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An Improved Asthma Action Plan: The Role of Patient-Family Engagement Desty Kamm, RN, BSN, MS Suma Rao-Gupta, MPH Ann & Robert H. Lurie Children’s Hospital of Chicago CHA Safety and Quality Conference March 22, 2017
Ann & Robert H. Lurie Children’s Hospital of Chicago
• Free-standing children’s hospital
• Serves children from 49 states and 34 countries
• Ranked in the top 10 children’s hospitals nationally (U.S. News & World Report) – Ranked in all 10 specialties
• Achieved 4th Magnet re-designation in 2015
2
Facility Facts
• 288 private rooms with plans to expand • 1.25 million square feet • 400+ feet tall • 23 stories • Rooftop heliport • Amenities for families • Healing environment • LEED Gold certified
3
Learning Objectives
• Recognize the impact of health literacy and the importance of incorporating the patient/family voice in creating resources that support improvement efforts and achieving optimal outcomes.
• Identify the benefits of leveraging technology to improve clinician workflow, and compliance with patients/families.
4
Problem Statement
• Health literacy significantly impacts how consumers access, understand, and navigate the healthcare system. With asthma being a prominent childhood disease, parent/caregiver understanding of asthma management is paramount. Consequently, measuring and assessing the clarity and usability of an asthma action plan with parents and providers is a vital step in supporting patient/family asthma management with an electronically accessible asthma action plan.
5
Project Goal
• To create a single, useable and readily interpretable electronic asthma action plan that represents multi-disciplinary collaboration, addresses health literacy components and incorporates patient and family feedback.
6
Multidisciplinary Engagement
7
Patients & Families
Patient & Family
Education
Hospitalist
Allergy
Pulmonary
General Pediatrics Nursing
Pharmacy
IM
DAR
Center for Excellence
8
Key Driver Diagram (KDD) Aim Primary
Drivers Secondary
Drivers Interventions
Increase asthma action
plan compliance
from a baseline of 74% to ≥
90% by FY16 and sustain
the improvement
over 12 months.
Knowledge
Providers not aware of action plans
Paper gets lost before getting scanned
Variation in patient and families ability to understand the action
plan
Variation Paper copies not available
Lack of agreement between clinicians
Workflow Variability of when the action plan is
completed
Variability in practice
Created a single version
Garnered evidence and practice based
agreement on content
Created an electronic asthma
action plan Conducted user and
workflow testing
Incorporated human factors engineering
into the design
Incorporated patients/families in the design +literacy Provided messaging
on changes, dashboard and 1:1
feedback
Innovative Approach
• Low health literacy is a challenge universally faced by healthcare providers, impacting their communication with patients and families. – Providing tools to support this process are crucial – Incorporating patient/family feedback was a novel approach to meaningful
improvement • Streamline existing processes • Create consensus • Arrive at an improved solution
9
Gathering Parent Feedback – Inpatient Unit and Outpatient Clinic
• Patient and family feedback gathered through 1:1 interviews • Parents evaluated a laminated color copy of the revised AAP to be built
electronically for clinician use. Parents were asked questions regarding: – (1) Ease of use – (2) Ease of understanding – (3) Use at home
• Parents were asked to correctly identify which zone their child would fall into if they were: – (a) Doing well – (b) In immediate danger – (c) Having trouble but not needing to go to the ER
10
Results of Parent Evaluation and Pilot
• 35 parents were included in the evaluative process • First round of AAP evaluation: 12 inpatient parents, and 11 outpatient
clinic parents • Second round of AAP evaluation: 5 inpatient parents and 7 outpatient
clinic parents evaluated the modified plan • 100% of the parents interviewed responded that the information was
understandable, and that they would use it at home • 97% of the parents interviewed were able to correctly identify the correct
zone for their child
11
Improved Asthma Action Plan
12
Asthma Action Plan
13
Successfully created a single version with approval from key stakeholders
Enhanced report ability
Less clicks!
Enhanced medication lists
Conducted 1:1 feedback sessions with families
Colored printers
Translated into Spanish
The Carrot
14
Maintenance of Certification • Engages front-line
clinicians • Facilitates ongoing QI
Nursing-ADVANCE • Fosters buy-in • Recognizes dedication
and participation
Asthma Clinical Care Guideline Metrics
Outcome Measure
LOS
Intermediate Outcome Measure
Time to Q3 Albuterol
Process Measures
Order Set Utilization
Asthma Action Plan Utilization
LCAS Scoring Tool
Admission Note Utilization
Influenza Vaccination Rate
Balancing Measures
CAT Calls
Return to the ED within 72 hours
7 Day Readmission Rate
30 Day Readmission Rate
15
50%
60%
70%
80%
90%
100%
Asthma Action Plan Compliance
Pre and Post Intervention Data
16 Month
% C
ompl
ianc
e
Pilot in OU Live Inpatient
GOAL
Pre-intervention Mean: 74% Post-intervention Mean 96%
Asthma Action Plan SPC Chart
17
Why is the data
different?
18
Next Steps
Now that the AAP is easily identifiable across the continuum of care ... • Make the electronic AAP accessible to patients/families through the
patient portal
• Extend the AAP to Ambulatory clinic sites (7 major clinic sites) and Community Connect practices (27 practices)
19
A Special Thanks to the Team!
20
Barbara Bayldon Margie Wisniewski
Laura Shreffler Rob Greenberg
Mary Nevin Rajesh Kumar
Eric Jones David Koscinski
Sangeeta Schroeder Waheeda Samady
Questions?
21
22
Contact Information
Desty Kamm, MS, RN, MS Director-Clinical Quality Ann & Robert H. Lurie Children’s Hospital of Chicago [email protected] Suma Rao-Gupta, MPH Director, Pedersen Family Learning Center and Health Sciences Library Ann & Robert H. Lurie Children’s Hospital of Chicago [email protected]
It takes a Village : Breaking the cycle of Asthma Readmissions - building
Community Based Co-ordinated Care for Pediatric Patients with Asthma
Cheryl Courtlandt MD Co-director , Center for Advancing Pediatric
Excellence Stephanie Goldberg RN, CCM Pediatric Outcome Specialist
3/22/2017 2
Levine Children’s Hospital
3/22/2017 3
Levine Children’s Hospital
3/22/2017 4 CHS University
CHS Cleveland CHS Pineville
CHS Union Levine Children’s Hospital
CHS Lincoln
Jeff Gordon Children’s Hospital/ CHS NorthEast
CHS Metro Hospitals Pediatric Care
CHS Stanly
3/22/2017 5
Children’s Service Line
An integrated network of pediatric
providers in Metro Charlotte
Care provided in both acute care
and ambulatory settings
19 hospital-based specialties
23 primary care practices
3/22/2017 6
Core Team Members Stephanie Goldberg RN, CCM Team Leader Cheryl Courtlandt MD – Physician Champion James Young MD – ED Physician Champion Mona Cooper RN – Lead, Mecklenburg County Health Department School Nursing Janet Goldstein RN – Lead Nurse Healthy@Home
3/22/2017 7
Core Team Members
Virgina Simpson - Lead CCPGM Julia Banks - Lead CC4C Amy Kern – Lead Long’s Pharmacy Salathia Davis – Lead Telehealth Cristy Smith – Lead , LCH Kelly Reeves RN - Center for Research and Outcomes
3/22/2017 8
Core Team Members
Wendy Nielsen - Lead, Union County School System Karen Drake -Lead, CC4C Union County Anda Reed – Lead, Healthy@Home Buth Burton- Quality Management , CCPGM
3/22/2017 9
Communication with School Nurse
3/22/2017 10
Readmissions
• Critical transitions of care
• Increasing complexity of care to be delivered in community
• Variable Heath Literacy
3/22/2017 11
LCH Readmissions Root Cause Analysis MRN Age Admit and Readmit Dates Ed Visits
Past Year Healthy @ Home,
N/A CCPGM,
N/A Kept f/u appts
Meds in Home
Social/Environmental/Other
5739787 10 10/29-31; 11/25-26 3 N/A N/A No Controller Needed
Triggers: Sports and Weather; Need PCP change due to move
5196465 14 7/13-7/15; 8/4-8/6 8/10-8/13; 10/28-10/30 11/14-11-17
5 Yes with Insurance N/A Partial Yes Vocal Cord Dysfunction; Pulmonology Infrequent, questions need for CPAP
5939424 3 10/29 11/14
2 Yes 10/30 Diff to sched visits d/t
mom’s avail
No referral
Yes Underdosing Controllers
Education needed; 8 albuterols given prior to admission
5627426 6 4/28-4-29; 9/9-9/14; 12/28-12/30
3 Refused Had visit in April
N/A F/u ? with Pulm
Dulera Mom noted at dc, pt was on Dulera; Referred to Pulmonologist
5180491 6 9/8-9/10; 12/10-12/13 1 Tele-Health f/u; No answer; Non admit to H@H
Unavail Smokers; “nebs since birth”
4700841 10 9/3-9/6; 12/29-1/1 3 12/31 Yes Yes Yes PICU, Start Pulmonology Medicaid Bus Passes;
No job or car 5931220 7 11/13-11/14; 1/8-1/10 3 1/10/14; no Medicaid
11/13 2nd referral; GM declined
Yes GP smoking in car; 911 at school Eviction notice; no housing; Gas card given; mom in TX
4714926 10 3/16-3/17; 4/28-4/29; 12/14-12/15; 1/24-1/26
8 12/20 x1;1 visit in shelter;lost contact Resume 1/26
Yes Yes Yes Shelter Aug-Dec; Smoking
3/22/2017 12
Co-ordination between 13 service providers
• Inpatient Services – Levine Children’s Hospital – Union County Hospital
• School Health Services – Charlotte –Mecklenberg County Public Schools – Union County Public Schools
• Healthy @ Home ( home health services ) – Mecklenberg County – Union County
• Community Care Partners of Greater Mecklenberg • Long’s Pharmacy Delivery service
3/22/2017 13
Co-ordination between 13 service providers
• Emergency Department – Levine Children’s Hospital – Union county Hospital
• Peer support specialists
• Telehealth services
• Telemedicine
• CC4C
3/22/2017 14
School Health Nursing
• 14,000 school aged children with asthma in Charlotte-
Mecklenburg schools (about 10% of population)
• 7500 school aged children with asthma in Union county Schools
• Nurse sees student and contacts within 7 days of return to school from hospitalization or ED visit
• Teaching of 3 key concepts and performance of ACT
3/22/2017 15
ACT scores – School Health
60
65
70
75
80
85
90
95
100
ACT - School Nursing
Percent Goal Median
3/22/2017 16
Home Health Services
• Series of visits over 2 months for 2 year old to 18 year olds
• Currently funded by government funded insurance only
• Services provided review of 3 key concepts, medication review , performance of ACT after 1 month
3/22/2017 17
Home Health Visits
40
50
60
70
80
90
100
May
-13
Jun-
13Ju
l-13
Aug
-13
Sep
-13
Oct
-13
Nov
-13
Dec
-13
Jan-
14Fe
b-14
Mar
-14
Apr
-14
May
-14
Jun-
14Ju
l-14
Aug
-14
Sep
-14
Oct
-14
Nov
-14
Dec
-14
Jan-
15Fe
b-15
Mar
-15
Apr
-15
May
-15
Jun-
15Ju
l-15
Aug
-15
Sep
-15
Oct
-15
Nov
-15
Dec
-15
Jan-
16Fe
b-16
Mar
-16
Apr
-16
May
-16
Jun-
16Ju
l-16
Aug
-16
Sep
-16
Oct
-16
Nov
-16
Dec
-16
Jan-
17
Discharge Medications present a first home visit
Percent of medications present at H@H visit Goal Median
3/22/2017 18
Long’s Pharmacy
3/22/2017 19
Home Health visits
40
50
60
70
80
90
100
Jul-1
3A
ug-1
3S
ep-1
3O
ct-1
3N
ov-1
3D
ec-1
3Ja
n-14
Feb-
14M
ar-1
4A
pr-1
4M
ay-1
4Ju
n-14
Jul-1
4A
ug-1
4S
ep-1
4O
ct-1
4N
ov-1
4D
ec-1
4Ja
n-15
Feb-
15M
ar-1
5A
pr-1
5M
ay-1
5Ju
n-15
Jul-1
5A
ug-1
5S
ep-1
5O
ct-1
5N
ov-1
5D
ec-1
5Ja
n-16
Feb-
16M
ar-1
6A
pr-1
6M
ay-1
6Ju
n-16
Jul-1
6A
ug-1
6S
ep-1
6O
ct-1
6N
ov-1
6D
ec-1
6Ja
n-17
Teach Back Performed on 3 Key Concepts of Self-Management
Teach Back Goal Median
3/22/2017 20
Telehealth
• Target group : 2 to 18 years with asthma
• Self Pay and commercial insurance
• Phone visits : Teaching 3 key concepts, medication reinforcement and utilizing Teach Back
3/22/2017 21
CCPGM
• Target : 2 to 18 years
• Medicaid insurance
• Environmental control Tools
• Transportation
• Social Concerns
3/22/2017 22
Peer Support
• Community based service
• In home support and PCP visits
• Reviewing the 3 key concepts and performing Asthma Control Test
• Referral to community services or PCP for additional care
3/22/2017 23
Emergency Room Utilization
• Decreased 20% for all visits, 85 % for those in self management programs
• Efforts focused on prevention of the initial admission and strengthening the connection to the medical home
• Home health referral from ED
• Notification to school nurse of ED visit
3/22/2017 24
3/22/2017 25
Asthma Readmissions
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
Asthma Readmissions
Percentage of asthma readmissions Goal Median National Standards
3/22/2017 26
Sustainability and Spread
Hardwired with constant PDSA cycles Teaching 3 key concepts and ACT Scores Use of Telemedicine Spread beyond Union County Partnering with independent practices and other providers of primary care to pediatric asthma patients
3/22/2017 27
Geoanalysis of high risk areas
3/22/2017 28
3/22/2017 29
Contact Information
[email protected] [email protected] Levine Children’s Hospital Charlotte, North Carolina
Asthma Clinical
Transformation Initiative
Cooper White M.D, Michael Bird M.D.,.
Akron Children’s Hospital
March 22, 2017
Children’s Hospital Association
Orlando FL
About Akron Children’s •Ranked a Best Children’s Hospital by U.S. News & World Report
•Magnet® Recognition for Nursing Excellence
•Largest independent pediatric provider in northern Ohio
•2 hospital campuses
•90 locations offering primary care, specialty services and urgent care
•The second busiest pediatric emergency department in Ohio
•Performs more pediatric surgeries than any other hospital in northeast Ohio
•5,500 employees
With more than 800,000 patient visits each year, we’ve been leading the way to healthier futures for children
and communities through expert medical care, prevention and wellness programs since 1890.
Asthma Quality Improvement: Akron Children’s Timeline
• 2006-8: Clinical Microsystems. Single practice. Goal to increase use of treatment plans.
• 2009-11: Chapter Quality Network. 3 practices. Statewide learning collaborative sponsored by the American Academy of Pediatrics
• 2013-2016: Community Health Needs Assessment (CHNA). Asthma established as a health needs priority. Multidisciplinary workgroups focused on different aspects of asthma care.
Timeline (continued)
• 2014: Asthma Registry becomes active in Epic.
• July 2015: Prioritized as an organizational “Clinical Transformation Priority”. Given increased resources and involvement of the Quality Dept.
• 2017-2020: Re-designated as a CHNA priority
2015 – 2017 Asthma Key Driver Diagram (KDD) – System Level Project Name: Clinical Transformation Priority: Asthma
Physician Co-Champions: Dr. P. Cooper White and Dr. David Chand
KEY DRIVERS What (big picture) needs to be done to accomplish the Aim)
Asthma Care Coordination
Guideline-Based Care (Standardization)
Identification of Asthma Patients (Risk Stratification)
Medication Management & Compliance
Date: 9/21/2016
Patient & Family Engagement
Technology
SMART AIM
Reduce Hospitalization rate from 2.70%* to < 2% (approx. 26% reduction), and ED visit rate from 5.84%* to <5% (approx. 14% reduction), by December 31, 2017. * Dec 2015, 12-month rolling average.
Evidence-Based; Asthma Pathway, Asthma Treatment Plan, Asthma Control Test, EZB, Flu Vaccine, Use of spirometry
INTERVENTIONS How (specific) we accomplish the Drivers
In the next 3 years, we aim to substantially
reduce the burden of asthma for our patients,
their families, and our community.
GLOBAL AIM
Education (Consistent across Continuum)
Informatics (Metrics, Asthma Registry)
Community Engagement
Access to Care at Appropriate Levels
Epic, MyChart, Reminders, Tele-Health, Smartphones/Apps, e.g. pulmonary effort, Interactive Patient TV, Social Media
Evaluate Home Environment, School Health, 24/7 Hot Lines; use of Spirometry; Literacy; Behavioral Health issues
Ordering, Filling, Usage; Increase correct/decrease incorrect medications, Medication demonstration devices for practices/units
EZB, Registry, School, Home Care, High Risk*, Co-Morbidity
Resources, Technology, Pt & Family Engagement, Hot-Lines, Support Groups, Phone
Standardized curriculum for IP & OP; mechanism to monitor; home env’t, School Health, trigger avoidance
Population Health, ACT Now, ED, Pulmonary, IP, Alternatives, Missed appointments
BPAs*, Documentation, Define*/Identify*/Pareto High Risk patients, Registry, Analytics
E.g. Asthma Care Management Team, Office/Staff Engagement; EZB, routine SW assessments for all high risk patients
(Most recent updates)
Increase % of Practices achieving >20% of Optimal Care (ACT & ATP by 12/31/17) & Flu Vaccine by 06/30/17) from <10% to 80%. Increase eligible CareSource member’s dispensed asthma controller medication, closing the gap between our 2015 performance (42%) and the national NCQA 90%ile (42.8%), by 20%, by 12/31/2016 (HEDIS). HEDIS Proxy measure, TBD
V4.1 (updates in italics)
Secondary Measures:
(PC, SH, Al, HC)
(IP, ED/UC)
(Pulm, PC, Al)
(IP, SH, HC)
(IP, SH, HC)
(PC)
(IP, SH, HC)
(IP, PC)
(SH, HC) Key: Green: In Progress * is Complete (Blue): Teams Testing Red: Potential Barrier
SMART AIM Reduce Hospitalization rate
from 2.70%* to < 2% (approx. 26% reduction), and ED visit
rate from 5.84%* to <5% (approx. 14% reduction), by
December 31, 2017. * Dec 2015, 12-month rolling average.
KEY DRIVERS Community Engagement
(SH, HC)
INTERVENTIONS E.g. Asthma Care Management Team,
Office/Staff Engagement; EZB, routine SW assessments for all high risk patients
School Health - Learning Structure
Key Drivers
DesignChanges/
Interventions Aim
Asthma Care is Coordinated across the continuum of care
Adequate training for Students & School Staff on Asthma
Available & Appropriate usage of ATP & Asthma Medication at school
Increased Asthma Awareness & Engagement of Student, Family
& School
Streamline the process for communication between ACH and school
• Consent for school communication prior to discharge/home going instruction
• Create Epic worklist for patients seen inpt/outpt/ED to school health clinical coordinator (for next day follow-up)
Work collaboratively with Home Care nurse and Asthma Care Team to identify strategies for increased education, medication management and compliance for students with moderate to severe asthma
Implement school located flu vaccination clinics Reduce hospitalization &
Emergency Department
visits for students with asthma.
Global AIM
6
School Health Services will improve asthma management in the school setting: • Increase identification of students with
(moderate to severe) asthma at school.
• Increase % of partnered school districts participation in school located flu vaccination clinics from 35% (2016) to 50% by December 2017.
• Implement stock rescue inhaler protocol in 50% of partnered school districts by December 2017.
Implement stock albuterol standing order and protocol for schools
Identify students with asthma • School: EZB for schools • ACH: patient identification of school
documented in Epic
Draft: 2/10/2017
Team Lead: Michele Wilmoth
Available & Accurate Data for Identification of Students with
Asthma
Increase education and training • EZB/student inhaler technique checklist • Teacher and school staff • School nursing staff (Simulation center/annual
competencies)
Easy Breathing©
• Primary Care improvement program for asthma developed by Michelle Cloutier MD, Connecticut Children’s Hospital.
• Questionnaire used to aid in identification and classification of asthma.
• Coherence between level of severity and treatment plan is the hallmark of the program.
• Treatment option “buffet” updated yearly.
Easy Breathing© at Akron Children’s
•38,000 children screened, 9300 with asthma
•28 practices trained
•150 + providers trained
•95% of those identified with persistent asthma prescribed a controller
•1500 new cases of asthma identified
Patients with asthma, enrolled vs. unenrolled in Easy Breathing© (p<0.05)
OR 95% CI Flu Vaccine 1.9 1.4-2.5 ATP 18.8 16.3-21.7 ACT 4.6 4.2-5.0 Optimal Care 26.8 21.7-33.0
There is a modest but significant decrease in ED visits for patients enrolled in Easy Breathing©.
Easy Breathing © 2017 priorities
• Expand screening
• Increase use of the Asthma Control Test (ACT)
Goal 2.0%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
Asthma Registry Hospitalization Rate
100% of Primary Care Practices trained in Easy
Breathing
Clinical Transformation
Priority
43% Reduction
since January 2015!
50% of Primary Care Practices trained in Easy
Breathing
Goal, 5.0%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
Asthma Registry ED Visit Rate Clinical
Transformation Priority
27% reduction
since January 2015!
50% of Primary Care Practices trained in Easy
Breathing
100% of Primary Care Practices trained in Easy
Breathing
0%
10%
20%
30%
40%
50%
60%
70%
Optimal Care %'s Asthma Registry Pts with an Akron Children’s Hospital PCP
Flu Vaccine (Seasonal) ACT ATP Optimal Care
ACT = Asthma Control Test ATP = Asthma Treatment Plan
Responsibilities for: Asthma Care Management
Team
Patient Identification
& Risk Stratification
Medications
Education
Managed Care
Follow-Up Appointments
School
Communication
Community Resources
Home
Healthcare Providers
Mission Statement: To identify and remove the barriers which prevent successful implementation of the plan of care for asthma patients.
Asthma Care Management Team
Asthma Care Management SMART Aim/Goal (Specific, Measurable, Attainable,
Relevant, time-bound)
SMART Aim: To achieve a 75% adherence rate with controller
medications among patients enrolled in a Medicaid HMO who are
diagnosed with severe persistent asthma and/or high risk asthma by
December 31st, 2017.
Top 3-5 Performance Improvement Priorities
• Increase the % of new prescriptions filled at Akron Children’s Hospital outpatient pharmacy (and at bedside) of hospitalized patients with asthma prior to discharge home to 50%.
• Achieve 95% adherence with documenting patient’s/family’s ability to identify the role of rescue and controller medications in the patient/family education tab of the EMR.
• Achieve 80% adherence with documenting patient’s/family’s ability to demonstrate correct techniques for medication administration in the patient/family education tab of the EMR.
(Based on being a High Risk, Problem-Prone, and/or High Volume Area)
Other Focus Areas
• Pulmonary and Allergy: High Risk populations and social determinants (transportation especially)
• ED: Follow-up
• Home Care: Expanded utilization. Standardization
• School Health: Easy Breathing for Schools in one district.
Resources: • QI Support • Project
Management • Analytics • Informatics
Team Resources
• QI Support • Dedicated Quality Improvement Specialist supporting the asthma teams
• Project Management • Providing PM for the teams
• Analytics • Dedicated Analyst supporting the asthma work – identifying ways to make
reports, data queries more efficient
• Informatics • Dedicated Physician Informaticists on Asthma team. Works with Epic team to
identify tools and enhancements in the EHR that improve asthma care
Next Steps
• Care Coordination
• Increasing collaboration with: • Schools
• Health Departments
• Alignment with Managed Care Organizations
• Demonstrate value of additional resources/attention on large-scale QI effort, make case for increasing resources
Thank you!
P. Cooper White, M.D. Clinical Professor, Pediatrics, NEOMED President, Medical Staff Associate Chair, Department of Pediatrics, Primary Care and Community Health Medical Director, Locust Pediatric Care Group 1 Perkins Sq. Akron, OH 44308 Phone: 330-543-3529 Email: [email protected]
Michael W. Bird, M.D., M.P.H. VP Quality and Patient Safety Co-Clinical Lead, Ohio Children’s Hospitals Solutions for Patient Safety 1 Perkins Sq. Akron, OH 44308 Phone: 330-543-4590 Email: [email protected]
www.akronchildrens.org