Comprehensive Improvement of Asthma Population Management at ILH

1. Comprehensive Improvement of Asthma Population Management at ILH Nereida A. Parada, MD FCCP FAAAAI Tulane Asthma Lead Clinical Associate Professor of Medicine TUSM Debra Brown FNP, DNB On behalf of the Asthma Team: N Parada T-Lead, R Tejedor L-Lead, L Williams, S O’Rourke, J Burke

2. Asthma Care • Components of Asthma Care • Improvement of Asthma Measures at ILH • Approach • Results • Focus on core values: Teaching, Research, Resources, Access, Quality, Service Reference: NIH: NHLBI-National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3: Guidelines for the Diagnosis and Management if Asthma. NIH Publication No. 08-4051. Accessed via www.nhlbi.nih.gov/guidelines/asthma/asthmagdln

3. Four Key Components of Asthma Care Assessment and monitoring Pharmacologic therapy Control of factors contributing to asthma severity Patient education for a partnership

4. Objective • To improve asthma measures and outcomes by addressing all components of care at all sites of asthma care

5. Objective • We sought to: • Increase competence and knowledge of providers • Enhance confidence of providers with in-services and “hands-on learning” • Increase patient’s self-efficacy and skills via education using a “friendlier” asthma guide and asthma action plan • Increase effectiveness of partnerships, between providers and patients, educators and patients, and asthma team and providers

6. Methods • Standardized providers education • Web in-service learning with evidence grade and rationale for each measure • Updated and created easy to use tools to facilitate guideline treatment options and completion of asthma action plan • Created a friendlier and improved asthma action plan (WAAP)- after IRB research findings • Updated patient education handout created in 2004 • Streamlined Allergy Testing (LSU Asthma Panel) • Expanded scope to include education in ED and Hospital

7. Provider Education and Tools • WILMA • Blue Card • Asthma Action Plan overhaul - Based on research • How to Fill an Asthma Action Plan • ACT

8. WILMA (Web In-service Learning) Program Goals LSU Asthma Care Indicators All asthma patients should have indicators addressed as above. A comprehensive approach is needed to control asthma. Individual guidelines-driven rationale for each indicator will be provided in the next slides with the existing evidence grade (A, B, C, or D) as applicable.

9. Four Key Components of Asthma Care • Assessment and monitoring • Severity classification • Impairment Evidence grade B • Risk Evidence grade C • Spirometry • Diagnosis Evidence grade C • Follow-up Evidence grade D • Assess control • Tool:Asthma Control test (ACT) Evidence grade A • Pharmacologic therapy • SABA most effective reliever Evidence grade A • ICS (most effective long-term controller) Evidence grade A • Smoking, exposure assessment Once (more, if smoker) • Control of factors contributing to asthma severity • Allergy testing Evidence grade A • Immunizations Flu, Pneumococcus High Risk population CDC • Patient education for a partnership • Written Asthma Action Plan (WAAP) Evidence grade B

10. 2007 Severity Assessment Guidelines

11. 2007 Treatment Guidelines

12. Blue Card (pocket size) 2004 2010

13. A multidisciplinary educational effort system-wide has been implemented to improve WAAP adherence to the asthma guidelines, specifically in the yellow and red zones. Quality of Asthma Action Plans 2010 ATS

14. WAAP Improvements Removed * Removed

15. How to Write an Asthma Action Plan

16. Patient Education • Updated 2004 version • Adding information about asthma control, where to obtain allergen barriers • Input from Ecoee Rooney RN and Julie Ahrend RN to make it more patient friendly • Used for clinic, ED and hospital patients

17. Patient Education • Guide to Asthma Care 2004 2010 1st one in system

18. Asthma Control Test (ACT) Activity limitation Symptoms Waking up at night Bronchodilator use Controlled? Score Interpretation 20-25 Well Controlled 16-19 Not Well Controlled < 16 Poorly Controlled 1st one in system to use Nathan RA et al, Development of the Asthma Control Test: A Survey for Assessing Asthma Control. JACI 2004;113:59-65

19. In Vitro Allergy Assay 29 Allergen panel RAST $117 (70% discount) $56 $28 2010

20. ED and Hospital Education • Number of patients educated from January 2011 to November 2011 = 457 • About 30-40 patient per month in the ED and Hospital setting • Over 660 patients educated in clinics and group classes since January 2007

21. MCL/ILH – Asthma Indicators

22. WAAP CLINICS

23. Allergy Test

24. Inpatient Asthma Admission Rate Our inpatient admission rate among asthma patients has recently declined and is now at about 0.1 admission per person-year. This is not that different from the admission rate among our non-chronic disease patient population.

25. 30 day ED Revisit The 30-day ED revisit rate among PC asthma patients has been slowly dropping and is now about 27%. That is similar to the overall ED revisit rate (all PC patients) of about 23%.

26. Co-Morbid Asthma ATS 2011

27. Special Thanks • Julie Morial MD, MPH • Cassandra Youmans MD,MPH, MS-HCM, FAAP, FACP • Ecoee Rooney RN • Julie Ahrend RN

28. Summary • All asthma measures have improved significantly since implementation of standardization of provider and patient education and creation of easy to use tools to facilitate patient care • These improvements are seen at all different sites of patient care: medical homes and resident and fellow teaching clinics from 2 medical schools (LSU and Tulane).