North East Independent School District (Asthma Awareness Education Program)
Let the Data Guide the Program
The RRT/AE-C who launched the AAEP saw the school health statistics indicating that 9.2% of the NEISD population had an asthma diagnosis. By analyzing survey data from parents and historical school nurse visit data, she identified the areas of the district experiencing high rates of asthma-related absenteeism, Albuterol use and asthma-related limitations on physical activity. Feedback from parents about their children’s asthma indicated that barriers to specialist asthma care existed and that many parents and children had never received effective asthma management education. These data helped to focus the program on the district’s “hot spots,” where students and families might need the most help, and provided insight into what kinds of help – education, self-management support, improved health care access and environmental controls – might be most effective at reducing the impact of asthma on student learning.
Conduct Needs-Based Planning
Nurse visit data showed that during the 2006-2007 school year school nurses made 120 EMS calls, and 67% of the students affected were transported for urgent health care services to emergency departments (ED) and hospitals. Analysis indicated that the EMS calls often resulted from families’ inability to pay for asthma medications. To address this need, AAEP leaders developed a nebulizer protocol that enables school nurses to deliver Albuterol treatments on site when the protocol’s symptom criteria are met. This policy change helped NEISD reduce EMS calls and transports, improve continuity of care with primary care physicians, increase class time instruction and reduce missed school days for affected students. The AAEP introduced an additional protocol that helps nurses identify uncontrolled asthma by tracking different types of inhaler usage. Where previously all inhaler use was documented under a single heading, NEISD nurses now record prescribed-as-needed (PRN) inhaler usage separately. This allows nurses to quickly identify, by their repeat appearance on the PRN list, students whose asthma is not effectively controlled.
The AAEP also developed an online Asthma Control Test (ACT) that can be accessed through the district’s intranet. Nurses now document baseline asthma control at the beginning of the school year and reassess control when students require PRN inhalers. The ACT and PRN data helps AAEP staff to identify possible environmental exposures or other exacerbating factors that may be present in the school environment. NEISD shares ACT results with parents, explains the signs of uncontrolled asthma and encourages coordination of asthma care with primary or asthma specialist health care providers.
Engage Your Community ‘Where it Lives’
The AAEP’s community outreach component is the Asthma Blow Out (ABO) program, a disease management education program delivered in the district’s most disproportionately affected communities. Through a range of health care and school district partners, the ABO delivers asthma management education to students, parents, grandparents and others through one-on-one medication compliance education and inhaler technique review, and targeted age-appropriate sessions. AAEP staff members are joined by RT/AE-Cs from local community hospitals, UTHSC-SA Respiratory Care Program, and physician offices to deliver asthma education. The program is supported through hospital-based asthma education programs, nonprofit asthma coalitions, Medicaid providers, pharmacies and others. At ABO events, students and families receive medication compliance education, valved holding chambers (spacers) and have access to flu vaccinations and education sessions tailored by age. Caregivers receive 80 minutes of asthma education from allergists and pediatric pulmonologists, secondary students receive two hours of asthma education, and elementary students receive 60 minutes of asthma education from campus nurses and physical education teachers trained in the national guidelines for asthma care.
Be Visible: Funders Support What They Know
In Texas, as in a handful of other states, average daily attendance rates are at the foundation of the state’s formula for distributing school revenue. During Asthma Awareness Week in 2010, AAEP staff, school district leaders and a student who benefitted from the program presented to the school board on AAEP’s impact. The student shared their personal asthma and academic performance improvement stories, and district leaders described the return on investment the AAEP is generating as a result of increased attendance of both students and staff. An effective school-based asthma control program like NEISD’s can quickly increase attendance and thereby pay for itself.
Use Data to Demonstrate Your Program’s Value
Based on Texas’ school funding formula, a one percent increase in average daily attendance for a district NEISD’s size generates an additional $3.5 million annually. The attendance data alone demonstrate the success of the AAEP: average daily attendance rates have increased since the program’s inception from 95.3% to 96.1%, and attendance during flu season has improved significantly. Based on these results, despite district-wide budget cuts in recent years, funding for AAEP has been sustained.
Promote Institutional Changes for Sustainability
NEISD recently implemented the Environmental Assessment for Facilities (EAF) program to support the AAEP. It is a standard environmental assessment to promote building health across the district, and it is based on the past five years of experience with environmental interventions related to asthma. The EAF includes classroom, custodial, maintenance and air sampling components. Results are shared with principals and teachers, custodial staff, and facilities and maintenance personnel in presentations that link facility environments and student health, attendance, academic performance and funding for the district. This effort promotes action by the entire school community to establish and maintain facility health.
NEISD has met its original goal of reaching every school in the district with an ABO. Moving forward, the ABO will deliver more targeted education at the campuses with the highest asthma rates. The AAEP has partnered with the UTHSC-San Antonio’s Respiratory Care Program, which is providing a Community Learning grant to enable senior Respiratory Care students to deliver the ABO to NEISD’s elementary students in the future.
INTEGRATED HEALTHCARE SERVICES: PROMOTE ROBUST PATIENT-PROVIDER INTERACTIONS
Families who had received letters from the school with their child’s Asthma Control Test results and a recommendation to contact their primary care provider provided feedback indicating that communication with their physicians was lacking. To help, AAEP staff created a Physician Reassessment form for district nurses to use to communicate with students’ physicians about asthma, its effect on quality of life, physical activity, attendance and academic performance.
STRONG COMMUNITY TIES: MAKE IT EASY TO ACCEPT SERVICES
The ABO eliminates common barriers to disease management education. It is a family event that takes place in the comfort of the neighborhood school, bus transportation is provided, and families can connect with disease management specialists at the event. Bilingual materials are provided, students receive academic incentives for participation and trusted PE teachers and school nurses provide hands-on education. Campus principals attend to demonstrate the school’s support and understanding of the challenges families face.
TAILORED ENVIRONMENTAL INTERVENTIONS: Educate Care Teams on Environmental Management
The AAEP promotes environmental asthma management at home and in the community. At ABO events, students and families receive counseling from allergists on their personal asthma triggers and how to reduce exposures. The AAEP also trains district-employed family specialists, who serve at the 35 most economically disadvantaged campuses, on asthma triggers and home assessments. The family specialists conduct home visits to deliver a range of services. Since the AAEP training, the specialists have incorporated home assessments and asthma control counseling into these visits.
NEISD’s AAEP was designed to reduce asthma symptoms at school, reduce barriers to guidelines-based treatment, improve district staff understanding of effective asthma management, ensure healthy school learning environments and improve quality of life for students with asthma and their families. The AAEP’s leaders evaluate progress against these goals.
Evaluate Program Implementation
The AAEP’s environmental component trains custodial staff on asthma triggers and prompted district adoption of green cleaning practices; educates teachers and principals on how to establish a healthy learning environment; and teaches high school students about asthma, environmental triggers and indoor air quality issues. Results demonstrate that NEISD’s efforts to manage school environments are working: at one elementary campus, PRN usage declined by 50% two months after the school implemented green and asthma-friendly cleaning practices. When PRN data did not improve as rapidly at several comparable campuses, the AAEP staff investigated and found several classrooms that were not adequately cleaned. After a review with custodial staff of ideal cleaning practices, the PRN data rapidly improved at those campuses as well. Similar investigations prompted by campus-specific PRN usage data – available now that PRN inhaler usage is tracked separately from scheduled inhaler usage – have led to targeted environmental assessments at additional locations within the district. The investigations revealed, for example, overuse of fragrances in a middle school locker room and the need to restore outdoor air ventilation supply. Once the issues were addressed, PRN usage declined by 40% at that middle school.
Evaluate Program Impact
The AAEP has improved student health. The district demonstrated a 50% overall reduction in inhaler usage during the first six weeks of the school year following the launch of the AAEP compared to the previous year. The AAEP’s enhanced school nurse protocols helped to improve asthma diagnosis, with 11.9% of the NEISD student population now diagnosed with asthma as opposed to the 9.2% identified at the program’s outset. NEISD has also achieved a 70% decrease in annual EMS transports for urgent health care services during the school day. Every one of NEISD’s 67 campus locations has participated in an ABO event, and the AAEP’s asthma awareness education has reached all 9,000 of the district’s employees.