We are in year one of intiating a district wide asthma action plan. We are collaborating with our Green and Healthy Homes program and one physician's group in our city. Buy-in from our two hopsital ERs is very slow. Ideas to help with this? Also, who did you say you were able to access for seminars for your nurses (money always an issue)? We do have two nurses attending the asthma educator institute this summer through the Amercian lung association. Can the Texas school district share their policies, protocols, and tools developed? It sounds like a great program!!

Built upon the foundation of the existing Asthma Clinic in 1997, the Center for Pediatric Medical Home Asthma Initiative formed in 2008 collaboratively with representative members of CPM, GHS, and the South Carolina Asthma Alliance. The initiative developed in response to growing asthma prevalence, increasing urgent and unscheduled health care utilization for asthma (i.e., emergency department (ED) visits and hospitalizations), increasing rates of ED recidivism for asthma care, and significant disparities in pediatric asthma outcomes across the community. The AAT’s partnerships and services have changed over time based on the social, cultural, and economic needs of their patients, resources available within the community, and the clinics’ and hospital’s needs and resources. But the overarching mission has remained the same: to deliver standardized evidence-based outpatient care to prevent hospitalizations and emergency department (ED) visits and to improve patient quality of life.

Ensure Mission-Program Alignment
The AAT delivers and coordinates consistent patient education in the home, school, child care facility, physician’s office, and community in order to promote self-management and reduce unplanned health care utilization. The AAT manages a registry for its asthma patients and delivers integrated care through a network of partners who help to reinforce self-care education, promote the connection to a medical home, and deliver environmental asthma controls. The AAT and its partners deliver training on the National Guidelines for the Diagnosis and Management of Asthma (EPR-3) for GHS Children’s Hospital Pediatric Residency Program and GHS Children’s Hospital Medicine-Pediatric Residency Programs’ medical students and for CPM nurses. CPM’s asthma clinic delivers guidelines-based care, including regular updating and online storage of pictorial, multilingual asthma action plans (AAPs) where inpatient and outpatient GHS providers can access them, as well as regular monitoring of asthma classification (i.e., spirometry), medication use, and health care utilization. All of the information is collected in an electronic medical record (EMR) that is available to inpatient and outpatient care providers. Qualifying families may also receive intensive case management to deliver asthma education, home visits, office coordination, and school visits, with a certified asthma educator (AE-C) from CPM serving as case manager.

Focus on the Resource Strategy at Every Step
The AAT recognized the need to address social, economic, cultural and environmental factors that make it difficult for some families to bring their children’s asthma under control. In order to address the many risks and compounding factors that complicate asthma, the AAT sought partners early on who could help reinforce asthma care messages patients received in the clinical setting everywhere patients spend time. The AAT also needed partners who could help control environmental factors contributing to asthma, particularly in homes, schools and child care facilities, and who could share the costs of comprehensive asthma care delivery. The AAT found the partners it needed in the Family Connection of South Carolina (FCSC) Project Breathe Easy (PBE), and the Greenville Pediatric Asthma Community Collaborative (GPACC).

PBE assists and educates primarily low-income and minority families with children with asthma through a parent-to-parent education model. Trained parent educators visit schools, laundromats, child care centers, health fairs, physician offices and neighborhoods with low-income housing to deliver asthma education and provide referrals to FCSC to ensure that families have access to a medical home. CPM offers its families with children with asthma a referral to PBE. A referral results in enrollment in the PBE home visit program with constant contact for a six month period, including in-home review and counseling on asthma symptoms and triggers, education on effective communication with doctors and schools about a child’s asthma, and a mattress and pillow encasement for the child’s room provided with funds from the GHS Children’s Hospital.

Let the Data Guide the Program
Parkview’s Asthma Education and Management Program was developed to address the growing incidence and impact of asthma-related illness in Parkview’s service area. Data demonstrating the need for the program were compiled from multiple sources including the Centers for Disease Control and Prevention, ISDH and county health department asthma surveillance data, local school districts, physicians and ED staff, and two community health assessment surveys. One of the community health assessment surveys gathered general health status information, and the other focused on the needs of low-income individuals. The data showed that asthma prevalence was increasing, particularly among Parkview’s lowest-income service areas, which include a federally-designated Medically Underserved Population. The data also indicated asthma was a major self-reported health concern for Parkview’s population and that asthma-related symptoms were one of the most frequent reasons for ED visits and the leading cause of school absenteeism. Discussions with community partners further revealed that people with asthma needed more information and support in order to self-manage their asthma and that many ED visits for asthma resulted from a lack of regular medical care, lack of appropriate controller medication use, and/or the inability to effectively self-manage.

Conduct Needs-Based Planning
In response to both the community health needs assessment and needs of partner agencies, Parkview, in conjunction with numerous community partners, developed strategies to target the identified needs. The program’s goals were to help patients manage and control their asthma, reduce asthma-related ED visits, establish a medical home, provide financial assistance for medication as needed, support effective asthma trigger management and improve quality of life.

Start Small to Get Big
Today, Parkview’s Asthma Education and Management Program is a multi-component initiative that identifies people with asthma through local schools, social service agencies and the ED. The program delivers self-management education and resources, as well as environmental asthma management services to those identified through the initiative. When the program launched in 2004, it focused on delivering age-appropriate educational materials to school children and adults; supporting school nurses in asthma care planning and case management; educating teachers, coaches, bus drivers, social service agency staff and nursing students on asthma symptoms and attacks; and working through the county Healthy Homes Program to deliver environmental home assessments. Five years later, Parkview added the ED component to its program to further support people whose asthma may not be under control.

Every year, Parkview and its partners provide asthma education to people including young children, adolescents, adult caregivers, school nurses, teachers, coaches, bus drivers and other school staff. They receive tailored comprehensive asthma disease management education, including counseling on environmental asthma triggers and how to avoid them. They also receive asthma management resources, such as spacers for inhalers and back-to-school asthma checklists. As needed, they receive referrals for home visits, treatment of comorbid conditions, financial support for medication and assistance in establishing a relationship with a primary care provider. The ED Asthma Call Back Program serves over 1,200 individuals on an annual basis and recruits patients after asthma-related ED visits rather than through schools and social service agencies. This program delivers the same education, support services and resources as described above.

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.