Chelsea Asthma Management Program

Background

The MGH Chelsea Pediatric Asthma program strives to improve the management
of asthma care for adolescent and pediatric patients with the aim of improving
their health and reducing emergency room visits and hospitalizations over time.
Chelsea is a dense city with a relatively high poverty rate and a majority
Latino population. These demographics are consistent with a higher risk of
hospitalization for asthma, as identified by the Massachusetts Department of
Public Health. A pediatric provider identifies a patient with asthma and the
Pediatric Asthma Program Coordinator facilitates communication and follow-up
between the provider and the patient. During the provider visit, the
coordinator reinforces the patients' understanding by providing education about
asthma including triggers, symptoms, medications, and by reviewing the patient’s
individualized action plan. The barriers to follow-through are identified and
strategies developed as a team. The coordinator also identifies patients in
need of other resources such as food resources, housing, domestic violence
intervention, etc.; and the coordinator refers to other programs within MGH
Chelsea and at community agencies. As needed, the coordinator conducts home
visits to reinforce asthma teaching and to identify potential environmental
hazards in the home.

Activities

- Assure that all pediatric patients with asthma have regular flu shots
through follow up reminders.

- Conduct home visits to assess the environmental triggers for patients
with severe-persistent uncontrolled asthma.

- Meet with patients at the health center to review specific areas
related to asthma control and to follow up on care recommendations laid out by
the provider. This could include reviewing medications, teaching on how to use
spacers or nebulizers, reviewing asthma triggers, and coaching around how to
overcome barriers to better control.

- Work with pediatric providers to ensure that patients have up-to-date
Asthma Action Plans. Support the providers in reinforcing the information in
the action plans with patients and their families.

- Review insurance records to understand which patients may need a
follow up appointment with their primary care provider to change their
medicines; (i.e. if a patient is using their inhalers more often than they
should and therefore has many prescription refills for inhalers).

- Identify and manage any new asthmatic patients through ASIG patient
registry.

- Monitor patients who are non-compliant with medications or who make
frequent visits to the Urgent Care and create six to one year plan for
improvement.

- Provide referrals to other MGH Chelsea programs and or community
based programs as needed.

- Provide trainings, health education seminars, and literature to
patients and families.

Outcomes

- Increase the score on the Asthma Control Test (ACT).

- Increase the use of Asthma Action Plans for those pediatric patients
on controller medications.

- Increase the percentage of pediatric asthma patients vaccinated
annually for influenza.

- Minimize visits to pediatrician for asthma over a three to six month
follow up period.

- Reduce the number of visits to urgent care or emergency room for
asthma.

- Empower parents on proper management of their children’s chronic
condition.

- Educate children over time to increase self-management of their own condition.