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: Program Components

There are five readily distinguishable components to this program:

1. redesign asthma clinical care from an acute to a chronic care approach
2. risk stratification
3. clinical care management
4. social care coordination by a community health worker
5. team training, coaching, and championing the program

A brief description of each of these five components follows.

1. Redesign Asthma Clinical Care From an Acute to a Chronic Care Approach

Conduct a preventative-based asthma clinic with planned visits.
All too often, asthma care is geared to respond to patients who are either at the threshold of an asthma episode or actually having an episode. Care follows a scenario of treating patients to get over the crisis and back to normal, and then releasing them. This approach assumes asthma to be an acute illness. In contrast, YES WE CAN clinical care is organized to address the chronic nature of asthma. The emphasis is on preventing asthma episodes and controlling asthma day-to-day. This reordering of traditional clinical care for asthma includes:

1. implementing an asthma cluster clinic care model
2. sequencing a care pathway of planned clinic visits, home visits, and follow-up clinical assessment phone calls
3. frequently reassessing asthma symptom control
4. assuring a written Asthma Action Plan for all children
5. having an “Asthma Depot” for all supplies and devices
6. making tools available such as a database, posters, materials with embedded National Asthma Education and Prevention Program (NAEPP) guidelines to cue providers during clinical encounters.

The asthma clinic is a time-efficient, patient-focused, prevention-based operation. It is relatively simple to implement, and is aligned with the NAEPP asthma guidelines. The template is a “cluster” clinic model consisting of coordinated, back-to-back planned appointments during a specified block of time with the asthma staff and equipment on hand. Scheduled patients may be there for the first time, or for return visits. The cluster clinic provides an opportunity to do an in-depth assessment or follow up, to diagnose asthma and establish the patient’s severity, to identify the patient’s allergies and other triggers, and to formulate or re-evaluate the best clinical management. The child and the family receive education from all three members of the asthma team, each time presented in slightly different form and tailored to the family’s educational needs.

A child with unstable asthma and, frequently, complicating social factors enters the YES WE CAN program generally as a referral from an ED, hospital, or the primary care physician. Over the next several months the child and caregiver will likely make three planned visits to the asthma clinic and have anywhere from one-to-three planned home visits by a CHW. A series of clinical assessment phone calls from the clinical case manager to the child’s caregiver are interspersed with these clinic and in-home interventions. During these calls, the child’s level of asthma control is discussed, and the caregiver is provided help to improve control as needed.

2. Risk Stratification-A Case Management Tool for Establishing Levels of Care

The job of the asthma team would be made easier if all enrolled children needed the same level of care. However, uniformity in pediatric asthma care is not practical or realistic. Population management requires stratifying or sorting the children with asthma into distinct subpopulations according to their risk level. Each of these subpopulations has different care needs and requires a different intensity of care. Children and families at low risk need fewer, less intensive services to achieve good asthma control and master asthma self-management skills. Children at higher risk require more intensive services. Population management enables the asthma team to direct the use of resources in a way that will result in the greatest improvement in asthma control for the population as a whole.

Medical criteria alone (hospital admissions, ED visits, and beta agonist use) are not sufficient to identify families in need of higher levels of care to stabilize their child’s asthma. Social and psychological issues also coincide with significantly higher risk of poorly controlled asthma. Low-income families are confronted with some social barriers and psychological challenges that make managing their child’s asthma more difficult.

The YES WE CAN risk stratification model can be illustrated graphically as a pyramid sliced into four sections depicting how a pediatric asthma population can be sorted into four risk levels, with each related to a level of service. The base of the pyramid, Level 1, represents the largest percentage of children: children with asthma that is generally under control. Level 2 indicates children who need basic case management. Children in Level 3 require moderate case management, and children in level 4 require intensive case management. This sorting of cases is used for planning care and for thinking through types and levels of interventions.

The goal is to target those children and families that are most in need of services such as home visits and close clinical care management. Families that fall into levels 2 and 3 of the risk stratification pyramid benefit most from these resource-intense interventions.

3. Clinical Care Management

Clinical case management involves coordinating care and interventions to optimize quality patient care, improve continuity of care, and ensure there are no gaps in services and no duplication of services. The clinical case manager coordinates the three components of clinical case management.

a. Case finding and case management
The clinical case manager coordinates the review, screening, and processing of referrals to the program, and tracks families through the care path. The clinical case manager calls the family when they do not follow up on a referral to the clinic, ensures the child is enrolled in the program, and is responsible for case-management of high-risk children in the program. The clinical case manager coordinates the asthma team and the clinic activities including preparation, logistics, patient flow, consultations, referrals, and follow-up appointments, and performs individual patient procedures, treatments, and tests. In addition, the clinical case manager works with the clinician to monitor asthma control and adjust medications.

b. Asthma self-management education
The clinical case manager provides family education on asthma and asthma self-management including trigger identification and trigger avoidance measures, appropriate use and understanding of medications (actions, side effects, dosage and sequencing), and self-monitoring. Assessing technique and refining skills in the use of the peak flow meter, the metered dose inhaler (MDI), and spacer are other responsibilities.

The educational protocols are based primarily on Pediatric Asthma: Promoting Best Practice-Guide for Managing Asthma in Children, 2002. The Guide was developed by the American Academy of Allergy, Asthma and Immunology in collaboration with the American Academy of Pediatrics, the National Heart, Lung, and Blood Institute and the NAEPP. The guide is based on and is consistent with the Expert Panel Report 2 (EPR-2): Guidelines for the Diagnosis and Management of Asthma, published by NAEPP in 1997.

c. Team coordination
The clinical case manager maintains communication with departments, hospitals, and community organizations and agencies to ensure referral systems are working to promote continuity of care and to ensure procedures and systems function smoothly. The clinical case manager also consults with the patient’s primary care providers to provide regular updates on the status of their patients.

4. Social Care Coordination by a Community Health Worker

Community healthcare workers (CHWs) are professionally educated, trained, and certified men and women who come from the communities of the families being served and are fluent in the family’s primary language. CHWs aid families in assessing their needs and strengths by helping them to identify problems and barriers to optimum asthma self-care. CHWs provide educational information to the families and assist them with environmental remediation during home visits. CHWs also conduct social assessments with primary caregivers to discover any problems that might keep the family from concentrating on their child’s asthma. Families in San Francisco living in old housing often experience excessive mold and mildew. CHWs have advocated on behalf of families with their landlords (often the public housing authority) to make roof repairs, replace windows, and clean, caulk, and paint mold-affected areas. In some circumstances, CHWs have assisted families in acquiring more suitable housing. CHWs help families acquire insurance coverage, and they resolve transportation and school issues that affect asthma management. CHWs refer caregivers to social services or to a social worker when the family’s specific social needs extend beyond the CHW’s capacity. CHWs inform the clinic how well the child is complying with the medication regimen and provide an additional resource in the clinic for family orientation, asthma education, and scheduling.

5. Championing, Coaching, and Training

The clinician is first and foremost a champion for the program, a strong advocate within the community and is the leader of the asthma team. As program champion, the clinician makes presentations in the community to improve understanding and to gain support for the program. Strong advocacy translates not only to program buy-in, but it can also result in obtaining volunteer help, donations of equipment, furnishings, and asthma prevention materials needed to launch and sustain the program.

Start-up activities are the responsibility of the clinician. A dry run of the clinic process ensures that each member of the asthma team understands the individual protocols and can perform their assigned tasks efficiently and effectively. The dry run includes a review of the use of the equipment, the medical forms, the registry, use of available facilities, and the asthma-education lessons. It also includes handling patient concerns, especially on the first visit. Special attention is given to incorporating the CHW into the clinical team.