Improved Patient Care Improved Patient Care Utilizing Wrap-Around Utilizing Wrap-Around Services:Services:Selected diagnosis of Selected diagnosis of Asthma and Stress Asthma and Stress Management Management

Saara Schwartz, MDMariela Gabaroni, MS, MCHES

ObjectivesObjectivesDefine Wrap Around servicesRecommendations for the

treatment of Asthma and Stress Management

Discuss a minimum of 3 benefits of utilizing wrap-around services

Discuss the use of technology to assist in patient education efforts and provide a holistic experience

What are Wrap-Around What are Wrap-Around Services?Services?In recent years, wrap-around has

been most commonly conceived of as an intensive, individualized care planning and management process

It is a holistic way of engaging individuals with specific needs

Why Wrap-around Why Wrap-around services?services? Today’s environment stresses

◦ “ Do More with Less”

How is this affecting care◦ less time with patients◦ education is abbreviated◦ Scenario…

My Magic WandMy Magic Wand Today patients want to get

better quickly. ◦ There is no time to be sick. So

they all request to be given a wonder drug.

However, if only given a medication…

◦ Results will only be short-term ◦ but will it help sustain

continued health?

How do we help patients How do we help patients maintain health?maintain health?

Who is part of the team?Who is part of the team?PatientCliniciansHealth EducatorsPharmacy staffAcupuncturistMassage TherapistNutritionistCounseling

Services Model

CLINICAL SERVICES

HEALTH EDUCATIONSERVICES

NUTRITIONSERVICES

COMPLEMENTARYALTERNATIVE

THERAPYSERVICES

PHARMACY SERVICES

RECREATIONAL SERVICES

COUNSELING SERVICES SOCIAL

SERVICES

Patient

Wrap-Around Program Wrap-Around Program FrameworkFramework

Comprehensive array of servicesCoordination of servicesCultural competenceEarly identification and interventionsStrength-based individualized service

planningAccountability through outcome

evaluation

Wrap-Around Concept Wrap-Around Concept is…is…

A framework and guide, not a prescription

Flexible and creative Adaptive to patient needs Consistent in philosophy

Wrap-Around Services at Florida International

University Student Health

Services

Diagnoses SelectedDiagnoses Selected◦Diagnostic Data

Asthma Increased incidence rate from July 2011 through

May 2013

◦NCHA data Stress

Fall 2012 National Data- 19.6% Fall 2012 FIU Data- 24.5%

AsthmaAsthmaThe prevalence in a student

population is 3.68% with a mildly growing trend

Females>MalesSmoking is common among

students with Asthma

Classifying Asthma Severity Classifying Asthma Severity Components of severity

Classification of asthma severity ≥ 12 years of age*

Intermittent Persistent-mild Persistent-moderate Persistent-severe

Impairment

Symptoms ≤ 2 days per week > 2 days per week, but

not daily

Daily Throughout the day

Nighttime awakenings ≤ 2 times per month 3 to 4 times per month > Once per week, but

not nightly

Often 7 times per week

Short-acting beta

agonist use for

symptom control (not

for prevention of

exercise-induced

bronchospasm)

≤ 2 days per week > 2 days per week, but

not more than once per

day

Daily Several times per day

Interference with

normal activity

None Minor limitation Some limitation Extremely limited

Lung function Normal FEV1 between

exacerbations; FEV1 >80

percent of predicted;

FEV1/FVC normal

FEV1 ≥ 80 percent of

predicted; FEV1/FVC

normal

FEV1 > 60 percent but <

80 percent of predicted;

FEV1/FVC reduced 5

percent

FEV1 < 60 percent of

predicted; FEV1/FVC

reduced >5 percent

Risk

Exacerbations

requiring oral

systemic

corticosteroids

0 to 1 per year† ≥ 2 per year† ≥ 2 per year† ≥ 2 per year†

Consider severity and interval since last exacerbation; frequency and severity may fluctuate over time

for patients in any severity category; relative annual risk of exacerbations may be related to FEV1

MedicationsMedicationsRescue Medications:

◦Albuterol ◦Xopenex◦Antihistamine

Maintenance Medications:◦Inhaled Corticosteroids◦Leukotrines◦Corticosteroids with long acting Beta

agonist

Why Treat?Why Treat?

Asthma should not complicate or cause missed days of

school. Asthma control, therefore, is a

must so that this period in a student’s life will be filled with academic successes and not

failures.

Challenges to the College Challenges to the College Student With AsthmaStudent With AsthmaThis may be the first time student

is away from home (need to take on the task of being independent)

Perceived attitudes “I am invincible”

Increase risk for illness:◦Dorms◦Roommates◦Sorority / Fraternity

Challenges to the College Challenges to the College Student With AsthmaStudent With AsthmaUnable to determine the severity

of their AsthmaWorsening of Symptoms at

CollegeUninsuredPerceived cost vs. Perceived gainTransportationIdentifying Resources

EducationEducationProvision of asthma education is

associated with decreased hospitalizations and emergency department visits for patients with asthma. Asthma education is underused by primary care physicians and rates have declined from 2001-2006. Interventions designed to promote awareness and greater use of asthma education is needed.

(reference: Decreasing frequency of asthma education in primary care. - Hersh AL - J Asthma - 01-FEB-2010; 47(1): 21-5)

Asthma Wrap-Around Asthma Wrap-Around ServicesServicesClinical visitReferralPre-testEducation sessions

◦Individual◦Classroom

Post-testFollow-upsEvaluation

Asthma Education Asthma Education SessionsSessions

STRESSSTRESSNCHA Data

◦Stress is the number one impediment to academic success

◦Anxiety is a close second impediment to academic success

◦Why?

Millennial GenerationMillennial GenerationHousehold income is higher, driven in

large part by the fact that both parents are working.

Positive social habits- teamwork, achievement, modesty, and good conduct

Negative attributes- being over scheduled, heavily monitored, and pressured to excel academically

They have witnessed in real time the horrible, man-made tragedies and natural disasters in a way that no other generation has experienced via television and Internet

The Millennium StudentThe Millennium StudentSpecialShelteredConfidentTeam-orientedAchievingPressuredConventional

College Stress:College Stress:The college years have been

considered one of the most stressful times in a person's life as well (Hales, 2009 )

College students are expected to carry a more difficult workload at a faster pace while adjusting to a new environment with little or no supervision (Missouri AHEAD, 2007).

College Stresses:College Stresses:New social situationsLoss of supervisionSearching for themselvesNeed to learn coping strategiesLack of sleep

◦New York Times Article http://www.nytimes.com/2013/04/28/opinion/sunday/diagnosing-the-wrong-deficit.html?pagewanted=3&src=me&_r=0

◦Huffington Post Article

Quick fixesQuick fixesSubstance Abuse

◦Marijuana◦Alcohol Abuse◦Increased Tobacco Use◦Performance enhancing drugs

SuicidePrescription Medication

MelatoninMelatoninMelatonin is a hormone made by

the pineal glandMelatonin helps control your

sleep and wake cyclesVery small amounts of it are

found in foods such as meats, grains, fruits, and vegetables

Light affects how much melatonin your body produces ( seasonal affective disorder)

Side Effects of MelatoninSide Effects of MelatoninSleepiness.Lower body temperature.Vivid dreams.Morning grogginess.Small changes in blood pressure.Cognitive dysfunction

BenzodiazepinesBenzodiazepinesBenzodiazepines are the anxiolytics of

choice in the acute management of generalized anxiety

Alprazolam 0.25-0.5mg; Lorazepam1-2mg or clonazopam 1-2mg are all controlled drugs, need an MD prescription, and are potentially dangerous because of dependency issues and the potential for overdosing.

The most common side effects for benzodiazepines are drowsiness and dizziness.

SSRIsSSRIsSSRIs or SNRI’s are the first-line medications for sustained treatment of generalized anxiety disorders, panic disorders, depression.

Expect a 2-4 week delay before these drugs begin to take effect.

Side Effects include insomnia, rashes, headaches, joint and muscle pain, stomach upset, nausea, or diarrhea. These problems are usually temporary, mild, or both.

SSRI Side EffectsSSRI Side EffectsBleeding problems-reduced blood clotting

capacity that increases risk for stomach or uterine bleeding. If patients use SSRIs and NSAIDs (aspirin, ibuprofen, naproxen, COX-2 inhibitors) at the same time, the risk more than doubles, so these drugs must be combined with care.

Diminish sexual interest, desire, performance, satisfaction, or all four. - Lowering the dose, switching antidepressants, or, for men, taking a drug like sildenafil (Viagra) can help.

Suicide- When compared with a placebo, all antidepressants, including SSRIs, seem to double the risk of suicidal thinking, from 1%–2% to 2%–4%, in both children and adults

Buspirone HClBuspirone HClBuspirone HCl 15-60mg usually

given in three divided doses daily. Side effects are common, benefits

are not seen for weeks; however there are no dependency issues with this class of drugs.

Possible side effects from Buspar are dizziness, headaches, nausea, nervousness, lightheadedness, excitement, and trouble sleeping.

Beta BlockersBeta BlockersBeta blockers control some of the

physical symptoms of anxiety, such as trembling and sweating.

Clinicians can prescribe Propranolol 10-20mg 30mins before performance for performance anxiety.

Common side effects from betablockers include fatigue, cold hands, dizziness, and weakness.

In addition, betablockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms.

Stress Management Wrap-Stress Management Wrap-AroundAround

Stress Management Stress Management ProgramProgramMassage TherapyMeditationAromatherapyAcupunctureStress Management ConsultationsTime ManagementYogaEvaluation

What coping mechanisms What coping mechanisms do college-aged Millennials do college-aged Millennials employ? employ?

Listening to musicSleepingSocial interactionsRelaxingSurfing the internetCalling parentPrayer

Benefits to the patientsBenefits to the patientsMore individualized careExposure to alternative therapies

in a safe and economical environment

Better understanding of the diagnoses and possible implications

Helps patient sustain optimal health

Benefits to Student Health Benefits to Student Health OperationsOperationsMaximize clinician timeBetter engagement with patientsCollaboration of careCreates a positive environment

for holistic care

Enhancing Wrap-Around Enhancing Wrap-Around through the use of through the use of

TechnologyTechnologyOnline tutorialsTweetsSmart appsSecure messagingYouTube videos

Questions?Questions?

Saara Schwartz, MDMedical DirectorFlorida International University Student Health Services

Email: schwarts@fiu.eduPhone: 305-348-5960

Mariela Gabaroni, MCHESAssociate DirectorFlorida International University Student Health Services

Email: xgabaron@fiu.eduPhone: 305-348-4020