Tri State Child Health Services Inc., a pediatric physician-hospital organization (PHO), strives to improve the quality of care and outcomes for children in the region through collaboration among community-based physicians, hospital-based physicians and Cincinnati Children’s Hospital Medical Center.

The PHO comprises Cincinnati Children’s, Ohio Valley Primary Care Associates (OVPCA) (an independent practice association), contracted and employed specialist physicians and community-based specialist physicians. The organization, a not-for-profit, taxable corporation joint venture, includes committees that oversee contracting, credentialing and performance improvement activities.

PHO Asthma Improvement Initiative and Outcomes

  • When launched in October 2003, more than a third (35 percent) of the region’s pediatric asthma population was identified as able to benefit from the asthma improvement collaborative. This equates to 13,000 children across 38 primary care practices (147 physicians) within Greater Cincinnati.
  • Among pediatric populations, the presence of asthma is high and care is usually managed by primary care practices. Building improvement capacity and redesigning care delivery at the primary care practice level creates sustainable systems for future improvement.
  • Extensive literature exists on the positive impact of improvement interventions on process and outcome measures. Through the implementation of these evidenced-based interventions, asthma-related emergency department / urgent care visits, hospital admissions, office visits due to symptom acuity, missed school and workdays, and daytime and evening symptoms can all be positively impacted.
  • The model for engaging community physicians, as well as accelerating and sustaining improvements, can be spread to other conditions, practices and hospitals. Clinicians who would like to track a patient’s progress are invited to download the asthma data collection form PDF that we use in our asthma improvement initiative.

Selected Key Outcome Measures

Rate of Inpatient and Short State Visits – Rolling 12 Month Period.


  • Following an initial uptick in line with improved data capture and oversight in 2008, PHO practices have maintained fewer inpatient and short-stay visits than the comparison non-PHO commercially insured population.

Rate of ED and Urgent Care Visits – Rolling 12 Month Period.


  • Following the initial uptick in line with improved data capture and oversight in 2008, PHO practices have maintained fewer emergency department and urgent care visits than the comparison non-PHO commercially insured population.

Proportion of Population Whose Parents and Physicians Have Agreement on Asthma Rating (Rolling 12 Month).

  • The rating of asthma control is obtained through the PHO patient registry. Success on this measure is defined as agreement on this control rating between the physician and parent / caregiver.

Cumulative Percent of Network Asthma Population Receiving “Perfect Care.”

Asthma perfect care is a component measure and includes three essential and evidence-based elements of care:

  1. Asthma must be severity classified.
  2. The asthmatic must receive a written copy of his or her management plan.
  3. If the asthmatic is diagnosed as “persistent,” he or she must be prescribed controller medication

These components must be validated through a documented encounter in the PHO registry within the prior 24 months. All three elements must be met for a success to be counted.

Continuous Improvement

  • Multidisciplinary practice quality leadership teams have been established, creating frequent opportunities for practices to share successful interventions.
  • Through practice workflow redesign, we have implemented and achieved high reliable use of the asthma decision support / data collection tool at the time of the patient encounter. The tool focuses on key components of evidence-based care, and includes separate sections for patients / parents and physicians to complete. By reviewing this information at the point of care, potentially problematic issues are identified, which in turn encourages discussion and problem solving among all parties.
  • Combining hospital and primary care practice billing data to reconfirm all-payor asthma population registry denominator at regular intervals.
  • Creating a web-based registry, with practices able to access “real-time,” actionable patient and practice-level data / reports, transparent comparative practice data on process and outcome measures, and network-level performance reports.
  • Working with the Governance Board (OVPCA) to set measurable practice participation expectations for key aspects of the asthma improvement initiative.
  • Governance Board review of asthma improvement initiative status during monthly meetings.
  • Incorporating practice and physician-level criteria / requirements into Maintenance of Certification (MOC) approval process to promote focus on system-level change within practices.
  • Partnering with the largest commercial payor to reward practices for flu shot and controller medication percentages. Practice level data for this initiative is sourced from the PHO registry.

New Areas of Activity

  • Assessing each practice on key dimensions of sustainability and implementation strategies to address gaps (e.g., embed high reliability change concepts into office workflow).
  • Obtaining a detailed understanding of factors underlying practices’ exemplar performance on process and outcome measures and share learnings across the network.
  • Performing a detailed analysis of the high-risk asthma subpopulation and develop / implement targeted interventions to further improve network-level outcome measures (e.g., specialist referral/evaluation).
  • Identifying improvement opportunities by reviewing each asthma-related admission and ED / urgent care visit using a root cause analysis approach.
  • Increasing the use of spirometry testing.
  • Developing / implementing strategies to improve primary care-specialist co-management, especially for high-risk subpopulations.
  • Partnering with the Cincinnati Children's Asthma Center to test an evidence-based electronic asthma decision support tool.
  • Improving care and outcomes for the children with special healthcare needs. This includes a focus on: registry / segmentation model, previsit planning, care coordination, community resources and financial planning.