Our program employs varying strategies dependent on where the asthmatic patient is encountered and is divided into two main classifications: acute-care and primary-care.
In the acute care setting, patients are encountered during an acute asthma episode in the emergency department or during an inpatient stay. In either instance, the patient receives tailored, patient-specific asthma education, which teaches basic information about asthma, reviews the patient’s medications, and provides skills demonstration on the patient’s inhalant devices. All patients are given an asthma action plan. School-aged children will have their asthma action plan faxed directly to the child’s school nurse for the management of asthma symptoms at school. If the patient has a primary care physician, a follow-up appointment is made with that physician and the asthma action plan will be sent to the physician’s office. All patients are referred to an outpatient asthma education class or home visit with our outpatient asthma outreach program.
The asthma outreach program staff receives a copy the patient’s admission record. The program staff will contact the patient within fourteen days of admission to schedule an asthma education session at the patient’s convenience in either the program office or in the patient’s home. During the asthma education session, each patient who is uninsured or underinsured is screened for funding eligibility using the Medicaider® screening software. In those instances where a patient does not have a primary care physician, the program staff will attempt to establish a primary medical home for these patients. Each patient completes a twenty-two question quality of life survey to evaluate the impact of asthma on the family’s quality of life. This questionnaire evaluates indicators such as: frequency of day and night symptoms, frequency of use of a peak flow meter, number of missed days from school and work, frequency of medication doses, etc. These indicators are measured against established metrics from the Institutes on Healthcare Improvement and are repeated at three months, six months and twelve months after the initial survey.
In the primary care setting, patients receive asthma education in conjunction with a scheduled primary care visit with the patient’s physician. Each month, on a scheduled day, eight appointments with a primary care provider are reserved for patients with asthma at seven area Seton Community Care Clinics. The Seton Community Clinic staff contact established patients with a known diagnosis of asthma to schedule an appointment. During each one-hour session, the patient, and/or the patient’s family, will receive asthma education consisting of: completion of a quality of life survey, education on asthma as a chronic disease; use of and care of inhalant devices, including skills demonstration; use of and care of a peak flow meter and diary; instruction on self-management and monitoring techniques; instruction on prescribed medications; and an asthma action plan. The asthma education and case management are provided by the Seton Asthma Outreach Program educators. The asthma action plan form is placed in the patient’s medical record and a copy is given to the patient or parent. School-aged children will have their asthma action plan faxed directly to the child’s school nurse.
The asthma educators also serve as case managers. During follow up telephone contacts where the quality of life survey is conducted, case managers will also survey the family’s socioeconomic needs. If at any point during the twelve month program period the patient becomes ineligible for previous insurance coverage, the Seton Asthma Center staff will screen the family for funding eligibility an attempt to establish insurance coverage and a medical provider for the asthmatic patient.
Goals:
•Improvement in quality of life and health of people with asthma;
•Reduction in the social and economic impact of asthma on the community;
•Optimization of the clinical management of asthma including environmental, system-wide and individual change
•Reduction in the prevalence, incidence, severity and risk of asthma.
•An established medical home for the target population
•Securing of healthcare funding for un-funded client
Objectives:
•Increase patients’ knowledge of asthma and skills in managing their asthma;
•Increase the skills, knowledge about and application of ‘best practice’ by health professionals;
•Establish appropriate organizational and communications systems for asthma management across the network and the community
•Increase understanding of the social, economic and environmental factors that impact asthma health;
•Reduce avoidable risks and help maintain healthy lifestyles and environments.
•Prevent or reduce the need for acute medical intervention for asthma
•Reduce direct and indirect costs associated with asthma
•Work to establish continuity and consistency in asthma management and education across the entire continuum of care
•Develop and maintain a central data repository for asthma disease management
Quality of life outcomes
With an effective asthma disease management program, it is anticipated that the improvement of the overall quality of life for each asthmatic child will be a natural result. Each participant will complete a series of 3 consecutive quality of life assessments; pre-, intermediate, and post-program assessment.
Some anticipated quality of life outcomes
•Asthmatic patient is sleeping through the night without fear of asthma exacerbation
•Asthmatic patient is spending more than five minutes outside
•Children miss fewer days from school due to asthma
•Parents and adult asthmatics miss fewer days from work due asthma
•Increased quality of life for asthmatics
•Active involvement of parents in the child’s asthma care
•Increased understanding of asthma and asthma management among individuals, healthcare providers and the community.
•Patients will have fewer days with asthma symptoms
•Altered attitudes and motivation toward behavior change
•Empowered patients who feel more confident in their ability to control asthma
