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By John, Obaid,
Alex, Frank,
Ashley, Marcela,
and Olesya
Target Population
Region Children with Asthma
Percentage of
Children with
Asthma
United 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
Percent
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+
Percent
Age group
Male
Female
Children Adults
Source: CDC Asthma: A Presentation of Asthma Management and Prevention
Target Population
Once narrowed down, we stared looking at specific
health organizations
 Most health organizations/hospitals do not handle case
management – cases are handled at provider level
Specialized projects aimed at management
 Northern California Breath Mobile
 Asthma 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 Program
 Targets ages 0 – 18
 Must live in Alameda County
 Must 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 breath
 Wheezing
 Cough-non productive
 Complaints of chest tightness
What 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 For
 Allergens: 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 Medications
Long Term (controller):
 Anti-inflammatory – inhaled corticosteroids which maintain
control of inflammation such as pulmicort and flovent.
 Non-steroidal anti inflammatory
 Modifiers – block inflammatory effects such as singulair (tab)
 Combo therapy – Advair
Quick Relief (rescue):
 Bronchodilators – beta adrenergic agonists such as albuterol and
terbutaline
 Oral steroids – acute episodes
 Severe life threatening episode – Epipen
Why is Case Management
Needed?
 Alameda county has the third highest hospitalization rates
of all 52 California counties
 Manage asthma to live a normal life
 Kids are missing numerous amount of days of school with
hospitalizations
 Parents 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
trucks
 Old housing – more mold
Case Management Challenges
 Unable to reach patients
 Cancelled appointments
 Set up first appointment, but no other visits
 Not seen as priority
Education
 Visual model of lung with
asthma
 Meds: 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 Management
Asthma 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
Breathmobile
 1st 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 Start
 1st Visit: The
Assessment
 2nd Visit :
Intervention
 3rd Visit:
Evaluation of
Interventions
Standards that Drive Care
National
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 Asthma
Continual 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 Asthma
Daily symptoms, nighttime symptoms >1 night/week, PEF or FEV1 is >60% and <80% of
predicted value, PEF variability >30%
Step 2: Mild Persistent Asthma
Symptoms >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 Asthma
Symptoms ≤2 times a week, nighttime symptoms ≤2 times a month, PEF or FEV1 ≥80% of
predicted value, PEF variability <20%
Standards for Evaluation
 Green 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 Best
Peak 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 Best
Peak 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 Management
Accepted by the NHLBI, the standards in
asthma case management include the
education and implementation of:
Inhaled Corticosteroids
Asthma Action Plan
Asthma Severity
Asthma Control
Follow-up Visits
Allergen and Irritant Exposure Control
National Goals
Asthma Management Goals outlined by the CDC
Achieve and maintain control of symptoms
Maintain normal activity levels, including exercise
Maintain pulmonary function as close to normal levels
as possible
Prevent asthma exacerbations
Avoid adverse effects from asthma medications
Prevent asthma mortality
Local Goals
Breathmobile 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
Breathmobile
 All staff has been certified as “certified asthma educators”
 Services are provided by health care professionals such as
RNs, NPs, RTs and MDs
Asthma Start
 Case management provided by licensed clinical social
workers (LCSW), not RNs
 Not “certified asthma educators” (CAE) at this moment
 Focus on home visits, support and education
 If the program starts serving adults – they will have to hire
RNs and all the staff will have to become CAE
Goal Outcomes
Asthma Start
 From 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 Outcomes
Breathmobile report for 2013-2014
 Project Goals are 70% Reduction in Patient ER Visits,
Hospitalizations and School Absences
(Total Children Seen 253)
Before
Breathmobile
After
Breathmobile
% Decrease
ER Visits 274 13 95%
Hospitalizations 138 0 100%
911 Calls 71 3 96%
School
Absenteeism
(days)
541 30 94%
Goal Outcomes
Breathmobile 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
Funding
 Breath mobile needs $500,000 annually to deliver
services and relies on public and private donations.
Contacts/Scheduling
 Asthma Start gets 60-70 referrals/month, but makes
40 visits/month
Limitations and Barriers for
Patients Poverty
 Education, low literacy
 Lack of access to healthcare, lack of transportation, excess
waiting lines in clinics
 Cultural behavior patterns
 Preference for using emergency services, rather than
routine care by African-Americans and Hispanics
Acute Asthma Exacerbation
Main Goal – Patient Stabilization
Pharmacological Treatment:
 Oxygen Support
 Beta Agonists
 Ipratropium
 Steroids
 Magnesium Sulfate
 Heliox
Chest Physiotherapy
Patient Comfort
Anxiety Reduction
Family support
Asthma Action Plan
Main Goal –
Patient
Education
Pharmacological
treatment
Asthma Action Plan
List of Asthma
Triggers
Instructions About
Steps to Take
During Acute
Asthma Attack
Asthma Action Plan
Main Goal – Patient Education
What the Staff RN Can Do
 Be knowledgeable
 Form trusting relationship with patient and family
 Provide patient-centered and family-centered care
 Be a detective
 Use individualized approach
 Advocate
 Encourage
 Support
Asthma Discharge Nurse?

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Pediatric Chronic Disease Case Management

  • 1. By John, Obaid, Alex, Frank, Ashley, Marcela, and Olesya
  • 2. Target Population Region Children with Asthma Percentage of Children with Asthma United 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%
  • 3. Target Population 0 2 4 6 8 10 12 14 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Percent Year White Black Hispanic Source: CDC Asthma: A Presentation of Asthma Management and Prevention
  • 4. 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+ Percent Age group Male Female Children Adults Source: CDC Asthma: A Presentation of Asthma Management and Prevention
  • 5. Target Population Once narrowed down, we stared looking at specific health organizations  Most health organizations/hospitals do not handle case management – cases are handled at provider level Specialized projects aimed at management  Northern California Breath Mobile  Asthma Start Program - Alameda County Public Health Department
  • 6. 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 Program  Targets ages 0 – 18  Must live in Alameda County  Must have Asthma Diagnosis
  • 7. 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.
  • 8. What is Asthma? Signs and Symptoms:  Shortness of breath  Wheezing  Cough-non productive  Complaints of chest tightness What 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.
  • 9. 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
  • 10. Common Triggers to Watch For  Allergens: 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.
  • 11. Important Medications Long Term (controller):  Anti-inflammatory – inhaled corticosteroids which maintain control of inflammation such as pulmicort and flovent.  Non-steroidal anti inflammatory  Modifiers – block inflammatory effects such as singulair (tab)  Combo therapy – Advair Quick Relief (rescue):  Bronchodilators – beta adrenergic agonists such as albuterol and terbutaline  Oral steroids – acute episodes  Severe life threatening episode – Epipen
  • 12. Why is Case Management Needed?  Alameda county has the third highest hospitalization rates of all 52 California counties  Manage asthma to live a normal life  Kids are missing numerous amount of days of school with hospitalizations  Parents 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 trucks  Old housing – more mold
  • 13. Case Management Challenges  Unable to reach patients  Cancelled appointments  Set up first appointment, but no other visits  Not seen as priority
  • 14. Education  Visual model of lung with asthma  Meds: 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.
  • 15. History of Asthma Management Asthma 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
  • 16. 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
  • 17. Local Asthma Programs Northern California Breathmobile Asthma Start Program
  • 19. Breathmobile  1st 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
  • 20. Asthma Start  1st Visit: The Assessment  2nd Visit : Intervention  3rd Visit: Evaluation of Interventions
  • 21. Standards that Drive Care National Heart, Lung, and Blood Association Centers for Disease Control and Prevention American Lung Association
  • 22. Asthma Severity Classification in Children 5 Years of Age and Older Step 4: Severe Persistent Asthma Continual 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 Asthma Daily symptoms, nighttime symptoms >1 night/week, PEF or FEV1 is >60% and <80% of predicted value, PEF variability >30% Step 2: Mild Persistent Asthma Symptoms >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 Asthma Symptoms ≤2 times a week, nighttime symptoms ≤2 times a month, PEF or FEV1 ≥80% of predicted value, PEF variability <20%
  • 23. Standards for Evaluation  Green 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 Best Peak 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 Best Peak 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.
  • 24. Standards for Case Management Accepted by the NHLBI, the standards in asthma case management include the education and implementation of: Inhaled Corticosteroids Asthma Action Plan Asthma Severity Asthma Control Follow-up Visits Allergen and Irritant Exposure Control
  • 25. National Goals Asthma Management Goals outlined by the CDC Achieve and maintain control of symptoms Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal levels as possible Prevent asthma exacerbations Avoid adverse effects from asthma medications Prevent asthma mortality
  • 26. Local Goals Breathmobile 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
  • 27. Case Management Skills Competencies and Certifications Breathmobile  All staff has been certified as “certified asthma educators”  Services are provided by health care professionals such as RNs, NPs, RTs and MDs Asthma Start  Case management provided by licensed clinical social workers (LCSW), not RNs  Not “certified asthma educators” (CAE) at this moment  Focus on home visits, support and education  If the program starts serving adults – they will have to hire RNs and all the staff will have to become CAE
  • 28. Goal Outcomes Asthma Start  From 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
  • 29. Goal Outcomes Breathmobile report for 2013-2014  Project Goals are 70% Reduction in Patient ER Visits, Hospitalizations and School Absences (Total Children Seen 253) Before Breathmobile After Breathmobile % Decrease ER Visits 274 13 95% Hospitalizations 138 0 100% 911 Calls 71 3 96% School Absenteeism (days) 541 30 94%
  • 30. Goal Outcomes Breathmobile 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
  • 31. Key Limitations for Organizations Funding  Breath mobile needs $500,000 annually to deliver services and relies on public and private donations. Contacts/Scheduling  Asthma Start gets 60-70 referrals/month, but makes 40 visits/month
  • 32. Limitations and Barriers for Patients Poverty  Education, low literacy  Lack of access to healthcare, lack of transportation, excess waiting lines in clinics  Cultural behavior patterns  Preference for using emergency services, rather than routine care by African-Americans and Hispanics
  • 33. Acute Asthma Exacerbation Main Goal – Patient Stabilization Pharmacological Treatment:  Oxygen Support  Beta Agonists  Ipratropium  Steroids  Magnesium Sulfate  Heliox Chest Physiotherapy Patient Comfort Anxiety Reduction Family support
  • 34. Asthma Action Plan Main Goal – Patient Education Pharmacological treatment
  • 35. Asthma Action Plan List of Asthma Triggers Instructions About Steps to Take During Acute Asthma Attack
  • 36. Asthma Action Plan Main Goal – Patient Education What the Staff RN Can Do  Be knowledgeable  Form trusting relationship with patient and family  Provide patient-centered and family-centered care  Be a detective  Use individualized approach  Advocate  Encourage  Support Asthma Discharge Nurse?

Editor's Notes

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