Building a Targeted Asthma Education and Management Program

Abstract

For individuals with asthma, self-management at home can be complex and overwhelming. The National Asthma Guidelines recommend education, ongoing assessment of control, and identification of those at high risk, as integral elements of improving outcomes for these individuals. Children’s Mercy implemented standardized, patient-centered asthma education interventions along with institution of asthma control assessment tools and targeted management of high risk asthmatics. Many of these tools are applicable for use in primary care ambulatory practices.

Introduction

Asthma is a chronic lung disease that impacts the lives of over 142,535 children in Missouri¹ and accounts for 13,148 emergency room visits state wide (2013 data)² including 5,883 visits at the Children’s Mercy Emergency Department during the same time frame. In addition to triggering increased health care utilization, poorly controlled asthma also negatively affects the quality of life of these children. In Missouri 57% of children with asthma had an asthma attack in the past year and 58% had to limit their activities due to asthma.²

Managing asthma on a day to day basis can be a struggle for patients and families. First, patients need to identify triggers and learn how to reduce and/or eliminate exposure. Second, there is a wide array of complex medications that not only look similar, but have different directions for use, different dosages, and different timings of the day when they need to be administered. And finally, patients and families need to learn self-management skills.

Asthma education therefore needs to be an integral component of any comprehensive asthma management program. Such education is essential to improving a patient’s comprehension and confidence in their home management, and has been shown to improve patient outcomes. According to the 2007 National Asthma Guidelines, “the benefits of educating people who have asthma in self-management skills of self assessment, use of medications and actions to control or prevent exacerbations, include reduction in urgent care visits and hospitalizations, reduction of asthma related health care costs, and improvement in health status.”³

Inception of a Novel Asthma Education Program

Recognizing the importance of asthma education, Children’s Mercy created an evidence based, metro-wide comprehensive asthma management and education program, the Kansas City Childhood Asthma Management Program (KC CAMP)⁴ in 1998. This program was based on a framework of evidence-based guidelines, use of written asthma action plans, and the availability of trained asthma educators at all points of care. A cardinal feature of KC CAMP was the focus on empowering the child and family to take control of their asthma, with the introduction of asthma action plans and self-management education conducted by an educator at each patient visit within the hospital system. KC CAMP was also involved in reaching out to community practices in the Kansas City area and tailoring asthma educational modules to the needs of their staff.

In 2005, KC CAMP signed a contract with a health plan to manage their asthma population. During the review of the educational program employed by the health plan, it became clear that their methodology was inconsistent, asthma educational content was variable, and insufficient time was allotted to meet the asthma needs of the patient/family. An Asthma Coordinator was therefore hired to bridge the gap in educational oversight. A Flip Chart method was developed to provide consistent content during every educational session with an asthma patient. The Flip Chart is a stand-up, 8.5″ × 11″, two-sided chart. During education, the patient/family views relevant pictures on one side of the flip chart, while the educator narrates the educational content on the other side. The asthma educational content is based on the 2007 National Asthma Guidelines and consists of patient/family goals, asthma control, basic asthma pathophysiology, roles of medications, triggers, asthma action plan instructions and device techniques. The Flip Chart also employs health literacy techniques such as the use of pictures, fifth through seventh grade reading level, non-medical terms, and teach-back technique to aid in learning and retention of the content. Booklets containing the same information are provided to patients/families during the educational session.

The Flip Chart method was implemented in an inpatient Asthma Class in 2011. Each caregiver and/or patient admitted to the hospital for asthma was invited to participate in the class. The class promoted open communication between patient/family and educator in a learning environment conducive to a variety of learning styles such as VARK (visual, auditory, reading and kinesthetic) or viewing, listening, reading, and hands-on interactive activities. In order to evaluate its effectiveness, structured surveys were given to all attendees before and after the class to assess the caregivers’ knowledge and comfort in managing asthma. Caregivers attending the class reported statistically significant greater comfort in managing asthma at home (p<0.0001), belief that they had the right information to know what to do when their child had an asthma attack (p<0.0001), and belief that they learned something new about asthma home management (p<0.0001). Due to the encouraging results the class was expanded to five days a week and opened up to the community. The Flip Chart became the standardized method for asthma education throughout the hospital system.

To help embed the Flip Chart Method into the asthma educational culture of the hospital, each location was given its own Flip Charts and booklets. The asthma educators, consisting of nurses and respiratory therapists, were provided training on the effective use of the Flip Chart, while concomitantly enabling them to obtain continuing education credits for their discipline. The goal of the standardized Flip Chart Method was to ensure consistency in the education delivered at the first visit that patients/families made to the Children’s Mercy system, regardless of the location (emergency department, urgent care, inpatient or clinic), along with repetition and reinforcement at each subsequent visit, thereby reducing patient/family confusion and improving retention. As per the 2007 National Asthma Guidelines, “Asthma self-management education should be integrated into all aspects of asthma care, and it requires repetition and reinforcement.”³

Since asthma is managed and education completed in many different locations throughout the Children’s Mercy system an internal asthma website was created to house, in one convenient location, patient and provider resources containing the standardized asthma educational content and quick access to evidence-based asthma management tools. An external asthma website was also built, specifically designed for patients/families/the community to have easy access to educational materials and links to reputable asthma information on the web. The website also contains asthma information for health care professionals including handouts, videos, and CME opportunities. (See Table 1.)

Table 1.

A table of different asthma resources being used at Children’s Mercy Hospital. You can find most of these on the website: www.childrensmercy.org/asthma

Asthma Resource	Type	Description	Age	Language Available
Asthma Class Video	Online Video	The video is a shortened, but interactive version of our in-person Asthma Class. Learn about asthma right at home	6-Adult	English
Pippy Learns about Asthma	Activity booklet	A fun and educational activity and coloring book that teaches children about asthma	2–12 years old	English
Asthma Controller Calendar	Paper Calendar with stickers	This calendar helps keep kids keep track of their daily medicine by using stickers to place on the calendar when they take their daily controller	4–16 years old	English
Asthma Booklet	Paper Booklet	A comprehensive and health literate overview of asthma for the community	6-adult	English/Spanish
Asthma Diary	Paper handout	The diary helps patients and families track daily asthma symptoms	6-adult	English/Spanish

While websites are a great way for families to gather valuable asthma information, many of our families are increasingly involved in social media sites like Facebook and Twitter. According to Pew Research Center, “As of January 2014, 74% of online adults use social networking sites.”⁶ To reach the social media population we started an asthma twitter account, @breatheKC. Through this we are able to post helpful asthma tips and daily pollen and mold counts. Twitter chats are another way to have open discussions with the community and answer any questions about asthma. Twitter has been a helpful tool in connecting with the local asthma community, as well as to reach a regional and national audience.

The asthma website has valuable information for the community; however, it does not include what we consider to be one of our best resources - the “Asthma Class.” While the Asthma Class is an effective tool for teaching asthma self-management, it requires attendance at a one hour class on a weekday, limiting its access to the family member who is with the hospitalized child. This leaves other family members and caregivers in the community without education on important asthma self-management tools. This observation prompted us to institute multiple interventions to enable asthma education to be more widely available in the community.

The first intervention we initiated was the ”Asthma Class video.” This video is an interactive condensed version of the actual Asthma Class, using the same evidence-based content and health literacy techniques. It was placed on the Children’s Mercy’s asthma website in November 2015 (www.childrensmercy.org/asthma). During the first three months the video received about 14 views per month. It was then introduced to community physicians in February 2016 through the Children’s Mercy Progress notes e-mail and the views increased to 33 per month. To further broaden asthma education opportunities across the community we plan to introduce Saturday Asthma Classes. The first two classes will take place during the spring season with further classes offered during the busy fall asthma season. Enrollment in an Asthma Class can be completed on line or through a phone call. (See Table 1.)

The Asthma Class is geared towards adults and older children, but younger children can still learn about asthma in a fun and interactive manner. An asthma activity book was created to stimulate the minds of children. The activity book “Pippy the Puffin Learns about Asthma” follows the adorable Pippy and his RT teacher through the adventures of asthma. The book includes many educational activities including: coloring, word search, maze, seek and find and dot-to-dot for a fun asthma educational experience. (See Table 1.)

The Children’s Mercy asthma program is continuously monitoring and updating the asthma educational materials to meet new evidence based guidelines and/or national standards. It is currently working towards alignment with all nine standards recommended in the recently published National Standards for Asthma Self-management Education.⁶ Although many of the standards are met, an Asthma Collaborative group is in place to provide the support needed for further implementation and monitoring of the standardized asthma educational program for the best possible outcomes for our asthma families as well as possible educational reimbursements by payors in the future.

Implementation of Guidelines-Recommended Asthma Control Assessment Tools

Asthma control is dependent upon a large number of variables including psychosocial and physiologic factors. The NHLBI Guidelines for the Diagnosis and Treatment of Asthma suggest that routine assessment of asthma control is an integral part of maintaining health and wellbeing³. These guidelines recommend use of a self-assessment questionnaire intended to capture the patient’s and family’s impression of asthma control, self-management skills, and overall satisfaction with care. One such tool is the Asthma Control Test™ (ACT)⁷, and its pediatric version, the Childhood Asthma Control Test™ (C-ACT)⁸. Use of this self-assessment tool has been advocated for all patients presenting to an outpatient clinic at Children’s Mercy.

Following the advent of the NAEPP guidelines a quality improvement project was initiated at our institution aimed at improving adherence to guidelines including use of the ACT and C-ACT in routine clinic care. The project was initiated at the Allergy, Asthma and Immunology (A/A/I) clinics with gradual systematic involvement of Pediatric and Adolescent Clinics. Data collection began on March 13, 2007 and ended in July 13, 2008. Each asthma patient between the ages of 4–18 years (and caretaker as applicable) was given a paper copy of the ACT/C-ACT to complete at each clinic visit while in the waiting room. Following the clinic visit, each provider recorded ACT/C-ACT scores along with information on demographics, asthma self-management plans, spirometry, exhaled nitric oxide, current medication lists by class, self-reported medication adherence, provider assessment of asthma severity, and actions taken by the provider in response to assessments of asthma control on individual one-page ‘visit planners’. Data from the ‘visit planners’ were extracted and stored in a web-based registry (“Asthma Control Tracker™”) by designated and trained personnel¹⁰. Of the cohort of 1338 children (1787 visits) evaluated in primary and specialty asthma clinics 47% had ACT and c-ACT scores that suggested uncontrolled asthma, and changes in physician treatment plans were associated with changes in ACT/C-ACT scores, even when physicians were unaware of ACT/C-ACT results¹¹. We determined that use of the web-based Asthma Control Tracker™ produced high levels of guideline adherence.

Bolstered by the results of the above project, process consisting of a paper ACT/C-ACT was initiated in 2011 to facilitate consistent completion at outpatient visits and subsequent documentation in the electronic medical record (EMR). A quality improvement project was implemented to improve the percent of ACT/C-ACT documented in the EMR from the baseline rate of 17%. This process involved a paper ACT/C-ACT given to the patient and the scores were manually entered into the EMR by the provider. In 2012, an iPad version of the ACT was implemented which allowed for patient to complete the assessment on the iPad and the results automatically integrated into the EMR. A year later, an ACT internet portal was placed on all exam room computers in the outpatient clinics for further ease of access. These improvements allow providers to track ACT scores over time and assess the impact of ongoing therapy on asthma control. Since July 2015 we have surpassed our institution-wide goal of 75%.

Implementation of a “High Risk” Asthma Management Protocol

The Asthma Coordinator promotes evidence based asthma management and education while analyzing and reporting quality outcomes to providers and staff. While analyzing temporal data, we were able to identify a trend in rising acute emergency department visits between 2001 and 2014, and a slight upward trend in hospitalizations. (See Figure 1.) As per the 2007 National Asthma Guidelines, “Patients who are at high risk for asthma-related death require special attention— particularly intensive education, monitoring and care.”³ To meet this need, a risk stratification model was developed to determine the high utilizers of asthma care, i.e. those with repetitive visits to acute care settings such as with emergency department visits, urgent care visits and hospital admissions. The model⁹ found that the historical count of acute care visits (ACVs) was predictive of future ACVs. (See Figures 2 and 3.) A significant increase in the probability of future ACVs was observed with each additional historical visit, effectively stratifying risk by the historical visit count. Notably, a small group of ambulatory patients accounted for a disproportionate number of future ACVs, namely, those with three or more historical ACVs were found to have a 60% chance of having a future acute care visit. This population was termed “high risk” meriting closer scrutiny and provision of enhanced asthma management services. Consequently, this is a simple model that can be used by providers in all outpatient practices to identify asthma patients who may require focused attention.

Figure 1.

Identity of a trend in rising acute emergency department visits between 2001 and 2014, and a slight upward trend in hospitalizations.

Figures 2 and 3.

The model below found that the historical count of acute care visits (ACVs) was predictive of future ACVs.

The same model was used with patients hospitalized for an asthma exacerbation. In 2014, a High Risk Asthma Protocol (HRAP) was launched in the inpatient setting using the parameters in the model as criteria for entry into the protocol:

• Greater than or equal to four ED/UCC/inpatient episodes in the past year (including the current visit)

• And/or current PICU admission or history of a cardiac arrest or intubation (admission resulting from ED/UCC visits counts as one episode).

The following ACV interventions were developed in order to decrease patient risk of future ACV: routine asthma inpatient care, provision of evidence based asthma action plans, asthma education through the Asthma Class, review of individual asthma action plans at the bedside and arrangement for follow up care. In addition, the high risk patient also receives a social work consult to assess for psychosocial barriers to ongoing follow-up care as an outpatient; an Environmental Health Referral for guidance regarding identification and avoidance of asthma triggers and, if indicated, a home evaluation; inpatient consultation with an asthma specialist as needed; ensuring that an outpatient follow up appointment is made to bridge the gap between emergency and primary care; and a summary of the inpatient visit and interventions sent to the primary care giver.

Based on our experience, we found that one of the most important aspects of the HRAP is the standardization of key outpatient interventions. The providers use the following interventions to assess asthma control to decrease risk of future ACVs: administration of the asthma control test to track asthma control, environmental health assessment, spirometry, exhaled nitric oxide testing, allergy testing, assessment for suitability of immune modulator therapy, influenza vaccine as needed, screening for the complications of systemic steroids, social work/case management and titration of asthma medications (step-up or step-down) as appropriate. Between November 2014 and April 2015, there were 78 high risk patients accounting for 10% of the hospitalized asthma population. Each patient was scored when enrolled into the HRAP and at one year post enrollment. The scoring consists of 1 point for every ED/UCC/hospitalization and 4 points for a PICU admission (admission resulting from ED/UCC visits counts as one point). There was a statistically significant (p<0.0001) decrease in HRAP scores from enrollment to one year post enrollment. (See Figure 4.) Our data suggests that use of a simple risk stratification model can help decrease acute care visits in the asthma population we serve.

Figure 4.

HRAP Outcomes

Conclusions

For those living with asthma, home management of asthma can be complex and frustrating. Whether in a hospital setting, private practice, or in the community it can be challenging to dedicate the time patients and families need to address their asthma needs. Asthma self-management education is an empowering strategy that creates understanding and self confidence in home management. A consistent approach to education with reinforcement at every visit will help to improve retention, decrease confusion and increase confidence in self-management skills. Some of the lessons learned in creating a comprehensive asthma program at Children’s Mercy may be able to be duplicated in primary care and specialists practices. Resources are available on our website www.childrensmecry.org/asthma. The Children’s Mercy Asthma Coordinators are always available at 816-960-8907 to provide guidance and assistance.

Biography

Helen Murphy, BHS, RRT, AE-C, Asthma Coordinator, (top left), and Jamie Wolverton, BHS, RRT-NPS, AE-C, Asthma Educator, (top right), are in the Allergy, Asthma and Immunology department at Children’s Mercy in Kansas City. Chitra Dinakar, MD, (bottom), MSMA member since 2002, and Missouri Medicine Editorial Board member for Allergy and Immunology, is Professor of Pediatrics, University of Missouri-Kansas City and Director, FARE Center of Excellence at Children’s Mercy, Division of Allergy/Immunology, Children’s Mercy Kansas City.

Contact: hmurphy@cmh.edu