YES WE CAN Children’s Asthma Program

This case study was prepared for CDC by Dr. LaMar Palmer of MAS Consultants. The purpose of the case study is to share the experience of one community as they attempt to address the problem of asthma. It does not represent an endorsement of this approach by CDC.

YES WE CAN Children’s Asthma Program: Operation of the Program

Overview

The program is carried out in community primary care settings where the majority of the children receive their asthma care. The YES WE CAN clinic combines the strengths of medicine and public health. A multidisciplinary asthma team guides each child through a care pathway that includes clinic visits, home visits, and clinical assessment follow-up phone calls. The team conducts clinical assessments and provides asthma education based on the NAEPP Guidelines. The CHW carries out an assessment of the home environment and provides guidance for reducing exposure to asthma triggers. An essential component of the model is the social support and the linking of families to community resources. The team takes into account the context of families’ lives so that strategies for improving the child’s asthma are practical and reality-based. The YES WE CAN approach focuses on factors that make an individual child’s asthma hard to manage, and then on ways to improve asthma control. The asthma team, working with the family, develops a care plan. The care plan outlines specific objectives, goals, and interventions designed to address the family’s needs as identified during the asthma clinic and home visits. The care plan proposes steps that the asthma team, other providers, and the family will take to improve the family’s ability to manage their lives and the child’s asthma. The care plan is an active document that changes over time as the family’s needs are addressed and change.

The Program was operated bilingually in English and Spanish, with some educational materials also provided in Cantonese.

The asthma registry is an important management tool that aids the asthma team in carrying out the clinic and managing patient caseload. Basically, the registry incorporates all of the ongoing information about patients in the asthma program. This stand-alone data base is essential for identifying, stratifying, and tracking asthma patients. During clinic visits, the asthma team members input patient health data into the registry (for example, symptoms, morbidity, spirometry, blood pressure, weight and height), asthma diagnosis and severity, and other information such as prescriptions and follow-up appointments. The registry is used to track patients to prevent loss to follow-up from families simply dropping out of the program, and to track interventions for each case. Asthma team members have on-demand access to the registry and input data on laptop computers during the clinic visit.

Entry into the Program

Most children are enrolled into the program following a visit for their asthma to urgent care, the ED, the hospital or their primary care provider. If families do not follow through on the referral, the clinical case manager contacts the family and invites the child and parent/caregiver to enroll in the program. If the family agrees, the child is scheduled for an asthma clinic visit.

Asthma Clinic Visit 1

Orientation
In a typical first clinic visit, the CHW meets the caregiver and the child when they arrive at the clinic. The CHW conducts a short orientation that introduces the family to the clinic, the facility, and the program; explains what they can expect during the visit; and tells them the expected length of the visit. The CHW introduces the caregiver to the "team" concept for addressing the child’s asthma, and explains the family’s role as part of the team.

Intake Questionnaire
The clinical case manager or designated medical assistant uses the intake questionnaire to question the caregiver (and the child when appropriate) about the child’s asthma in order to complete an asthma history. The questionnaire addresses morbidity, history of asthma and related illnesses, usual asthma symptoms, asthma triggers, home environment, and asthma control. Questions from the family about the child’s asthma are also recorded. The caregiver is asked if there are any social barriers or issues that stand in the way of managing the child’s asthma, and responses are recorded.

Asthma self-management education
The family views a KP/NC video titled "Your Child and Asthma," in English, Spanish or Cantonese. The clinical case manager or the CHW presents asthma self-management instruction and answers questions. The instructional format is one-on-one based on the individual family needs as determined by parent and child asthma knowledge deficits and their individual concerns. The initial educational component is centered on helping the child and caregiver to understand the medications and how they should be administered, to recognize an asthma attack and know what to do if one occurs, and to identify personal triggers and learn how to avoid them. Details about the educational program are described in Section V, Patient and Family Education.

Skin testing and spirometry
For children aged 5 years and older, the clinical case manager administers an allergy skin test for mites, cockroaches, cats, dogs, indoor mold, and local grasses and trees. The clinical case manager conducts peak flow test while observing the child’s technique, and assists the child in improving performance. Spirometry testing is also done. Following two-to-four puffs of albuterol and a 20-minute wait, post-bronchodilator spirometry is performed, and the skin test results are read.

Assessment, diagnosis, and treatment
The clinician becomes acquainted with the child and caregiver and reviews the child’s asthma health history from the intake questionnaire. The clinician conducts a physical assessment of the child, makes an asthma diagnosis, or confirms the previous asthma diagnosis, and determines asthma severity. The clinician then interprets the spirometry results, prescribes a treatment plan based on the NAEPP guidelines, provides prescriptions, and develops a written Asthma Action Plan for the child. Then the clinician teaches the family how to use the plan.

A medicine box is provided to the family at the first clinic visit. It is a rectangular plastic container with a lid, and is about the size of a shoebox. In addition to storing the asthma medications there, children keep their peak flow meters and spacers in the medicine box.

Follow up
Prior to terminating the visit, the CHW schedules the home visit and also schedules the next asthma clinic visit. The CHW answers any questions about asthma education or the program, and discusses the next steps for any urgent social need identified by the family during the visit. The clinical case manager informs the caregiver about the clinical assessment telephone call that will follow the home visit.

Flow Chart 1 shows how a typical patient would go through an initial asthma clinic visit.

Home Visit 1 (1–2 weeks following the 1st clinic visit)

Within a few days following the first asthma clinic visit, the CHW telephones the family to confirm the home visit date and time. In preparation for the visit, the CHW reviews the results of the first clinic visit, including the results of allergy tests or other tests and notes the medications prescribed and the known asthma triggers for the child. The CHW assembles items needed for the visit, which may include copies of the test results, mattress and pillow covers, videos or other educational materials, copies of the child’s Asthma Action Plan, and important phone numbers for the family.

At the home, the CHW goes over a prospective plan for the visit and obtains concurrence from the caregiver before proceeding. The CHW’s objectives are to:

• describe the role of the CHW as an ally to the family who will help them manage the child’s asthma and as an advocate in the community who will help resolve barriers the family faces to good asthma care
• answer questions
• verify that the prescriptions have been filled and the medications are being taken as prescribed
• observe how the child takes the medicine
• show the caregiver how to organize the medicine box and where to place the Asthma Action Plan
• review the results of allergy testing with the caregiver
• ask questions about triggers of the child’s asthma and when episodes are most likely to occur
• verify asthma knowledge and review asthma self-management educational materials as needed
• walk through the house (especially the child’s bedroom) with the caregiver with a trigger checklist, and note any visible asthma triggers
• if the child is allergic to dust mites, help the caregiver place mattress and pillow covers on the child’s bed
• determine the caregiver’s strengths and level of self-confidence in dealing with the child’s asthma
• assess barriers to appropriate care and disease management such as not having a primary care provider, no health insurance, housing issues, employment issues, childcare problems, transportation difficulties, family issues, language barrier
• ask the caregiver what they want to work on and work with them to develop a plan that includes actions the family can take to reduce triggers in the home

Clinical Assessment Call 1 (one month following 1st clinic visit)

The clinical case manager initiates the clinical assessment telephone call to the child’s caregiver. Clinical assessment calls provide for close monitoring of the clinical progress of each child. This helps to optimize the family’s ability to manage their child’s asthma effectively and to get the child on the right medication at the lowest effective dose before going back to his/her primary care provider for continuing asthma care. Before placing the call, the clinical case manager reviews the child’s medical history, asthma triggers, environmental exposure, medications, Asthma Action Plan, and social/psychological issues. The clinical case manager reviews the case management care plan for specific problems, goals, interventions, and timelines. The clinical case manager’s objectives for the clinical assessment call are to:

• address any questions or concerns the family may have about asthma or challenges they may be facing
• assess current asthma control by reviewing peak flow numbers, frequency of symptoms, beta agonist use, and activity limitations
• if asthma control has not been achieved, assess the child’s self-management skills and try to determine the causative factors. (The Telephone Assessment Protocol contains a set of questions to ask the parent in order to help the clinical case manager determine why the child’s asthma is not under control: not taking medications, not using them correctly, inadequate environmental control, presence of viral infections, allergic rhinitis, sinusitis, family not understanding the Asthma Action Plan, and so on.)
• assess the family’s readiness to make needed behavior changes that will lead to improved disease control. If the family is ready, the clinical case manager helps caregivers identify realistic solutions to the problems and helps them to set goals to successfully accomplish needed changes.
• assess the caregiver’s confidence in his or her own ability to manage the child’s asthma
• review the Asthma Action Plan with the caregiver
• summarize agreements and next steps with the caregiver

Following the assessment call, the clinical case manager consults with the clinician about the need for medication changes or adjustments, creates a new Asthma Action Plan if needed, arranges for any needed medication refills or equipment, and sends a reminder to the family about the next clinic visit and telephone follow-up call.

Asthma Clinic Visit 2 (at 2–3 months)

During the second clinic visit, the CHW meets the family and follows up on their progress on reaching the goals set at the home visit. The CHW discusses what will occur during the second clinic visit and how long the visit will take. The CHW answers questions about the program or the visit and provides information as needed.

The clinical case manager measures peak flow and spirometry in children aged 5 years and older and administers 2–4 puffs of albuterol as ordered by the clinician. The clinical case manager meets with each child and family to discuss issues and concerns and assess the status of the child’s asthma. If the asthma is not controlled, the clinical case manager explores reasons and works with the family to set goals for improved control. The clinical case manager then assesses self-management skills and provides information on self-management as needed. After 20 minutes, the post-bronchodilator spirometry is administered.

The clinician reviews the child’s records, performs a physical assessment, and interprets the spirometry results. The clinician does a reassessment of asthma control and initiates or makes adjustments to the medications and the Asthma Action Plan as needed. The clinician provides the prescriptions for new medications, metered dose inhalers, and spacers as needed.

The CHW schedules the next home visit, if needed, and also schedules the next asthma clinic visit. The CHW answers questions about self-management and the asthma program, and discusses the next steps for any urgent psychosocial needs the family has identified.

Following the second (and any subsequent clinic visits) the clinical case manager makes clinical assessment telephone calls to the family to answer any questions or concerns the family may have and to assess the status of asthma control. The clinical case manager encourages the caregiver to sustain asthma self-management behaviors and recognizes accomplishments achieved. If self-management is not working, the clinical case manager probes to understand the problems and provides counsel and support to the caregiver as needed. They review the Asthma Action Plan together and resolve problems associated with adherence with medications. Succeeding asthma clinic visits and additional clinical assessment phone calls follow the same process that was described previously in this report. Flow Chart 2 shows how a typical patient would go through a return asthma clinic visit.

Home Visit 2 (1–2 weeks later)

During the follow-up visit to the child’s home, the CHW conducts a self-management education review, a medication review, and an Asthma Action Plan review. The CHW encourages the family and elicits and responds to patient and family questions. The child is asked to demonstrate how he/she takes the medications. A primary objective of this, visit and subsequent visits is to follow up on recommendations made during the first visit to reduce asthma triggers in the home and to encourage and assist families as needed. Another objective is to follow up on referrals and family concerns.

Asthma Clinic Closure Visit (at 6–12 months)

For subsequent clinic visits, the clinician and the clinical case manager follow the same protocols as in the second visit. When the results of the clinic visit show that the child’s asthma is under control and the family is practicing good asthma self-management, the clinician and the clinical case manager determine that, from a medical standpoint, the child can be returned to primary care. Indications of good asthma control are defined in the program as:

1. minimal (if any) chronic symptoms, including nocturnal symptoms less frequently than twice a month
2. infrequent exacerbations
3. minimal need for bronchodilators (less than two times a week)
4. no limitations on activities, including exercise
5. peak expiratory flow is consistently greater than or equal to 80% (optimally 90%) of personal best
6. minimal, if any, adverse effects from asthma medicines

Families demonstrate good self-management skills when they understand

1. personal asthma triggers and how to avoid them
2. correct inhaler and spacer techniques
3. how to measure peak flow
4. how to use medications correctly
5. how to recognize an asthma flare-up
6. how to adjust medications during an asthma flare-up
7. have systems in place to effectively manage asthma, for example, Asthma Action Plan posted and use of medication/equipment boxes.

Criteria for closure of care management by the asthma clinic also includes a social evaluation that considers the following questions.

1. Does the child have insurance coverage?
2. Does the family have a primary care provider?
3. Does the family have an Asthma Action Plan, prescribed medications, and equipment on hand?

When the criteria are met and the answers to the social questions are affirmative, the decision is made to return the child to primary care, and the family is so informed. The clinical case manager coordinates the transition from asthma clinic care back to enhanced primary care. If either the health criteria or the social criteria are not met, the child continues care in the asthma clinic until such time as these criteria are met.

Flow Chart 3 depicts the operation of the four levels of care in the program. Children with the greatest need receive the greatest amount of clinical, environmental, and social care. The flow chart also demonstrates the sequencing of interventions between clinical visits, home visits, and clinical assessment phone calls. The interventions continue until the child’s asthma is shown to be under control, the family demonstrates good self-management skills, and the family has acquired primary care, health insurance, and access to asthma medications and prevention supplies.