Childhood Asthma And How Asthma Educators Can Help

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Childhood Asthma and How AsthmaEducators Can HelpFloyd J. Malveaux, M.D., Ph.D.Executive DirectorMerck Childhood Asthma Network, Inc.(202) 326-5200floyd malveaux@merck.com

Childhood Asthma is Challenging onMany Levels – Asthma Educators Can HelpWidespread and Serious Asthma is the most common chroniccondition among children 55% had at least one asthma attack in theprevious year 1 in 7 ever diagnosedCostly 8-10 billion in medical expenditures Additional 10 billion in indirect costs 40% higher emergency department costsPreventable and Avoidable Asthma educators have been shown toeffectively reduce the number of days withsymptoms, emergency department visitsand hospitalizations

MCAN-Funded Programs Across the CountryIntegrate Asthma Educators Into the Care TeamThe Merck Childhood Asthma Network, Inc.(MCAN) enhances the quality of life for childrenwith asthma and their families, and reduces theburden of the disease on them and society by: Improving access to and the quality ofasthma healthcare services for children,especially those who are vulnerable andmedically underserved Advocating for policies that expediteimplementation, dissemination andsustainability of science-based asthma care Increasing awareness and knowledge ofasthma and quality asthma careThe Merck Childhood Asthma Network,Inc. (MCAN) is a nonprofit 501(c)(3)organization founded in 2005 and fundedby The Merck Foundation

Partnerships, Breakthrough Ideas Communicate Value ofAsthma Educators, Create Path for Widespread AdoptionCommunity Healthcare for Asthma Management and Preventionof Symptoms (CHAMPS)Head-off Environmental Asthma in Louisiana (HEAL), Phase IICare Coordination Program Sites(Chicago, Los Angeles, Philadelphia and Puerto Rico)Childhood Asthma Leadership Coalition (CALC)“Putting Together the Pieces to Manage Childhood Asthma”Infographic

ASSOCIATION OFASTHMA EDUCATORS (AAE)Chanda Nicole Holsey, DrPH, MPH, AE-CPresidentAssociation of Asthma Educatorscholsey@HALOforFamilies.org(678) 358-5048

Mission & VisionMissionAAE is the premier inter-professional organization striving forexcellence to raise the competency of diverse individuals whoeducate patients and families living with asthma.VisionThe leading resource for asthma educators and the premierprovider of evidence-based asthma education: Advocates for patients with asthma and their families Advocates for underserved and minority populations, andaddresses disparities in asthma outcomes Improves asthma management and education outcomes

Who We Are Asthma educators Nurses Advanced practice nurses Respiratory therapists Pharmacists Physicians Physician Assistants Allied health professionals Public/community health professionals Health educators School health professionals Social workers

AAE Responds to Disparities ThroughCommunity Service Projects New Orleans 2009– Parish Nurses & Outreach Workers asthma training– Parish Nurses & Outreach Workers continue to use presenters as a resource– Asthma Health Fair for over 25 patients and families Orlando 2010– AAE partnered with Not One More Life, Inc. (NOML) to work with the NemoursChildren's Clinic – Orlando, Division of Pediatric Pulmonology to present a NOMLasthma educational program that consisted of asthma screening, counseling, referral,and outcome monitoring as a means to address the disparities in morbidity andmortality attributable to asthma and other lung diseases among minority and poorpopulations.– The program was provided at a Christian Health Clinic, Grace Medical Home, inOrlando, FL. Portland 2012– AAE partnered with Josiah Hill Clinic, Healthy Homes Coalition and the AmericanLung Association of the Mountain Pacific to offer a free asthma educationalsession to low-income women in the Portland/NW region who are impacted byasthma.– The title of the program was “Everyone Needs to Take a Breath!” We focused onasthma self-management, challenges and solutions.– The program was provided at Highland Christian Center, in Portland, OR.

Important Barrier in the Field ofAsthma Education – Reimbursement There are CPT billing codes Unlike diabetes, there is not comprehensive nationalreimbursement of asthmaeducationReimbursement is state-by-statePrograms need to go to payerswithin the state and educate themon what program proposes to doSuccesses include MaineHealth &Minnesota Health CareMore policy work /aade/ resources/pdf/Reimbursement Tips 2009.pdfhttp://www.mmc.org/workfiles/mh 09.pdf

THE ROLE OF ASTHMA EDUCATORS INASTHMA EDUCATION AND MANAGEMENTEllen O'Kelley, PNP-BC, AE-CAssociation of Asthma Educatorsellen.okelley@Vanderbilt.Edu(615) 343-7617

What is an Asthma Educator?Simply stated, the educator/counselor is one who hasin-depth evidence-based knowledge of asthma and itsmanagement and is able to impart this knowledge topatients in an effective manner that results in theability of the patient to adequately manage his/herasthma.

Who are Asthma Educators? NursesRespiratory therapistsNurse practitionersPhysician assistantsPhysiciansPharmacistsCase managersSocial workersHealth educatorsCommunity health workersSchool and allied healthprofessionals

Settings Where Asthma Education CanTake Place‘EPR-3: Asthma self-managementeducation is essential to providepatients with the skills necessary tocontrol asthma and improveoutcomes (EvidenceA). Asthma educatorsNursesAdvanced practice nursesRespiratory therapistsPharmacistsPhysiciansPhysician AssistantsAllied health professionalsPublic/community healthprofessionals Health educators School health professionals Social workers

How is Asthma Education Beneficial?Meta-Analysis of 37 studies27 compared asthma education interventions with ‘usual care’Findings: Asthma education was associated with statisticallysignificant decreases in mean hospitalizations and emergencydepartment (ED) visits. Trend toward lower odds of ED visits Asthma education did not affect odds of admissions or meannumber of urgent doctor visits10 compared different types of asthma education interventionsFindings: Results suggest that providing more sessions and moreopportunities for interactive learning may produce betteroutcomes.Effects of Asthma Education on Children’s Use of Acute Care Servies: A Meta-analysis.Coffman, JM, et al. Pediatrics:2008;121;575-586.

How to Perform Asthma EducationResearchers used a chronic care model and invited 23 patientswith asthma 13 – 80 years old to describe their asthma-relatedmedical experiences and their opinion on five leaflets aboutasthma medications.They found that slightly over half the patients felt that theinformation given to them by their healthcare provider wasunclear or confusing or not what they wanted.The investigators concluded that patients prefer‘personal contacts’ rather than ‘written sources’.Patients with chronic asthma found medicine information to be unclear or confusing, did not receive complete information on medicine use and sideeffects, and found leaflets to be unhelpful. Evidence Based Nursing:2005;8;28

Components of Asthma EducationThat Promote Self-Management Pathophysiology Asthma Action Plan Medications Triggers Device use & technique Medication use outside thehome Asthma attacks Address adherence Co-morbidities Teach children as they getolderAND THE LIST GOES ON!

Certified Asthma Educator (AE-C)National Asthma Educator Certification Board (NAECB) Separate from the Association of Asthma Educators(www.NAECB.com) Certification period is for 7 years May use the designation ‘AE-C’ Eligibility: Licensed/credentialed health care professionalsOR individuals providing direct patient asthma educationwith a minimum of 1,000 hours experience in theseactivities.

Advantages of Becoming a CertifiedAsthma Educator‘Demonstrates that rigorous education andexperience requirements have been met’ (NAECB)Reimbursement may be contingent on becoming acertified asthma educatorMay lead to increased pay and recognition in theworkplace

Certification ExamConsidered by many to be a difficult exam.Ways to improve success Self-assessment examination – NAECB National Asthma Educator Certification andRecertification Review Course (live or on DVD) – AAE(www.asthmaeducators.org) Coming soon! Review course designed especially forcommunity health workers – AAE

Professional Challenges Experienced Subspecialty in an academic clinic Primary focus: management of children with moderateto-severe persistent asthma Incorporating NHLBI guidelines into practice affectspatient flow Developing an asthma program is time-consuming

Insights from the Head-offEnvironmental Asthma in Louisiana(HEAL), Phase II ProjectKristi Isaac Rapp, PharmD, AE-C, BCACPPrincipal Investigator, HEAL Phase II ProjectClinical Associate ProfessorXavier University of LouisianaCollege of Pharmacykrapp1@xula.edu(504) 520-5349

Asthma Prevalence in Post-KatrinaGreater New Orleans AreaBy ParishOrleans12.8%– 6,041 children have asthma– 19,754 adults have asthmaSt. Bernard 12.7%St. Tammany 10.7%Plaquemines 10.4%Jefferson9.9%Louisiana Department of Health and Hospitals, Asthma Management andPrevention Program, Louisiana Asthma Prevalence by Parish, 2008.

HEAL, Phase II OverviewGoals & ComponentsAsthma Education Builds upon the lessonslearned from HEAL I. Implement a multicomponent pediatric asthmacare project in the greaterNew Orleans area. Identify and sustain aspectsof HEAL, Phase II, associatedwith positive asthmaoutcomes.Electronic Health SystemHealthcare Provider TrainingCommunity Outreach

Collaboration Key to HEAL, Phase II SuccessXavier UniversityCollege of PharmacyCenter for Minority Healthand Health DisparitiesResearch and EducationChildren’sHealth FundPediatricMobile Unit(CHF)Daughters ofCharityHealthCenters(DCHC)Merck Childhood AsthmaNetwork, Inc. (MCAN)

Moving Towards ImplementationPlanning PeriodPilot TestingInstitutionalizationof Enhancements Building trust between collaboratorsCollecting informationAssessing workflowsAnalyzing benefits and identifying enhancements Training of StaffImplementationOngoing meetingsProposed refinements Finalized enhancements Ongoing testing Monitoring patient care outcomes

Clinic WorkflowMedical Assistant- Asthma Control Test (ACT)/Childhood Asthma Control Test (C-ACT)- Peak flow reading and predicted peak flowPhysician- Reviews and totals ACT/C-ACT score- Determines level of severity or control- Completes Asthma Action Plan and ASIAsthma Educator (AE-C)- Asthma Education Inventory- Child Asthma Risk Assessment Tool (CARAT),- Asthma Belief Scale- Caregiver/Patient Satisfaction Surveys- 2 weeks follow-up calls following clinic- 6 and 12 month follow-up

HEAL, Phase II Closing the Gapin Asthma Care- Diagnoses level ofseverity and planscare- Comprehensiveasthma care- Trained on EPR-3asthma guidelines- Comprehensiveand tailoredasthma education- Follow-up onreducing asthmasymptoms- Follow-up at 6 and12 months- Reduced asthmalevel of control- Reduced schoolabsenteeism- Reducedemergency roomvisits andhospitalizations

Baseline & Follow-up Data (n 89)Baseline0%20%6-month follow-up40%60%63%Uncontrolled asthma*36%Symptom days in the past4 weeks80%70%30%School absenteeism20%43%OCS burst*22%53%SABA use39%42%ER visit*Hospitalization80%22%11%8%*2-sample test of equal proportions (p-value 0.05)100%

Addressing Implementation ChallengesHealth SystemIntegration Endorsement by medical director Prompting healthcare provider ondocumentation Implementation of incentives for clinicalpersonnelFollow-up Implementation of incentives for 6- and12-month follow-up Distribution of follow-up calling list topartners Mailing letter to hard-to-reach patients

Asthma Educators: Bridging theGap in Community Health CareDenise Woodall-Ruff, M.D.PediatricianDaughters of Charity Services of New OrleansDenise.Woodall-Ruff@dcsno.org(504) 207-3060, Ext. 2250

Adherence to Guidelines The National Heart, Lung, and Blood Institute (NHLBI)recommends that all patients with asthma receiveeducation.Without appropriate self-management and asthmaeducation, physician recommendations are less likely to beeffective.For years, studies have shown that primary care providers’adherence to NHLBI asthma management guidelines ispoor.

Adherence to Guidelines Significant gaps exist between evidence-basedguidelines and everyday primary care practice.Possible explanations: Limited time during a typical office visitIncrease in scope of services expected from the provider

Asthma Educators Promote BestCare Practices Asthma educators (AE) help to fill in the gapbetween evidence-based guidelines and “real-life”practice.AE provide the opportunity for routinedissemination of education to all asthma patients.

Asthma Educators Promote BestCare Practices Asthma educators can uncover importanthistorical information that otherwise getsmissed in a limited office visit. Medicationadherence issues Environmental triggers Asthma action plan counseling

Life “Before” the Asthma Educator Patient scheduled for a 15-minute office visitMedical history and physical examConsideration of maintenance medicationsdependent on history and symptomsAsthma action plan written or previous onereviewedVisit ends with educational instructions providedby a medical assistant

Life “After” the Asthma EducatorAFTERBEFORE Patient scheduledfor a 15-minuteoffice visitMedical history andphysical exam Asthma control testgiven prior to providerwalking in roomAsthma educator mayvisit with establishedpatient prior toprovider encounter

Life “After” the Asthma EducatorAFTERBEFORE Consideration ofmaintenancemedicationsdependent on historyand symptoms.Asthma action plan(AAP) written orprevious onereviewed Maintenancemedications prescribedaccording to evidencebased guidelines(stepwise approachchart, ACT score, etc.) Asthma action planwritten or reprinted forpatient, then reviewedby asthma educator.

Life “After” the Asthma EducatorAFTERBEFORE Visit ends witheducationalmaterials providedby a medicalassistant Visit ends with educationalmaterial provided by anasthma educator.Review of any newmedications prescribedDemonstration of inhalermedication techniquesReassurance that add’lasthma educationquestions are answered bya trained asthmaprofessional.

Asthma Educators: Bridging theGaps Primary care providers face challenges foradherence to evidence-based guidelines forasthma managementAsthma educators are instrumental in assistingproviders to follow recommended practiceguidelinesAsthma educators can be effectively integratedinto a community health care setting to make asignificant difference in the standard of care forall asthma patients

Q&AIf your question is not answered during the Q&Asession, please direct it to individual presenter: Dr. Floyd Malveaux: floyd malveaux@merck.com Chanda Holsey: cholsey@HALOforFamilies.org Ellen O’Kelley: ellen.okelley@Vanderbilt.Edu Kristi Rapp: krapp1@xula.edu Dr. Denise Woodall-Ruff: Denise.WoodallRuff@dcsno.org

Childhood Asthma is Challenging on Many Levels – Asthma Educators Can Help Asthma is the most common chronic condition among children 55% had at least one asthma attack in the previous ye

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