Pediatric Chronic Disease Case Management: Asthma

By John, Obaid, Alex,

Frank, Ashley, Marcela, and

Olesya

Target Population

Region Children with Asthma

Percentage of Children with

AsthmaUnited States 6,800,000 (CDC 2012) 9.3%California 1,200,000 (CA Dpt Public Health

2013)12.5%

Alameda County 307,180 (CA Dpt Public Health 2013)

19.6%

Target Population

0

2

4

6

8

10

12

14

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Perc

ent

Year

White Black Hispanic

Source: CDC Asthma: A Presentation of Asthma Management and Prevention

Target Population

0

2

4

6

8

10

12

14

0-4 5-14 15-17 18-24 25-34 35-44 45-54 55-64 65+

Perc

ent

Age group

Male

FemaleChildren Adults

Source: CDC Asthma: A Presentation of Asthma Management and Prevention

Target PopulationOnce narrowed down, we stared looking at

specific health organizationsMost health organizations/hospitals do not

handle case management – cases are handled at provider level

Specialized projects aimed at managementNorthern California Breath MobileAsthma Start Program - Alameda County Public

Health Department

Target Population Northern California Breath Mobile

Targets preschool to 12th grade asthma patients

Mobile services circulate to schools in the community to provide services

Asthma Start ProgramTargets ages 0 – 18Must live in Alameda CountyMust have Asthma Diagnosis

What is Asthma?Asthma is a chronic disease involving inflammation and constriction of the airways that makes breathing difficult. 80% of life threatening asthma attacks occur at night.

What is Asthma?Signs and Symptoms:Shortness of breathWheezingCough-non productiveComplaints of chest tightnessWhat Triggers It?Different things can trigger asthma attacks in

different people. These irritants and allergens may not cause an immediate attack, but they build up in the system and when there are enough, one of them will trigger an attack.

Who Has Asthma?Anyone can have it. The number of reported cases are rising. Children are at risk. African Americans, Asians, Latino and other ethnic groups show slightly higher incidences than Caucasians

Common Triggers to Watch ForAllergens: pollens, outdoor mold dust mites,

furry and feathered animal dander, cockroach dander and droppings, indoor molds, house cleaning – can stir up dust.

Irritants: perfumes – including those in soaps and cleaning products, air pollution, tobacco smoke, cold weather, colds and viruses, wet paint, glues, fumes – from gas, wood, heaters mad fireplaces.

Other: forms of physical and mental stress, some forms of exercise.

Important MedicationsLong Term (controller):Anti-inflammatory – inhaled corticosteroids which maintain

control of inflammation such as pulmicort and flovent. Non-steroidal anti inflammatoryModifiers – block inflammatory effects such as singulair (tab)Combo therapy – Advair

Quick Relief (rescue):Bronchodilators – beta adrenergic agonists such as albuterol

and terbutalineOral steroids – acute episodesSevere life threatening episode – Epipen

Why is Case Management Needed?Alameda county has the third highest hospitalization

rates of all 52 California countiesManage asthma to live a normal lifeKids are missing numerous amount of days of school

with hospitalizationsParents are missing work and can’t afford to miss work

Asthma triggers prevalent in Alameda County:Polluted air – closer to highway 880, a common route

for trucksOld housing – more mold

Case Management ChallengesUnable to reach patientsCancelled appointmentsSet up first appointment, but no other visitsNot seen as priority

EducationVisual model of lung with

asthmaMeds: 2 goals –

understand the difference between controller and rescue meds, and always have albuterol with them

Goal: keep kids out of the hospital and Emergency room, keep parents at work, and keep kids at school.

History of Asthma ManagementAsthma Like An Egyptian-Ancients heated sun-dried stammonium leaves and roots over bricks and inhaled the fumes  1500 BC China- tea called “MA” contained ephedrine

Hippocrates circa 450 BC.- Greek word for "panting"

Moses Maimonides (1135-1204 AD) makes the weather connection

Bernardino Ramazzini (1633-1714 AD) known to some as the father of sports medicine, detected a link between asthma and organic dust. He also recognized exercise-induced asthma.

1900s-1960s— high use of ephedrine and atropine in cigarettes

1930-1950 known as one of the holy seven psychosomatic illnesses.

1957-invention of the inhaler 1960-wide use of inhaled corticosteroids

Eastbay History of Pediatric Asthma Case Management

1995-Asthma Mobile founded in Southern California.

2005-RN brings the Breathmobile to the Bay Area

2001-Asthma Start, Alameda County

Local Asthma Programs

Northern California Breathmobile Asthma Start Program

Service Delivery Model

Breathmobile1st Step: Health Risk

Assessment

2nd Step: Nurse’s Station

3rd Step: Pulmonary Function Test. Most important step

4th Step: Physician Assessment

5th Step: Entire Team Helps Individualize Asthma Action Plan

Asthma Start1st Visit: The

Assessment

2nd Visit : Intervention

3rd Visit: Evaluation of Interventions

Standards that Drive CareNational Heart, Lung, and Blood Association

Centers for Disease Control and Prevention

American Lung Association

Asthma Severity Classification in Children 5 Years of Age and Older

Step 4: Severe Persistent AsthmaContinual symptoms, frequent nighttime symptoms, Peak Expiratory Flow (PEF) or Forced Expiratory Volume in 1 Second (FEV1) is ≤60% of predicted value, PEF variability >30%

Step 3: Moderate Persistent AsthmaDaily symptoms, nighttime symptoms >1 night/week, PEF or FEV1 is >60% and <80% of predicted value, PEF variability >30%

Step 2: Mild Persistent AsthmaSymptoms >2 times a week but <1 time a day, nighttime symptoms >2 times a month, PEF or FEV1 ≥80% of predicted value, PEF variability 20-30%

Step 1: Mild Intermittent AsthmaSymptoms ≤2 times a week, nighttime symptoms ≤2 times a month, PEF or FEV1 ≥80% of predicted value, PEF variability <20%

Standards for EvaluationGreen Zone: 80-100% of Personal Best

Peak flow rate signals all clear. A reading in this zone means that your asthma is under reasonably good control. It would be advisable to continue your prescribed program of management.

Yellow Zone: 50-80% of Personal BestPeak flow rate signals caution. It is a time for decisions. Your airways are narrowing and may require extra treatment. Your symptoms can get better or worse depending on what you do, or how and when you use your prescribed medication. You and your healthcare provider should have a plan for yellow zone readings.

Red Zone: Less than 50% of Personal BestPeak flow rate signals a Medical Alert. Immediate decisions and actions need to be taken. Severe airway narrowing may be occurring. Take your rescue medications right away. Contact your healthcare provider now and follow the plan he has given you for red zone readings.

Standards for Case ManagementAccepted by the NHLBI, the standards in asthma case management include the education and implementation of: Inhaled CorticosteroidsAsthma Action PlanAsthma SeverityAsthma ControlFollow-up VisitsAllergen and Irritant Exposure Control

National GoalsAsthma Management Goals outlined by the CDC

Achieve and maintain control of symptomsMaintain normal activity levels, including

exerciseMaintain pulmonary function as close to

normal levels as possiblePrevent asthma exacerbationsAvoid adverse effects from asthma

medicationsPrevent asthma mortality

Local GoalsBreathmobile Asthma Start

Reduce asthma-related emergency room visits

Reduce asthma related hospitalizations

Reduce school absenteeism due to asthma (children in preschool-aged and K-12)

Improve asthma management and education for families and children with asthma

Prevent emergency room visits and hospitalizations related to asthma

Enhance awareness and understanding of asthma

Improve the ability of families to control the child’s asthma

Prevent missed days of work and school

Case Management Skills Competencies and Certifications

BreathmobileAll staff has been certified as “certified asthma

educators”Services are provided by health care professionals such

as RNs, NPs, RTs and MDs Asthma StartCase management provided by licensed clinical social

workers (LCSW), not RNsNot “certified asthma educators” (CAE) at this momentFocus on home visits, support and educationIf the program starts serving adults – they will have to

hire RNs and all the staff will have to become CAE

Goal OutcomesAsthma StartFrom Jan 2013 to present 1828 unduplicated referrals received• 98% of caregivers pass the post test with a score 90% or better• 100% of caregivers report increased confidence in managing

their child’s asthma• 100% of the caregivers reduced at least one identified asthma

trigger 

Pre-Case Management

Post-Case Management

Improvement

Hospitalized in Past 12 Months

32% 3% 91% Decrease

Visited ED in the Past 12 Months

56% 13% 77% Decrease

Goal OutcomesBreathmobile report for 2013-2014Project Goals are 70% Reduction in Patient ER Visits,

Hospitalizations and School Absences(Total Children Seen 253)  Before

BreathmobileAfter Breathmobile

% Decrease

ER Visits 274 13 95%Hospitalizations

138 0 100%

911 Calls 71 3 96%School Absenteeism (days)

541 30 94%

Goal OutcomesBreathmobile Estimated Cost Savings $$$$

$$$$ER (based on $3,500 per visit)

$914,000

School (based on $35 per day per student)

$ 17,885

Hospital (based on $16,000 per stay)

$ 2,208,000

911 Calls (based on $7,000 per call)

$ 476,000

Total Cost Savings $ 3,615,885

Key Limitations for Organizations FundingBreath mobile needs $500,000 annually to

deliver services and relies on public and private donations.

Contacts/SchedulingAsthma Start gets 60-70 referrals/month, but

makes 40 visits/month

Limitations and Barriers for PatientsPoverty Education, low literacy Lack of access to healthcare, lack of transportation,

excess waiting lines in clinicsCultural behavior patternsPreference for using emergency services, rather than

routine care by African-Americans and Hispanics

Acute Asthma ExacerbationMain Goal – Patient Stabilization  Pharmacological Treatment:Oxygen SupportBeta Agonists IpratropiumSteroids Magnesium SulfateHeliox

Chest PhysiotherapyPatient ComfortAnxiety ReductionFamily support

Asthma Action PlanMain Goal –

Patient Education

Pharmacological treatment

Asthma Action Plan

List of Asthma Triggers

Instructions About Steps to Take During Acute Asthma Attack

Asthma Action PlanMain Goal – Patient Education

What the Staff RN Can DoBe knowledgeableForm trusting relationship with patient and familyProvide patient-centered and family-centered careBe a detectiveUse individualized approachAdvocateEncourageSupport

Asthma Discharge Nurse?