Astma

ASTHMA INITIATIVES

The number of people in the United States with asthma has doubled in the past 15 years to an estimated 15 million. African-American, low-income residents in Chicago, a population served by the Cook County Bureau of Health Services, are among the heaviest affected by asthma in the nation.

ASTHMA SPECIALTY CENTERS

In May 2001, the Cook County Bureau of Health Services’ Asthma Task Force developed the Asthma Champion Initiative. As a part of this initiative, two Asthma Specialty Centers were created, on the west and south sides of the city at Fantus Health Center, 621 S. Winchester Avenue and Provident Hospital of Cook County, 500 E. 5lst Street, respectively. These clinics offer complete education, diagnostic testing, medication and education to all adults and children of Cook County regardless of their ability to pay.

ASTHMA CHAMPIONS

The Asthma Champion Initiative also provides for the Asthma Task Force to train primary care physicians at the Bureau’s community health centers. To date, 25 primary care teams (typically comprised of a physician and nurse) have completed or are currently enrolled in an intensive, four-month clinical rotation in the Asthma Specialty Centers.
The teams are mentored by pulmonologists, allergists and asthma nurses. Over time, the champions made a real contribution to managing the high volume of asthmatics in the Specialty Centers.

RESEARCH

The Bureau’s Asthma Task Force is also active in the National Center of Excellence to reduce Asthma Disparities. The purpose of this project is to develop a collaborative research program between Northwestern University Feinberg School of Medicine and the Stroger Hospital of Cook County to fully characterize the relationship of social stress, coping and self-regulatory health behaviors in the context of asthma disparities among African-American and low-income populations. Once characterized, the project will then develop and test an intervention strategy to reduce asthma disparities in high-risk populations based on evidence-based models that have demonstrated success in social working, nursing and community interventions. The project was funded by the National Institute of Health from 2002-2007.

Statement of the Problem or Issue

Asthma is a chronic disease and has become a public health epidemic. The number of people in the U.S. with asthma has doubled in the past 15 years to an estimated 15 million. Since the early 1980s, asthma morbidity and mortality have been increasing dramatically despite advances in medical technology and in the development of new pharmacologic agents for its treatment. Experts agree that most of the negative effects of asthma are preventable, however; recent data from the U.S. Public Health Services shows that this country falls far short of meetings its asthma goals. While that National Asthma Education and Prevention Program (NAEPP) established national guidelines for the diagnosis and management of asthma and revised and promoted them in 1998, many health centers, particularly the most stressed safety net providers, have real challenges with their implementation. Significant asthma disparities in prevalence, morbidity and mortality exist by race and socioeconomic status, with African American, low-income residents in Chicago bearing one of the heaviest asthma burdens in the nation.

Target Population
The target population for the initiative is the asthmatic patient population served by the Cook County Bureau of Health Services. More specifically, two of the Bureau’s three hospitals (John H. Stroger Jr. Hospital of Cook County and Provident Hospital) and their asthma specialty centers, and the network of over 30 ambulatory care sites and interested community health centers located in the most medically fragile areas of the County. The population is comprised of predominately uninsured and underinsured residents of Chicago and suburban Cook County.

Program Design
The ACI was designed to develop primary care teams to champion care improvements in asthma at their ambulatory sites. The team began by developing asthma specialty centers into high quality training centers. County ambulatory sites as well as federally funded community health centers with high asthma volume are invited to participate in the initiative. A partnership agreement is made with the sites to negotiate the amount of time required for teams to develop the clinical and quality improvement skills needed to become a “champion.” These teams, typically comprised of a physician and nurse, are enrolled in an intensive, four-month clinical rotation, spending one session per week seeing patients in the asthma clinic. Teams are mentored by pulmonologists, allergists and asthma nurses. Over time, the champions made a real contribution to managing the high volume of asthmatics in the specialty centers.

The teams also participate in a chronic care improvement collaborative, based on the model promoted by the Institute for HealthCare Improvement. The framework used is the Chronic Care Model, and a rapid cycle improvement process is taught and tested. Teams are supported by project faculty and staff in developing measurable objectives and mobilizing their health care centers to make system wide improvements to support asthma care consistent with the NAEPP guidelines. A contract with Northwestern University’s Center for Healthcare Studies was developed to analyze and present chart audit data for the participating sites to present at quarterly meetings of the collaborative. These meetings are used for continuing education on quality improvement processes, sharing strategies and outcomes, as well as peer support.

Program Impact and Outcomes
Clinical competencies were developed by faculty to ensure skills to enable providers to practice consistently with the NAEPP guidelines. The following clinical experience was typically sufficient to achieve the competencies. Nurse champions conduct nursing assessments, teach peak flow/MDI technique, review action plans, and medication instructions for 20 patients, as well as provide nursing intervention for at least 3 patients during an acute asthma exacerbation. Physician/nurse practitioners champions conduct medical assessments and develop written treatment plans with 20 patients, follow up with at least 40 patients, and manage at least 3 patients during an acute asthma
exacerbation.

Project faculty and staff developed and reproduced materials for the centers and participating primary care sites to support providers in care based on the NHLBI asthma guidelines: asthma action plans and education brochures at reading level and languages appropriate for patients, asthma guidelines pocket cards and wall posters for physician reference, asthma progress note stamp, and demonstration equipment kits to support patient education.

Participation in the chronic care improvement collaborative required quarterly chart audits to monitor changes in care over time. Attached are graphs based on chart audits of a cohort of 9 participating sites over the course of the first year of the initiative. Several graphs, for example, indicate significant improvement in the quality of patient assessment which include: documentation of peak expiratory flow rate, 10.6% increase; documentation of missed school days in patients <18 years, 37.4% increase; documentation of daytime symptoms, 26.9% increase; documentation of unplanned urgent care/hospitalization, 11 %; and documentation of asthma severity based on the NAEPP guidelines, increase 22.3%. Improvements in self-management support include, for example, documentation of the use of an action plan including when to contact provider or EMS, increase 23.6%; documentation that the patients’ MDI technique was observed, increase 6.8%; documentation that a new or continued inhaled steroid was prescribed, increase 7%.

Dr. Lori Riley, a family practice physician from Cook County Englewood Health Center, participated in the Initiative and stated: “I had the opportunity to review cases with an adult pulmonologist and a pediatric allergist for four months. Now, instead of sending a patient to a specialist right away, I am better able to initiate a treatment plan. I’m a lot more hands-on, I site and develop a written action plan and demonstrate how to use the equipment with patients. I spend a lot more time as an educator and less as a rescuer.

Innovation/Creativity
While the project received start up funding from the federal Central Management Services and the Illinois Department of Public Aid, the majority of costs for the initiative were absorbed by the Bureau. The Bureau mobilized its internal training capacity, making a commitment to bring together both asthma specialist and primary care providers in a way that uses their time differently, which develops staff competencies and relationships, and ultimately improves the system of care for patients with asthma.

Lessons Learned
A clinical coordinator is an essential part of the quality improvement process, providing assistance to teams through regular on-site visits between quarterly meetings of the collaborative. The clinical coordinator assists with plan-do-study- act cycles, identifies and provides tangible resources to support the teams, assists in conducting chart audits for reporting outcomes, and coordinates quarterly meetings of the collaborative.

Champions need to be mature providers with leadership skills who can influence the practice of their peers, and help to enlist the support of their medical and nursing directors/administrators to enable providers to dedicate the time necessary for the improvement process to take hold in their health centers.