Asthma Education In The Office Setting

1. Asthma Education In The Office Setting Mary Bouthiette RN, AE-C Dartmouth Hitchcock Manchester Updated March 2011

2. Disclosure • Mary Bouthiette RN, AE-C has no financial interest in any commercial entity discussed in this presentation. • Mary Bouthiette RN, AE-C will not discuss experimental or off label use of medications or devices

3. The 4 Components of Asthma Management • Component 1: Assessing and Monitoring Asthma Severity and Asthma Control • Component 2: Education for a Partnership in Asthma Care • Component 3: Control of Environmental Factors and Comorbid Conditions That Affect Asthma • Component 4: Medications

4. 4 Common Mistakes in Asthma Education • Using the same teaching techniques with every patient • Trying to teach too much information during the appointment • Failing to involve patients, parents and/or children • Not Including interpreters if available Tracie Hardin MPH, AE-C Talking About Asthma AAE

5. Most Difficult Concept to Convey to Patients • Taking controller medications EVERY DAY! • Asthma is treatable and regular ER visits are not just a part of having asthma • Asthma can be a life threatening condition • Asthma is chronic and not episodic Talking About Asthma, Fall 2009

6. Education Approaches Require Patients To: • Effectively carry out complex medication regimens • Institute environmental control strategies • Communicate appropriately with health care providers • Detect and self treat most asthma exacerbations American Lung Association

7. Importance of Patient Education • Mechanism through which patients and parents learn to effectively self manage their asthma • Powerful tool for helping patients gain the motivation, skill and confidence to control their asthma

9. Turning Education into Action For someone to effectively manage their asthma they need to:

10. Benefits of Self-Management Skills • Reduction of urgent care visits and hospitalizations • Reduction of asthma-related health care costs • Improvement in health status and asthma control

11. Opportunities for Education • ED/Hospital Based Education • Clinic/Office Based • Pharmacists • School Setting • Computer Based

12. 3 Main Learning Styles • Visual learners • Auditory learners • Active learners

13. Visual Learners • Gather information best by looking reading and watching • May favor illustrated explanations or charts • May take notes

14. Auditory Learners • Learn well by discussing ideas • May learn better being read written information out loud • Are easily distracted by noises

15. Active Learners • Learn effectively through touch, movement and space • Learn skills by imitation and practice

16. People Learn Best if TheySee, Hear and Do • Verbal explanations with demonstration • Use examples and analogies • Provide written materials in basic language • Ask for return demonstration

17. People Learn Best if TheySee, Hear, and Do • Ask questions and listen • Encourage questions and test their understanding • End with “What else can I answer for you?” • Repeat key concepts in asthma education at each visit to reinforce asthma management skills

18. Selecting Patient Education Materials Must Be • From a reliable source • Accurate • Current • Written at the appropriate education level • Evaluated before you use them for teaching

19. Barriers to Learning and Adherence • Conflicting information • Uncomfortable environment • Uniformed instructor • Attitude of instructor • Previous negative experiences with learning • Education level • Understanding level: material is inappropriate or too complex • Reading comprehension • Hearing/Visual impairment • Language - English is a second language • Too much information at one time

20. Key Educational Messages • Understand basic facts about asthma • Define well controlled asthma and current level of control • Recognize the roles of medications • Assess patient skills

21. Key Educational Messages • Identify when and how to handle signs and symptoms of worsening asthma • Recognize when and where to seek care • Identify environmental exposure control measures

22. Understand Basic Facts About Asthma • What is asthma? • The role of inflammation • What happens during an attack? • Early warning signs and symptoms • Exercise and asthma

23. Roles of Medications • How medication works • Controller vs. quick relief-understanding the difference • Importance of long-term controller medications EVERY DAY!

24. Inhaled Corticosteroids • Most effective long term control therapy for persistent asthma • Prevent symptoms by reducing inflammation • Must be taken daily • Risk of side effects are minimal

25. Quick Relief Medications • SABA’s relax airway muscles to provide prompt relief of symptoms • Patient’s taking SABA’s > 2 days per week are not well controlled • Patient’s should be instructed to restart or to increase their long term control medication

26. Propellant Changes“CFC to “HFA” • Chlorofluorocarbon (CFC) – chemical that damages the ozone layer of the earth • “Out-lawed” by Montreal Protocol in December 2008 • Generic HFA’s won’t be available until 2012 • Hydrofluoroalkane (HFA) - an earth-friendly alternative • Different spray force, taste and mouth-feel (warmer) • More costly (~$20 more that CFC generic beta-agonist) • More care of spray spout, more priming necessary

27. HFA MDIFeatures • Spray plume is composed of smaller droplets, less forceful and warmer • Eliminates ozone depleting MDI impact • Priming required- guidelines differ markedly by product • Operationally similar to CFC MDI’s • Weekly mouthpiece cleaning required

29. HFA Priming Instructions • Proair N, 14d/3 sprays • Proventil N, 14d/4 sprays • Ventolin N, 14d/4 sprays • Xopenex N, 3d or if dropped/4 sprays • Flovent N, 7d or if dropped/4 sprays • Advair N, 28d or if dropped/2 sprays • Symbicort N, 7d or if dropped/2 sprays Talking About Asthma , Fall 2007

30. HFA Canister & Water • Do not expose canister to water • Do not use “float test” to determine how much medication remains in the individual canister • Contact of the medication with water may obstruct canister outlet

31. Patient Skills • Taking medications correctly • Inhaler technique-You can NOT take a deep breath in if you are already full! • Use of devices as prescribed such as valved holding chamber, spacer and/or nebulizer • The numerous device options available should be viewed as opportunities for individualizing patient care and education Journal of Asthma & Allergy Educators August 2010

32. Respiratory Inhaler Chart

33. Patients Need Help Distinguishing Medications • Which of these inhalers do you have • Which one do you take daily • Which do you take when you are problems with your asthma • Which one prevents future asthma problems • What is the name of your ICS? • Do you use a Valved Holding Chamber with your MDI’s

34. Environmental Exposure • Identification, avoidance and control of environmental triggers at home, school and work • Recommend measures to control asthma triggers • Allergy skin testing may be necessary to identify individual triggers • Secondhand smoke exposure is linked to > asthma symptoms, < lung function and greater use of health services among those who have asthma

35. Asthma Education • Asthma self-management education is essential to provide patients with skills necessary to control asthma and improve outcomes • Begin at the time of diagnosis and continue through follow-up care • Involve all members of the health care team

36. Self Monitoring • Monitor symptoms and peak flow • Assess level of asthma control • Recognize early signs and symptoms of worsening asthma • Seeking medical care as appropriate

37. Self Management Education • Improves patient outcomes such as reduced ER/hospitalizations, limitations on activities, improved health status, quality of life and asthma control • Is cost effective • Encourages self-reliance-patient knows what to do

38. Written AAP • Take daily actions to control asthma • Adjust medication in response to worsening asthma • Provides patients/families with an easy reference for remembering how to manage their asthma • Seek medical care as appropriate • Must be updated periodically

39. Written AAP • Should be reviewed and adjusted at each follow up visit • Personal Best Peak Flow’s must be refigured with children periodically • For children a copy of the plan should be given to each caregiver, to school and daycare.

40. Encourage Patient’sAdherence to AAP • Choosing treatment that achieves outcomes and addresses preferences that are important to the patient • Reviewing at each visit the success of the treatment plan • Reviewing patient’s concerns • Encouraging family involvement • Tailoring the self-management approach to literacy level of patient

41. What is an AE-C? • An expert in teaching, educating and counseling individuals with asthma and their families in the knowledge and skills necessary to minimize the impact of asthma on their quality of life.

42. NAECB Exam • A National Exam Certification for Certified Asthma Educators • Voluntary testing program, used to assess qualified health professionals knowledge of asthma • 125 AE-C’s in Massachusetts • 25 AE-C’s in NH • 33 AE-C’s in Maine • 55 AE-C’s in Connecticut

43. CPT Codes • 98960-Education and training for patient self-management by a qualified , non-physician healthcare professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes, individual patient • 98961- 2 to 4 patients • 98962- 5 to 8 patients Alliancetechmedical.com NAECB

44. CPT Codes • Nurse Visit Charge-99211 • Peak Flow Meters-A4614 • Valved Holding Chambers-A4627 • Spirometry-94060 Alliancetechmedical.com

45. If You Could Only Do 4Things • Ask how much albuterol are you using • Ask what makes you cough or wheeze • Test lung function with spirometry • Schedule planned visits

46. THANK-YOUANY QUESTIONS? mebouth@comcast.net

47. Asthma Education Resources • www.breatherville.org • www.aaaai.org • www.asthmaeducators.org • www.aafa.org • www.nhlbi.nih.gov • www.Acaai.Org • www.lungusa.org