,248
Alameda
County
Alliance
Referral
Fee
Doctor
Visit
ED Visit Doctor
visit
Medication
and Inhaler
Costs
Doctor
visit
Hospitalization
The Cost of Uncontrolled Asthma

11. Our Progress
• 161 children enrolled
• 80 homes received environmental treatments to reduce
asthma triggers
• 77 Speck monitors placed
• Housing interventions to reduce asthma triggers
include:
• Indoor Air Quality (IAQ): carpets replaced with smooth
flooring; ventilation/exhaust fans repaired/replaced
• Moisture/Mold: Leaks repaired
• Pests: Integrated Pest Management (IPM) provided
• Families report that SPECK monitors provide visual
proof of behaviors that impact indoor air quality and
that guides behavior change

12. Children Referred to Asthma Start
District Number of Cases
1 (Scott Haggerty) 13
2 (Richard Valle) 33
3 (Wilma Chan) 124
4 (Nate Miley) 130
5 (Keith Carson) 65
In the last 12 months there have been 364 children referred to the
program by Alameda Alliance for Health.
364 Referrals x $3500 per ED Visit = $1,274,000

13. Project Impact
• Improve Indoor Air Quality
• Reduce Moisture
• Eliminate Mold
• Prevent Pests from Entering Living
Space
BEFORE
AFTER
BEFORE
AFTER

14. Project Impact
BEFORE
BEFORE
AFTER
AFTER

15. Family Stories

16. Lessons Learned
• Enrollment takes time! Family lives are hectic and
challenging-- making scheduling several
appointments a challenge
• Vulnerable immigrant families need assurance
participation is not a path to eviction or creating
attention for ICE
• The families who do participate do appreciate the
efforts provided by staff and benefit.
• There are challenges to working with landlords
regarding known asthma triggers or safety code
violations.

17. Project Evaluation
Asthma Control Test Score
(N=62) Baseline Mean Score After Intervention Score Score Improvement
1. Work Away Score 4.1 4.8 0.7
2. Short Breath Score 4.1 4.8 0.7
3. Wake Up Score 4.0 4.8 0.7
4. Use Inhaler Score 3.5 4.3 0.9
5. Control Score 3.9 4.5 0.6
Total Score 19.6 23.1 3.5
Overall, the score improved from 19.6, asthma symptoms may not be as well controlled
as they could be to 23.1, asthma symptoms are well controlled.
Asthma Start Knowledge
Knowledge (points)
(N=63)
Baseline
Score
After Intervention
Score
Score
Improvement
Child Med (max = 3) 1.8 2.6 0.7
Rats Asthma (1) 0.3 0.7 0.4
Pets Allergy (1) 0.5 0.9 0.4
Clean Floor (1) 0.7 0.9 0.2
High Pollution (1) 0.7 1.0 0.2
Washing Sheet (1) 0.7 0.9 0.2
Asthma Cured (1) 0.8 0.9 0.2
Window Open (1) 0.8 1.0 0.1
Rid Roaches (1) 0.8 1.0 0.1
Child Sports (1) 0.8 0.9 0.0
Total Test Score 7.9 10.7 2.8
% Correctness 65.9 88.9 23.0
Client Questionnaire
Right
Answer
Baseline Response After Intervention Response %
ImprovedCorrect (#) Wrong (#) % Correct Correct (#) Wrong (#) % Correct
Use Bleach for Cleaning FALSE 9 21 30.0 26 4 86.7 56.7
Use Fragrance Free Cleaners TRUE 4 26 13.3 20 10 66.7 53.3
Use Scented Candles FALSE 22 8 73.3 29 1 96.7 23.3
Wet Dusting or Mopping TRUE 24 6 80.0 30 0 100.0 20.0
Use Dust Mite Control Powder TRUE 24 6 80.0 30 0 100.0 20.0
Wash Stuffed Animals Hot TRUE 12 18 40.0 17 13 56.7 16.7
Use Bathroom Fan or Window TRUE 21 9 70.0 25 5 83.3 13.3
Use Hepa Vacuum TRUE 3 27 10.0 7 23 23.3 13.3
Keep Food on Counters FALSE 25 5 83.3 29 1 96.7 13.3
Vacuum When Child at Home FALSE 23 7 76.7 26 4 86.7 10.0
Use Cooktop Fan TRUE 23 7 76.7 25 5 83.3 6.7
Use Flea Bombs FALSE 27 3 90.0 29 1 96.7 6.7
Wash Child Hand After Pet TRUE 8 22 26.7 8 22 26.7 0.0
Allow Pets on Bed FALSE 28 2 93.3 28 2 93.3 0.0
Bathe Pets More Often TRUE 7 23 23.3 7 23 23.3 0.0
Total 260 190 57.8 336 114 74.7 16.9

18. Project Evaluation
• Asthma control test scores improved from “not well-
controlled” to “well-controlled”, with use inhaler score
improved the most;
• Knowledge of asthma improved from 66% to 89%, with child
medication improved most;
• Behavior of removing indoor triggers improved from 58% to
75%, with not using bleach for cleaning, not using fragrance
cleaner, not using scented candles, mopping and dusting
using wet cloths and using dust control powder improved
most;
• 70% reduction housing conditions related to asthma triggers
(pre vs post)
• Behaviors on bathing pets more often, washing child hands
after contacting a pet and washing stuffed animals in hot
water are still low in scoring and need further
improvements;

19. Why Pay For Success?
• Innovative
financing of social
interventions
driving innovative
solutions for long
term challenges
• Performance
driven social
sector emerging
• Expand funding
sources
Pay For Success 101

20. The Benefits of Successful Impact
The Families
• Quality of life for the
child
• Quality of life for
caregiver
• Reduced out of pocket
health care costs
• Reduced missed days of
school
• Reduced missed days of
work
Organizations
• Reduced health care costs to
health insurance companies
• Reduced health care costs to
MediCal/Medicaid
• Reduced ED use treating chronic
disease that can be controlled
• Reduced EMS calls
• Reduced loss to schools from
reduced ADA
• Improved productivity for
employers (when parents can
focus at work)

21. Cost to County
$0 (Grant Supported)
Financing a PFS Pilot Program for Alameda County
Steps in Developing the PFS
Feasibility Stage
* Complete final
feasibility items
* Formalize Alliance
arrangement &
finalize data
measurement
Result: Program Pilot
Launch
1
Pilot Stage
* Serve 250 low-
income County
residents over 1 year
Result: Validate
Alliance’s savings to
fund on-going &
scale; Pay for Success
covers any gap funds
2
Ongoing
* Alliance savings
covers program costs
* Cost savings for
other County agencies
Result: Other providers
join; sustainable
scaling
3
Cost to County
One time $1M allocated
Cost to County
NONE. Covered by
Alliance / other providers

22. Alliance’s Savings Can Fund Program
Pilot Project
Budget
Components
Program costs
Per Participant
Average Healthcare
Interventions
Avoided per Child
Estimated
Treatment
Costs
Avoided ROI
Intervention and
Administrative
Costs
$2,562
.46 ED Visits and .23
Hospitalizations
$11,340 3.4
Pilot to validate costs and savings to Alameda Alliance
• 65% of children in Asthma START visited ED during 6 months prior to
starting program (average cost: $3,500)
• 45% of children in Asthma START had been hospitalized
(average cost $23,248 )
Projections indicate dollars saved by Alameda Alliance
more than covers program costs – pilot to validate

23. Announcements & Next Steps
• This project has captured national attention and PBS News
Hour will be broadcasting a story about the program
• KPIX CBS 5 has expressed an interest in creating a story
about this project
• Look for continued efficiencies, course corrections to
improve project impact
• Enrollment continues until July 2017 when we anticipate
reaching 250 participants
• Initial health utilization data to be reviewed
August/September 2017
• Entire cohort will be studied once the participants have
completed 12 months post intervention
• Anticipated outcome of reduced healthcare cost and ROI
calculations to be presented to end payor by August 2018.

24. Thank You!
• Referrals to the Program:
Brenda Rueda-Yamashita
Chronic Disease Program Director
Alameda County Public Health Dept.
7200 Bancroft Ave., Ste. 202
Oakland, CA 94605
(510) 577-7081
• For More Information:
http://impact4health.wikispaces.com/Welcome