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: Lessons Learned
Not all families need home visits.
In the initial YES WE CAN demonstration program, all families were required to accept home visits. Experience made it clear, however, that not all families benefited from home visits. There was not always a need for social help, improvements in environmental controls, or asthma self-management reinforcement. Also, some families who agreed to have home visits did not follow through to complete all their visits. The conclusion reached was that home visits were not always the best use of the CHW’s time. As a result, families are no longer required to accept home visits to be enrolled in the program.
CHWs conduct asthma education in the clinic.
YES WE CAN has always preferred to conduct patient and family asthma educational activities at the point of care. In the initial demonstration project, the clinical case manager conducted the family educational program during the clinic visits. The CHW’s job was to reinforce in the home the learning gained at the clinic. Experience showed that involving the CHWs more with the families early on in the clinic improved the asthma team’s rapport with the family and better prepared the family to later receive the CHW in the home. Having the CHW deliver the initial asthma care instruction in the clinic also freed up the clinical case manager’s time for other tasks. Now CHWs routinely conduct the education program. This program change has also strengthened the "team" concept of asthma care.
Smooth resupply of asthma prevention supplies is essential.
In the early days of the project, acquiring asthma-prevention supplies (spacers, peak flow meters, mattress and pillow covers) was difficult and haphazard. Although these items were always available to the YES WE CAN clinic, there was no system in place for routinely transporting them from the provider to the clinic. Often, a CHW would have travel across town at the last minute to pick up supplies for the clinic. Now, the asthma prevention supplies are gathered up each month by a delivery service from the Medi-Cal managed care plan provider and delivered to the clinics on a regular schedule.
Improved caseload management is needed.
Inadequate tracking and monitoring of patients caused inefficiencies in the program and resulted in diminished effectiveness and unnecessary costs. Some children did not complete their asthma treatment program and were lost to the program. Some children who completed the program kept coming back to the clinic for asthma care, instead of returning to their primary care provider at the conclusion of the intensive intervention. Others made too many unnecessary visits while in the program. Better monitoring of progress along the care pathway was needed. The introduction of the asthma registry patient database and improvements in caseload monitoring helped solve these problems. Enrolled children are no longer dropping off the care pathway and becoming lost to the program. Improved caseload monitoring helps control the number of visits a child may have and aids in transitioning families back to their primary care provider.
Written protocols are essential.
In the beginning of the demonstration project, the clinical and home visit protocols lacked the necessary detail to ensure consistency, reliability, and repeatability. Further, without the written descriptions of each asthma team member’s duties and responsibilities, the explanation of how the medical/ social model of care operates, knowledge of the protocols, and how to apply risk in assigning care, the probability of YES WE CAN being successfully replicated anywhere else was greatly reduced. Between 2001 and 2003 Community Health Works and KP/NC staff members worked tirelessly to systematize the processes and supply supporting instruction, along with checklists and job aids to guide the processes. The protocols are all now codified into three manuals called the YES WE CAN Toolkit.
An oversight committee for management and decision-making is beneficial.
In the planning phase of the project, it is a good idea to put in place an interdisciplinary oversight group that can act as a steering committee for the program. Members of the group should be the organizational decision makers. The oversight group will likely be comprised of leaders from the founding organizations and leaders representing stakeholders in the community. The primary founding organization for the asthma program also needs strong leadership support from its own top management.
Grants are necessary but not sufficient.
Grants are good sources of funding to launch a community-based asthma program; however, it is not wise to rely on grant money to fund the long-term operation of the program. Other more sustainable funds are needed so that the program is not dependent on any single funding source for survival.
Primary care support is critical.
For the program to be successful, it must have buy-in from the primary care providers in the area and other medical groups who will provide patient referrals. Program directors and asthma champions pioneering this program in new areas will have to make program presentations in the community and look for opportunities to seek buy-in from these groups of medical professionals.
Patience is needed.
It is likely that a new program will not run smoothly as soon as it starts, but with lots of work, a clinic can be up and running in 90 days. It may take 6 months to be fully functional and efficient (considering staffing and training, setting up facilities and a patient registry, establishing protocols and learning the asthma-education routines, and obtaining equipment and supplies including computers, cell phones, telephones, desks, and bookshelves).
Start with a dry run of the asthma clinic.
It can be helpful to carry out a dry run or a mini-drill of the clinic and to think through, and then actually walk through, the entire process from start to finish. Such practice helps assure that everyone knows and understands the protocols to follow, and how and why they fit together. It may be prudent to conduct a dry run for the clinic more than once.
Cohesion of the asthma team is a critical element.
Mutual respect among all the asthma team members is an essential requirement for success of the program. In the triumvirate that comprises the team, two of its members, the clinician and the clinical case manager, are recognized health professionals. The CHWs’ education and work experience is dissimilar. There may be a tendency among the medically trained team members to interact differently with the CHW than with each other. The CHWs must be fully integrated into the team if the team is to have strength and function smoothly. The program will need strong supervision and time for the team to gel and integrate the CHW into the clinical setting.