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
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
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?